Biventricular Hypertrophy

Definition

• 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

• Right ventricular hypertrophy
• Left ventricular hypertrophy
• Right atrial enlargement
• Left atrial enlargement

Further Reading

• ECG BASICS — Waves, Intervals, Segments and Clinical Interpretation
• ECG CLINICAL CASES — Your favourite ECG’s placed in clinical context with a challenging Q&A approach
• ECG and Cardiology Eponymous Syndromes — Cheats guide to eponymous emancipation
• ECG Exam Template — a framework for the FACEM part 2 exam.
• ECG Reference Sites on the WEB — the best of the rest

Author Credits

References

• 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.