40 year old male with Syncope

40 year old male has noticed a slowly increasing dyspnoea on exertion and more recently, syncopal episodes. The only cardiac relevant history is dislipidaemia. He does report however that his father started to get tired and short of breath in his forties and died suddenly in his fifties.

Exam shows no JVP distention, clear lungs bilaterally and dual heart sounds with a loud systolic murmur.
Systematically, what does this ECG show? What is this patient at high risk of? what are the differentials and most likely diagnosis?

• This ECG shows a regular, wide complex rhythm at a rate of around 75 beats per minute.
• The Axis is leftward at around -60 degrees.
• The precordial axis (R wave progression) is abnormal
• There are a few measurement abnormalities noted:
  P wave in Lead II is 140ms
  PR interval is constant, but around 360ms
  The QRS duration is around 160ms
• There are amplitude related abnormalities noted:
  Q wave with Tall R wave in aVL around 11mm
  Dominant R wave in V1
  Almost equiphasic complex in V6
• There are suggestive signs of previous infarct with large Q waves in leads V1-V3 and Twave flattening

With this information we can conclude: Sinus rhythm at 75bpm with 1st degree AV block, right bundle branch block, left anterior fascicular block, left atrial enlargement, with probable bi-ventricular hypertrophy.

This patient is at high risk of complete heart block and dilated cardiomyopathy.

Differentials include: Hypertrophic obstructive cardiomyopathy, aortic and mitral stenosis/ regurgitation, congenital heart defects such as VSD, ASD, etc.
The most likely however that fits with the scenario is a stenotic bicuspid aortic valve.