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Dr. Mete ALPASLAN
Pulmonary Stenosis and the ECG
Congenital form of pulmonary stenosis is more frequently observed than the acquired form.
The ECG may be normal in some patients with mild pulmonary stenosis.
ECG abnormalities that may be seen in pulmonary stenosis
Right axis deviation: sometimes this may be the only ECG abnormality in mild pulmonary stenosis. Severe pulmonary stenosis will result in significant right axis deviation.
In patients with moderate pulmonary stenosis, R wave amplitude in lead C1 increases. rsR' pattern may be observed in lead C1.
If pulmonary stenosis is severe, the R wave amplitude in C1 may be >20 mm (>2mV).
Right atrial abnormality: Pulmonary stenosis is one of the few diseases that increase P wave amplitude extremely.
Right ventricular hypertrophy pattern in adults.
In patients with severe pulmonary stenosis,
Q waves may be seen in leads
C1-C3.
References
Chou's Electrocardiography in Clinical Practice. Adult and Pediatric. 5th ed. Philadelphia. WB Saunders. 2001.
ECG 1. The ECG above belongs to a 6 years old child. Because of critical pulmonary stenosis in the neonatal period, he had
undergone first pulmonary balloon valvuloplasty and then pulmonary valvulotomy. Recently, the echocardiography revealed
severe tricuspid regurgitation and moderate pulmonary regurgitation. Right atrial abnormality is so obvious that the amplitude
of the P wave in lead II is above than that of the following QRS complex. In severe pulmonary stenosis, also a higher than
expected R wave amplitude in lead C1 is usually observed.
Pediatric cardiologist Dr. Mahmut Gokdemir has donated this ECG to our website.
Click here for a more detailed ECG
ECG 2. The ECG above belongs to a 3.5 years-old boy who has both pulmonary stenosis and an 18mm wide non-restrictive type
ASD. The peak systolic gradient at the pulmonary valve was measured 60mmHg by echocardiography and 40mmHg by right
heart catheterization. Echocardiography showed dilation of right heart chambers. This patient has both right ventricular (RV)
volume overload due to non-restrictive type ASD and RV pressure overload due to pulmonary stenosis.
The heart rate is 118/min. (normal for his age). There is right axis deviation.
The increased amplitude of R' wave in C1 suggests RV hypertrophy.
Crochetage sign in leads III and aVF is the other abnormality in the above ECG.
Pediatric cardiologist Dr. Mahmut Gokdemir has donated this ECG to our website.
Click here for a more detailed ECG
ECG 3. The ECG above belongs to a 5 months-old child with pulmonary stenosis. The maximum systolic gradient at the level of
pulmonary valve was 54 mmHg. The ECG shows right axis deviation and right ventricular hypertrophy.
Pediatric cardiologist Dr. Mahmut Gokdemir has donated this ECG to our website.
Click here for a more detailed ECG
ECG 4. The ECG above belongs to a 6 years-old girl with severe pulmonary stenosis. The peak systolic pulmonary valve
gradient is 120 mmHg. The ECG shows right ventricular hypertrophy. This patient also has right to left shunt flow through an
atrial septal defect.
Pediatric cardiologist Dr. Mahmut Gokdemir has donated this ECG to our website.
Click here for a more detailed ECG
ECG 5. The ECG above belongs to a 6 months-old child who had undergone cutting balloon for pulmonary stenosis. He also
has inferior type Total Anomalous Pulmonary Venous Drainage. Echocardiography revealed dilated right heart chambers.
The ECG shows right ventricular hypertrophy and right atrial abnormality.
Pediatric cardiologist Dr. Mahmut Gokdemir has donated this ECG to our website.
Click here for a more detailed ECG
ECG 6. The ECG above belongs to a 7 years-old boy who had been operated for TGA after which he develeoped neopulmonary
stenosis with a peak systolic gradient of 170 mmHg. Echocardiography revealed dilated right heart chambers in this patient.
The ECG shows right ventricular hypertrophy.
Pediatric cardiologist Dr. Mahmut Gokdemir has donated this ECG to our website.
Click here for a more detailed ECG
ECG 7. The ECG above belongs to a 20 years-old man with severe congenital pulmonary stenosis resulting in significant
right ventricular hypertrophy with right atrial dilatation. Echocardiography measured pulmonary valve peak systolic gradient
as 178 mmHg. The ECG shows tall P waves in lead II indicating right atrial abnormality . Right axis deviation is also seen.
Chest leads are recorded at a calibration of 5 mm/mV.
Click here for a more detailed ECG
The ECG above has been used with the permission of Anatolian Journal of Cardiology and AVES Publishing.
Click here to read the relevant article of Dr. Ozturk et al.
ECG 8. The ECG above belongs to a 18 years-old girl with congenital pulmonary stenosis. The maximum systolic gradient at the
level of pulmonary valve was 90 mmHg and the mean gradient was 60mmHg. The ECG shows right axis deviation and
right ventricular hypertrophy.
Crochetage sign is seen in lead aVF.
Click here for a more detailed ECG
ECG 9. The ECG above belongs to a 5 years-old girl who has echocardiographically detected mild pulmonary valvular stenosis.
Mild pulmonary stenosis does not result in right ventricular strain.
Pediatric cardiologist Dr. Mahmut Gokdemir has donated the above ECG to our website.
Click here for a more detailed ECG
ECG 10. The ECG above belongs to a 29 years-old man.
He had been operated for VSD and pulmonary stenosis, 20 years ago.
Recent ECHOcardiography showed 130 mmhg peak systolic subvalvular gradient in the right ventricle.
ECHO also showed right ventricular hypertrophy. His right atrium and right ventricle were dilated.
R wave amplitude in lead V1 is 54mm.
Right bundle branch block and right axis deviation is also seen.
Click here for a more detailed ECG
ECG 11. Above is an ECG from a 72 years-old man.
He had undergone surgery for hemodynamically significant pulmonary stenosis, 42 years ago.
ECHOcardiography on the same day with the ECG showed 25 mmHg peak systolic pulmonary gradient.
The right ventricle was dilated and hypertrophic, while both atria were also dilated.
The rhythm is atrial fibrillation: irregular RR intervals without P waves.
The patient is taking Digoxin. Sagging type ST segment depression is due to Digoxin effect.
Click here for a more detailed ECG
Congenital form of pulmonary stenosis is more frequently observed than the acquired form.
The ECG may be normal in some patients with mild pulmonary stenosis.
ECG abnormalities that may be seen in pulmonary stenosis
Right axis deviation: sometimes this may be the only ECG abnormality in mild pulmonary stenosis. Severe pulmonary stenosis will result in significant right axis deviation.
In patients with moderate pulmonary stenosis, R wave amplitude in lead C1 increases. rsR' pattern may be observed in lead C1.
If pulmonary stenosis is severe, the R wave amplitude in C1 may be >20 mm (>2mV).
Right atrial abnormality: Pulmonary stenosis is one of the few diseases that increase P wave amplitude extremely.
Right ventricular hypertrophy pattern in adults.
In patients with severe pulmonary stenosis,
Q waves may be seen in leads
C1-C3.
References
Chou's Electrocardiography in Clinical Practice. Adult and Pediatric. 5th ed. Philadelphia. WB Saunders. 2001.
ECG 1. The ECG above belongs to a 6 years old child. Because of critical pulmonary stenosis in the neonatal period, he had
undergone first pulmonary balloon valvuloplasty and then pulmonary valvulotomy. Recently, the echocardiography revealed
severe tricuspid regurgitation and moderate pulmonary regurgitation. Right atrial abnormality is so obvious that the amplitude
of the P wave in lead II is above than that of the following QRS complex. In severe pulmonary stenosis, also a higher than
expected R wave amplitude in lead C1 is usually observed.
Pediatric cardiologist Dr. Mahmut Gokdemir has donated this ECG to our website.
Click here for a more detailed ECG
ECG 2. The ECG above belongs to a 3.5 years-old boy who has both pulmonary stenosis and an 18mm wide non-restrictive type
ASD. The peak systolic gradient at the pulmonary valve was measured 60mmHg by echocardiography and 40mmHg by right
heart catheterization. Echocardiography showed dilation of right heart chambers. This patient has both right ventricular (RV)
volume overload due to non-restrictive type ASD and RV pressure overload due to pulmonary stenosis.
The heart rate is 118/min. (normal for his age). There is right axis deviation.
The increased amplitude of R' wave in C1 suggests RV hypertrophy.
Crochetage sign in leads III and aVF is the other abnormality in the above ECG.
Pediatric cardiologist Dr. Mahmut Gokdemir has donated this ECG to our website.
Click here for a more detailed ECG
ECG 3. The ECG above belongs to a 5 months-old child with pulmonary stenosis. The maximum systolic gradient at the level of
pulmonary valve was 54 mmHg. The ECG shows right axis deviation and right ventricular hypertrophy.
Pediatric cardiologist Dr. Mahmut Gokdemir has donated this ECG to our website.
Click here for a more detailed ECG
ECG 4. The ECG above belongs to a 6 years-old girl with severe pulmonary stenosis. The peak systolic pulmonary valve
gradient is 120 mmHg. The ECG shows right ventricular hypertrophy. This patient also has right to left shunt flow through an
atrial septal defect.
Pediatric cardiologist Dr. Mahmut Gokdemir has donated this ECG to our website.
Click here for a more detailed ECG
ECG 5. The ECG above belongs to a 6 months-old child who had undergone cutting balloon for pulmonary stenosis. He also
has inferior type Total Anomalous Pulmonary Venous Drainage. Echocardiography revealed dilated right heart chambers.
The ECG shows right ventricular hypertrophy and right atrial abnormality.
Pediatric cardiologist Dr. Mahmut Gokdemir has donated this ECG to our website.
Click here for a more detailed ECG
ECG 6. The ECG above belongs to a 7 years-old boy who had been operated for TGA after which he develeoped neopulmonary
stenosis with a peak systolic gradient of 170 mmHg. Echocardiography revealed dilated right heart chambers in this patient.
The ECG shows right ventricular hypertrophy.
Pediatric cardiologist Dr. Mahmut Gokdemir has donated this ECG to our website.
Click here for a more detailed ECG
ECG 7. The ECG above belongs to a 20 years-old man with severe congenital pulmonary stenosis resulting in significant
right ventricular hypertrophy with right atrial dilatation. Echocardiography measured pulmonary valve peak systolic gradient
as 178 mmHg. The ECG shows tall P waves in lead II indicating right atrial abnormality . Right axis deviation is also seen.
Chest leads are recorded at a calibration of 5 mm/mV.
Click here for a more detailed ECG
The ECG above has been used with the permission of Anatolian Journal of Cardiology and AVES Publishing.
Click here to read the relevant article of Dr. Ozturk et al.
ECG 8. The ECG above belongs to a 18 years-old girl with congenital pulmonary stenosis. The maximum systolic gradient at the
level of pulmonary valve was 90 mmHg and the mean gradient was 60mmHg. The ECG shows right axis deviation and
right ventricular hypertrophy.
Crochetage sign is seen in lead aVF.
Click here for a more detailed ECG
ECG 9. The ECG above belongs to a 5 years-old girl who has echocardiographically detected mild pulmonary valvular stenosis.
Mild pulmonary stenosis does not result in right ventricular strain.
Pediatric cardiologist Dr. Mahmut Gokdemir has donated the above ECG to our website.
Click here for a more detailed ECG
ECG 10. The ECG above belongs to a 29 years-old man.
He had been operated for VSD and pulmonary stenosis, 20 years ago.
Recent ECHOcardiography showed 130 mmhg peak systolic subvalvular gradient in the right ventricle.
ECHO also showed right ventricular hypertrophy. His right atrium and right ventricle were dilated.
R wave amplitude in lead V1 is 54mm.
Right bundle branch block and right axis deviation is also seen.
Click here for a more detailed ECG
ECG 11. Above is an ECG from a 72 years-old man.
He had undergone surgery for hemodynamically significant pulmonary stenosis, 42 years ago.
ECHOcardiography on the same day with the ECG showed 25 mmHg peak systolic pulmonary gradient.
The right ventricle was dilated and hypertrophic, while both atria were also dilated.
The rhythm is atrial fibrillation: irregular RR intervals without P waves.
The patient is taking Digoxin. Sagging type ST segment depression is due to Digoxin effect.
Click here for a more detailed ECG