Ebsteins anomaly of the tricuspid valve electrocardiogram

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]}; Claudia P. Hochberg, M.D.; Priyamvada Singh, MBBS [3] Assistant Editor-In-Chief: Kristin Feeney, B.S. [4]

Overview

The EKG is abnormal in 50 to 60% of patients, and will often show signs of right atrial enlargement, including "Himalayan" P waves which are P waves greater than 2.5 mm in height in leads 2, 3, and aVF.

Electrocardiogram

10-lead ECG of a woman with Ebstein's anomaly. The ECG shows signs of right atrial enlargement. Other P waves are broad and tall, these are termed "Himalayan" P waves. There is also a right bundle branch block pattern and a first degree atrioventricular block (prolonged PR-interval) due to intra-atrial conduction delay. There is no evidence of a Kent-bundle in this patient. There is T wave inversion in V1-4 and a marked Q wave in III; these changes are characteristic for Ebstein's anomaly and do not reflect ischemic ECG changes in this patient.

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Other abnormalities that can be seen on the ECG include:

• The EKG is abnormal in 50 to 67%.

• About 50% of individuals with Ebstein's anomaly have evidence of Wolff-Parkinson-White Syndrome (syndrome of pre-excitation of the ventricles due to an accessory pathway known as the Bundle of Kent), secondary to the the apical displacement of the septal tricuspid valve leaflet resulting in discontinuity of the central fibrous body. WPW has a left bundle branch pattern with predominant S waves in the right precordium
• Signs of right atrial enlargement or tall and broad 'Himalayan' P waves,

• First degree atrioventricular block manifesting as a prolonged PR-interval,

• Low amplitude QRS complexes in the right precordial leads,

• Atypical right bundle branch block,

• T wave inversion in V1-V4 and Q waves in V1-V4 and II, III and aVF.

• A short PR interval and a delta wave and low voltages.

• Supraventricular tachycardia and other forms of rhythm disturbances such as atrial flutter or atrial fibrillation, may be seen