Hypertrophy of both 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 LVH and 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 ventricular septal defect (VSD).
In the presence of LVH – Additional signs indicating RVH:
- 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:
- Tall R waves and deep S waves in V2-5.
- QRS amplitude > 50 mm.
- Large biphasic QRS complexes (tall R waves + deep S waves) in V2-5.
- Katz-Wachtel phenomenon — 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.
- 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 / T-wave inversion in V4-6).
- Signs of right atrial enlargement — peaked P waves in lead II.
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.
- 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.
- Right ventricular hypertrophy
- Left ventricular hypertrophy
- Right atrial enlargement
- Left atrial enlargement
- Katz-Wachtel phenomenon
- Louis Nelson Katz (1897 – 1973)
- Wiesbauer F, Kühn P. ECG Yellow Belt online course: Become an ECG expert. Medmastery
- Wiesbauer F, Kühn P. ECG Blue Belt online course: Learn to diagnose any rhythm problem. Medmastery
- Rawshani A. Clinical ECG Interpretation ECG Waves
- Smith SW. Dr Smith’s ECG blog.
- Mattu A, Tabas JA, Brady WJ. Electrocardiography in Emergency, Acute, and Critical Care. 2e, 2019
- Brady WJ, Lipinski MJ et al. Electrocardiogram in Clinical Medicine. 1e, 2020
- Straus DG, Schocken DD. Marriott’s Practical Electrocardiography 13e, 2021
- Hampton J. The ECG Made Practical 7e, 2019
- Grauer K. ECG Pocket Brain (Expanded) 6e, 2014
- Brady WJ, Truwit JD. Critical Decisions in Emergency and Acute Care Electrocardiography 1e, 2009
- Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice: Adult and Pediatric 6e, 2008
- Mattu A, Brady W. ECG’s for the Emergency Physician Part I 1e, 2003 and Part II
- 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