Biventricular Hypertrophy

Biventricular Hypertrophy

Hypertrophy of both the left and right ventricles.

The ECG has a low sensitivity for the diagnosis of biventricular hypertrophy (BVH), as the opposing left and right ventricular forces tend to cancel each other out.

  • There may be signs of both Left Ventricular Hypertrophy (LVH) and Right Ventricular Hypertrophy (RVH) on the same ECG – e.g. positive diagnostic criteria for LVH with some additional features suggestive of RVH.
  • The Katz-Wachtel phenomenon – large biphasic QRS complexes in V2-5. This is the classic ECG pattern of BVH, most commonly seen in children with congenital heart disease e.g. ventricular septal defect (VSD).

In the presence of LVH – Additional signs indicating RVH include

  • Right atrial enlargement.
  • Right axis deviation.
  • Tall biphasic QRS complexes in multiple leads.
  • Deep S waves in V5-6.

In the presence of RVHAdditional signs indicating LVH include:

  • Tall R waves and deep S waves in V2-5.
  • QRS amplitude > 50 mm.

Katz-Wachtel phenomenon

  • Large biphasic QRS complexes (tall R waves + deep S waves) in V2-5.

ECG Examples
Example 1
ECG Dilated cardiomyopathy Biventricular hypertrophy

Biventricular hypertrophy:

  • Large biphasic QRS complexes in V2-5.
  • LVH: Voltage criteria for LVH (S V2 + R V5 = 35 mm, R aVL > 11 mm) with signs of LV strain (T-wave inversion in V4-6).
  • Persistent S waves in V5-6 suggestive of associated RVH.

Example 2
ECG Biventricular hypertrophy Katz-Wachtel phenomenon

Biventricular hypertrophy

  • Katz-Wachtel phenomenon — biphasic QRS complexes in the precordial leads.
  • Enormous voltages — QRS amplitude > 50 mm in V2.
  • Easily meets voltage criteria for LVH and there are associated features of LV strain (ST depression and T-wave inversion in V4-6).
  • Signs of right atrial enlargement — peaked P waves in lead II.

Example 3
Katz-Wachtel phenomenon Biventricular hypertrophy in a child with VSD
Child with isolated ventricular septal defect

Biventricular hypertrophy in a child with VSD:

  • Katz-Wachtel phenomenon – large biphasic QRS complexes in V2-5.
  • Enormous QRS voltages.
  • Right axis deviation and T-wave inversion in V1-3 are normal findings on the paediatric ECG.


Advanced Reading



LITFL Further Reading


Emergency Physician in Prehospital and Retrieval Medicine in Sydney, Australia. He has a passion for ECG interpretation and medical education | ECG Library |

MBBS (UWA) CCPU (RCE, Biliary, DVT, E-FAST, AAA) Adult/Paediatric Emergency Medicine Advanced Trainee in Melbourne, Australia. Special interests in diagnostic and procedural ultrasound, medical education, and ECG interpretation. Editor-in-chief of the LITFL ECG Library. Twitter: @rob_buttner

One comment

  1. Example 1 is incorrect – there is a left arm left leg switch (not there are larger P waves high laterally then in II)
    There are no persistent S waves in V5/V6
    There is simply LVH with a limb lead error, it is not biventricular hyperthrophy

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