Underwriting Puzzler Answer (2/15/14, Vol. 5, #1)

ECG Underwriting
Presented by: Bill Rooney, M.D.
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ECG Puzzler
Here is an ECG on a 31 y/o male who is applying for life insurance. Application mentions
having a “Mustard Procedure” as a child. How would you interpret this ECG?
ECG Puzzler
After inspecting for technical issues let’s examine the ECG using our usual routine:
1) Rhythm 2) Axis 3) Intervals 4) Q waves 5) Hypertrophy 6) ST/T waves
Technically, any
No. The copy could be of
better quality but….
Normal rhythm?
Yes, normal sinus rhythm
Normal Axis?
No! Right Axis Deviation
(RAD) present. ~ +145o
Normal Intervals?
No. QRS complex ~0.10
Significant Q
Yes, Right Ventricular
Hypertrophy (RVH)
ST/T wave
Yes, RVH strain pattern with ST depression/T wave
inversion in the right precordial leads (V1-3)
ECG Puzzler
RVH should be suspected when there is:
R in V1 >6 mm
R in V1 and S in V5 or V6 >10.5 mm
Right Axis Deviation (RAD)
R/S ratio in V1 >1
Right atrial hypertrophy
Incomplete RBBB present
So, what is the Mustard
procedure? How does it
compare to other surgical
The Mustard Procedure is one
of the surgical procedures
performed shortly after birth
when the congenital heart
defect known as transposition
of the great arteries occurs.
Let’s go to the next slide and
review that condition.
D-Transposition of the Great Arteries
Transposition of the great arteries is a
congenital heart defect.
• The aorta arises from the right
• The pulmonary artery arises from
the left ventricle.
Surgery is required for survival
There are two commonly performed
operations for this condition
(Sometimes there are other
associated heart defects requiring
other procedures but we won’t get into
that today)
• Arterial switch procedure
• Atrial switch procedures (Mustard
and Senning procedure)
Atrial switch procedure
The Mustard procedure is
what this individual had
performed. In this procedure
an intra-Atrial tunnel is
surgically formed.
The result of this procedure is that
the right ventricle pumps blood to
the systemic circulation instead of
the typical pumping of blood to the
lungs. This can eventually cause
significant right ventricular
Long term risk of this procedure include:
Right ventricular failure
Tunnel (baffle) related complications such as obstruction at the right atrialsuperior vena cava junction
Arterial switch procedure
The arterial switch procedure is
what is more commonly used
now. The aorta and the
pulmonary artery are transected
and then translocated to the
opposite root. This creates
ventriculo-arterial concordance
(aorta-left ventricle; pulmonary
artery-right ventricle)
Suture lines
This procedure requires
dissection and then reimplantation of the coronary
arteries. The procedure is
usually done within the first 2
weeks of life.
Long term complications of
the arterial switch
procedure include:
• Pulmonary artery
• Coronary artery
• Neo-aortic root dilation
• Neo-aortic regurgitation
However, this procedure
can change a uniformly
fatal disorder without some
kind of repair to a long term
fairly favorable outcome!
Back to this specific ECG. The ECG showing RVH
is a clue that there appears to be significant mortality
concerns in this individual. Interesting ECG indeed!!
That concludes this issue’s ECG
Underwriting Puzzler!! Contact me if
you have any questions!!

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