Biventricular Hypertrophy


  • Hypertrophy of both the left and right ventricles.

Electrocardiographic Features

  • 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 ventriculo-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.

Katz-Wachtel phenomenon

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


Example ECGs

Example 1

Biventricular hypertrophy:

  • 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.


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 / T-wave inversion in V4-6).
  • Signs of right atrial enlargement — peaked P waves in lead II.

This great ECG was originally posted by Swarnalatha on the Cardiac Diagnostics website (view website).


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.

This great ECG was originally posted by Johnson Francis for Cardiophile MD (view website).

Related Topics

Further Reading

Author Credits


  • Chan TC, Brady WJ, Harrigan RA, Ornato JP, Rosen P. ECG in Emergency Medicine and Acute Care. Elsevier Mosby 2005.
  • Surawicz B, Knilans T. Chou’s Electrocardiography in Clinical Practice (6th edition), Saunders 2008.
  • Wagner, GS. Marriott’s Practical Electrocardiography (11th edition), Lippincott Williams & Wilkins 2007.
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