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 RVH – Additional 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

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

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

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.

References

• Katz LN and Wachtel H. The diphasic QRS type of electrocardiogram in congenital heart disease. Am Heart J; 1937, 13: 202-206.
• Elliott LP, Anderson RC, Tuna N, Adams P, Neufeld HN. Complete Transposition of the Great Vessels: II. An Electrocardiographic Analysis. Circulation; 1963; 27:1118-1127.

Related Topics

• Right ventricular hypertrophy
• Left ventricular hypertrophy
• Right atrial enlargement
• Left atrial enlargement
• Katz-Wachtel phenomenon
• Louis Nelson Katz (1897 – 1973)

Advanced Reading

Online

• Wiesbauer F, Kühn P. ECG Mastery: Yellow Belt online course. Understand ECG basics. Medmastery
• Wiesbauer F, Kühn P. ECG Mastery: Blue Belt online course: Become an ECG expert. Medmastery
• Kühn P, Houghton A. ECG Mastery: Black Belt Workshop. Advanced ECG interpretation. Medmastery
• Rawshani A. Clinical ECG Interpretation ECG Waves
• Smith SW. Dr Smith’s ECG blog.
• Wiesbauer F. Little Black Book of ECG Secrets. Medmastery PDF

Textbooks

• Zimmerman FH. ECG Core Curriculum. 2023
• Mattu A, Berberian J, Brady WJ. Emergency ECGs: Case-Based Review and Interpretations, 2022
• Straus DG, Schocken DD. Marriott’s Practical Electrocardiography 13e, 2021
• Brady WJ, Lipinski MJ et al. Electrocardiogram in Clinical Medicine. 1e, 2020
• Mattu A, Tabas JA, Brady WJ. Electrocardiography in Emergency, Acute, and Critical Care. 2e, 2019
• Hampton J, Adlam D. The ECG Made Practical 7e, 2019
• Kühn P, Lang C, Wiesbauer F. ECG Mastery: The Simplest Way to Learn the ECG. 2015
• Grauer K. ECG Pocket Brain (Expanded) 6e, 2014
• Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric 6e, 2008
• Chan TC. ECG in Emergency Medicine and Acute Care 1e, 2004

LITFL Further Reading

• ECG Library Basics – Waves, Intervals, Segments and Clinical Interpretation
• ECG A to Z by diagnosis – ECG interpretation in clinical context
• ECG Exigency and Cardiovascular Curveball – ECG Clinical Cases
• 100 ECG Quiz – Self-assessment tool for examination practice
• ECG Reference SITES and BOOKS – the best of the rest