A 38-year-old male presented with chest pain. Patient reports having a procedure at the age of 12 for congenital heart disease.

Interpretation: 

Rate: 78

Rhythm: Sinus

Axis: Northwest axis   (Extreme axis deviation)

Morphology:  STE in leads  I, II, III, aVF, V3-V6,

TWI in  aVR and V1 (can be seen normally as well)

R wave abnormalities:

1. Dominant R wave in V1,

2. Dominant R in aVR,

3. Poor progression of R wave V4-V6

Widespread Q waves inferio-lateral leads

Intervals:    Normal PR/QTC intervals

The above ECG shows prominent R and Q wave abnormalities.  There is a wide differential diagnosis for these abnormalities. In the context of congenital heart disease the Q waves could be suggestive of rotation or surgery of the heart, however in the context of chest pain with the ST changes ischaemia should be excluded. Dominant R wave in aVR in this context could be due to dextracardia or incorrect lead placement, but normal P wave axis in limb leads excludes incorrect lead placement.

The patient was admitted under cardiology as he had chest pain/ECG changes and positive trop (0.23), however, repeat trops were 0.08 and 0.05 at 6 and 12 hours respectively. The trop rise was thought to be from an episode of SVT the patient might have had.

He underwent MPS which showed no significant myocardial ischemia.

ECG compared to old ECG showed no significant changes.

This patient had Fontan procedure for Congenital heart disease at age of 12 years.

Fontan procedure    It involves diverting the venous blood from the inferior vena cava (IVC) and superior vena cava (SVC) to the pulmonary arteries without passing through the morphologic right ventricle; i.e., the systemic and pulmonary circulations are placed in series with the functional single ventricle.

Patients with congenital heart disease should carry a copy of their ECG with them, as can be seen by the above ECG it can be markedly abnormal

Further reading:

R wave