• Images in cardiology

An 8 year old girl with a history of a murmur since early childhood had progressive shortness of breath and palpitations for two years. Two dimensional echocardiogram showed thickening of the tricuspid valve and pulmonic valve with a notably enlarged right atrium. A colour flow, Doppler examination revealed severe tricuspid valve stenosis with severe regurgitation and severe pulmonic stenosis. The findings of echocardiography were confirmed by catheterisation. Carcinoid syndrome, Leopard syndrome, and Noonan’s syndrome were ruled out. The patient was diagnosed as having congenital combined tricuspid and pulmonic stenosis and referred directly for cardiac surgery.

Her recent 12 lead ECG revealed important diagnostic information and signs of right ventricular and right atrial pressure overloading consistent with pulmonary valve and tricuspid valve severe stenosis. It shows a normal sinus rhythm, right atrial enlargement, and right ventricular hypertrophy with right ventricular forces. The P waves are tall (> 5 mm) and peaked in lead II (black arrow). These types of P waves are called giant P waves or Himalayan P waves and are caused by reflected dilated right atrium resulting from pressure overloading.