What Do You Think 4

8 year-old female with minor palpitations at night.

I was asked if V1 was normal for age.

What do you think?

The presence of R waves in V1,T wave inversion until V3 or even V4 and maybe early repolarization are referred to as persistent juvenile changes. Because the T wave changes are most common, it is often referred to as persistent juvenile T wave “changes” or “pattern”or “inversion”. It usually disappears by about 10-years but may persist longer. I remember dramatic examples, when I lived in the USA, in the ECGs of African-Americans who were well into their 20’s,

Here are some examples:

6-year old female

Small R in V1 and T wave inversion until V4.

9-year old male:

Small R in V1 and T wave inversion until V2.

I looked carefully at our ECG and noted a large R wave in V1 and no T wave inversion. In turn, V4 had almost no R wave and T wave inversion.

I asked that the ECG be repeated and here is the result:

V1 and V4 have been reversed (red and yellow highlight).

We have been so absorbed in the lead reversion, that we missed the nipple and notch on V2, V3 (blue highlight). This is due to unevenness in ventricular repolarization and is probably innocent. It is classically seen in elite athletes and in my experience in apparently normal children as shown: