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9/14/2019
1
Surface ECG Recognition /
Localization of Idiopathic Ventricular
Arrhythmias
Sanjay Dixit, M.D.
Professor, University of Pennsylvania School of Medicine
Director, Cardiac Electrophysiology, Philadelphia V.A.M.C.
45144
23885
808761
1199
233
1216
0
200
400
600
800
1000
1200
1400
ICM ARVC/D LVCM Idio RV Idio LV ILVT Pap VF trig Other
UPENN PVC / VT Ablations 1999-2018
(N = 4729)
40%
Outflow Tract and Basal Interventricular Septal Region:
Common sites of origin for idiopathic VAs
MV TV
PV
AV
- Heart model figure courtesy Samuel Asirvatham, MD
Anteroseptal Sup. RVOT
Aortic Cusp Region
Aorto-Mitral Continuity
Superior Basal Epicardium
Superior & lateral MA
Infero-basal septum
Infero-basal Crux
Outflow Tract Tachycardias: Typical ECG ManifestationsI
II
III
aVR
V6
aVL
aVF
V5
V4
V3
V2
V1
I
II
III
aVR
V6
aVL
aVF
V5
V4
V3
V2
V1
I
II
III
aVR
V6
aVL
aVF
V5
V4
V3
V2
V1
- Inferiorly
directed axis
- Left or Right
Bundle branch
Block pattern
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Influence of Cardiac Orientation on Unique ECG
Manifestations of Outflow Tract Tachycardias:
Morphology in lead V1 & Precordial Transition
RVOT
AV
MV
RC LC
NC
MV
AV
PV
aVR
RVFW
aVF
V1
V6
II
I
III
aVL
RV Septal RCC LV Septal LCC AMC
Position of ECG Leads V1 & V2:
Localization of Outflow Tract Tachycardia
- Anter, Dixit et al, Heart Rhythm 2012;9:697
Change in position:
Leads V1 and V2
Anterior RVOT Left-Right Cusp
Influence of Cardiac Orientation on Unique ECG
Manifestations of Outflow Tract Tachycardias:
Morphology in limb lead I
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Free Wall
Septum
3 2 13 2 1
PV
aVF
V2
V3
V4
V5
V6
II
I
III
aVR
aVL
V1
aVF
V2
V3
V4
V5
V6
II
I
III
aVR
aVL
V1
Free WallSeptum
12
3
12
3
Superior RVOT
- Dixit S et al, J Cardiovasc Electrophysiol. 2003;13(1):1-7
Position of ECG Lead I:
Localization of Outflow Tract Tachycardia
- Anter, Dixit et al, Heart Rhythm 2012;9:697
RVOT
Right Coronary Cusp
I
II
III
aVR
V6
aVL
aVF
V5
V4
V3
V2
V1
Left Coronary Cusp
I
II
III
aVR
V6
aVL
aVF
V5
V4
V3
V2
V1
21 3
Aortic Cusp Region The V2 Transition Ratio: A New ECG Criterion for
Distinguishing LV From RV Outflow Tachycardia Origin
I
II
III
R
L
F
I
II
III
R
L
F
V1
V2
V3
V4
V5
V6
V1
V2
V3
V4
V5
V6
Patient 1 Patient 2
Betensky … Gerstenfeld. JACC 2011;57:2255-62
9/14/2019
4
RVOT (n=18) LVOT (n=18)
TRANSITION RATIO =
(R/R+S)VT
(R/R+S)SR
0.29 1.16RS
RS
V1
V2
V3
V4
V5
V6
V1
V2
V3
V4
V5
V6
Results – V2 Transition Ratio
0.6
RCC
NCC
The V2 Transition Ratio: A New ECG Criterion for
Distinguishing LV From RV Outflow Tachycardia Origin
I
II
III
R
L
F
I
II
III
R
L
F
V1
V2
V3
V4
V5
V6
V1
V2
V3
V4
V5
V6
RVOT LVOT
Betensky … Gerstenfeld. JACC 2011;57:2255-62
Patient 1 Patient 2
Summary – ECG Criteria OT PVCs
LBB/inferior, precordial xition = V4 RVOT
LBB/inferior, precordial xition ≤ V2 Ao cusp
LBB/inferior, precordial xition = V3 V2 ratio
LBB/inferior, precordial xition ≥V5 *Consider ARVC
*Hoffmayer et al. JACC 2011;58:831-838.
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Activation in RVOTLBI PVCs with transition ≥ V4 Mapping in the Right CuspLBI PVC Pace MapDistance between earliest RVOT & Cusp location: 1cm
LV Summit: Anatomic Correlates
GCVAIV
LCC
NCCRCC
RVO
T
LVOT
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LV Summit VT: ECG Manifestations
I
II
III
aVR
V1
aVL
aVF
V6
I
II
III
aVR
V1
aVL
aVF
V6
I
II
III
aVR
V1
aVL
aVF
V6
LV Summit VT: ECG Manifestations
I
II
III
aVR
V1
aVL
aVF
V6
I
II
III
aVR
V1
aVL
aVF
V6
PERCUTANEOUS EPICARDIAL ABLATION OF VENTRICULAR ARRHYTHMIAS
ARISING FROM THE LEFT VENTRICULAR SUMMIT: OUTCOMES AND ECG
PREDICTORS OF SUCCESS
ECG Features associated
with successful epicardial
ablation of LV summit
VT:
1. Q wave ratio in leads
aVL/aVR >1.85.
2. R/S wave ratio in lead V1
>2.
3. Lack of initial “q” wave
in lead V1.
- Santangeli, Dixit et al, Circulation A&E, 2015;8:337
Localizing idiopathic ventricular arrhythmias
originating from the inferior basal septal region
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ECG features of VAs originating from the basal infero-septal LV
- Jackson L, Dixit S et al. J Am Coll Cardiol 2019;5:833-42
ECG features to differentiate VAs originating from
infero-basal LV endocardium Vs infero-basal crux region
- Jackson L, Dixit S et al. J Am Coll Cardiol 2019;5:833-42
ECG features of VAs originating from the slow pathway region
- Briceno D, Dixit S et al. Heart Rhythm Journal 2019;16:1421
MV TV
PV
AV
Inferior lead discordance in idiopathic ventricular arrhythmias
- Enriquez A et al. JCE 2017;28:1179-1186
SPR Region Mod. Band AL Pap Muscle
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ECG localization of VAs arising from the outflow
tract region and inferior basal septum: Summary
• Although these arrhythmias originate from narrow zones, they manifest distinct ECG morphologies.
• Careful analysis of 12 lead ECG can help in successful localization of the site of origin of these arrhythmias.
• To facilitate accurate ECG localization attention should be paid to lead placement, precordial transition patterns, patient’s body habitus and age.
Other Challenges to ECG
Localization of Outflow Tract
Tachycardias MV
TV
AV
AV
MVTV
PVA. B.
Influence of Age on Cardiac Orientation in
the Thoracic Cavity
- Maeda S, Lin D et al.
9/14/2019
9
- Timmermans, et al., Circulation 2003
RVOT VT Originating Above Pulmonic Valve
- Bala et al, Heart Rhythm 2010;7:312
VT Above The Right / Left Coronary Cusp Margin
VPD/VT from GCV/AIV – Accessible Area
I
IIIII
aVRaVL
aV
FV1
V6
QS in lead
1
Rs in V1
Santangeli, Marchlinski et al. Card EP Clinic. 2015 In Press
CS
Os
LCC
RCCNCC
AIV
NCC
RCC
LCC AIV
CS
Os
The Inaccessible AreaAblation from Adjacent Structures
LCC, LV Endo, RVOT
LCC
LV Endo
RVOT
W.A. McAlpine Collection-UCLA Cardiac Arrhythmia Center (with
permission)
9/14/2019
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Ablation from LCC or Adjacent Endocardium of VT
Source Near the AIV (Earliest site/best PM) -16pts
Clue for Successful ablation – Anatomical Proximity
ECG clue - Q wave ratio aVL/aVR - <1.45
SuccessfulUnsuccessful
Anatomic Distance <13.5mm
Abularach et al Heart Rhythm. 2012;9:865-873
9pts7pts
Other clues:
• <5 ms difference in activation
• Output better
PM match
Ablation from Adjacent SitesClue for Successful ablation – Better PM Match with
High Output Pacing (Index of Anatomical Proximity)
Santangeli and Marchlinski. Heart Rhythm 2015. In Press
>20 mA ≤20 mA
AIV
LCC LV endo
RVOT
Targeting the inaccessible area of LV summit from
antero-septal RVOT
- Frankel et al, Circulation A&E, 2014;7:984
RAO LAO
- Frankel et al, Circulation A&E, 2014;7:984
Targeting the inaccessible area of LV summit from
antero-septal RVOT
9/14/2019
11
Septal - ParahisianAMCSup MASup Lat MALat MA
1 2 4 53
M V
AV
3
1
2 4
5
Inferior
Superior
Lateral Septal
200 msec
I
II
III
aVR
V6
aVL
aVF
V5
V4
V3
V2
V1
I
II
III
aVR
V6
aVL
aVF
V5
V4
V3
V2
V1
PA View
- Heart Rhythm, 2005
Is the outflow tract region arrhythmogenic by design?
• Developmentally the outflow tract (OFT) is derived from the second heart fieldwhich is molecularly and phenotypically different from the first heart field that gives rise to the left ventricle.
• The prenatal OFT remains undifferentiated and slowly conducting until it is incorporated into the RVOT; it is devoid of Tbx5 (which is required for expression of Cx40) and has no Cx43 expression.
• Remnants of the embryonic OFT phenotype and expression profile in the adult RVOT may determine its electrophysiologic characteristics and vulnerability to arrhythmias.
• There is heterogeneity over the apex to base axis of the heart and fate based mapping studies in the chicken heart show that cells located initially in the AV canal and OFT will become part of the base of ventricles.
Proximity of Outflow Tract Structures
RVOT & Cusps
LCC
RVOT
LCC
RVOT
Cusps & GCV
LCC
GCV
LCC
GCV
Basal LV & GCV
GCV
Basal
LV
GCV
Basal
LV
Epicardial ablation of LV Summit VT:
PENN experience
• Over 10 year period, 86 patients
with LV summit VT ablated.
• In the majority (n=63; 73%) the VT
was successfully ablated from
adjacent structures.
• In remaining 23 patients, epicardial
ablation was attempted in 14 and
was successful in only 5.
• Presence of ≥2 of the previous ECG
criteria predicted epicardial success
with 100% sensitivity and 72%
specificity.
- Santangeli, Dixit et al, Circulation A&E, 2015;8:337
9/14/2019
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Outflow Tract Tachycardia: Unique
Features
• Mechanism: Triggered rhythm (DAD mediated)
• Focal site of origin
• Absence of structural heart disease
• Morphology of clinical arrhythmia can be mimicked by pace-mapping
• Pace mapping can be used to develop ECG criteria for localizing site(s) of origin of clinical tachycardias
• Electro-anatomic mapping facilitates accurate catheter localization and pace mapping
V A
I
II
III
aVR
V6
aVL
aVF
V5
V4
V3
V2
V1
CSPi
CSD
A B
LV
RVA
VT Originating From The Epicardium
Clinical PVC: LBBB, Inferior Axis, Small R wave in lead V1
QRS
Duration
(msec)
PDR in
Lead II
PDR in
Lead V3
PDR 0.55
in Lead II
or V3
R / S < 1
in
Lead V2
QS
morphology
in Lead I
EPI VT 19751 0.530.17* 0.510.126/7 (88%)* 6/7 (88%)* 7/7 (100%)*
ENDO VT 17421 0.460.09 0.370.08 0 0 0
* p < 0.05
ECG Characteristics of Epicardial
versus
Endocardial VT
- Bala, Dixit, et al. HRS 2006
Differentiating Epicardial from Endocardial location in the Anterior LV required
≥ 2 of the 3 pre-specified criteria
9/14/2019
13
E.C.G. Criteria for Distinguishing Epicardial from Endocardial VT
originating in the Superior / Basal Left Ventricle
• ECG recordings of epicardial VT in 7 pts (all right bundle branch block morphology) were compared to VT originating from corresponding endocardial sites in 6 pts
• ECGs were specifically analyzed for:
➢ 1) Peak deflection ratio (PDR): Ratio of time to 1st peak / nadir and QRS duration (QRSd) in leads II and V3
➢ 2) Lead V2: Ratio of R and S wave amplitude
➢ 3) Lead I: QRS morphology
- Bala, Dixit, et al. HRS 2006
Epicardial Sites
Endocardial Sites
Coronary SinusAIV
LCC
NCCRCC
R
V
O
T
LVOT
1st RF Lesion……………………………E.C.G. Criteria for Distinguishing Epicardial from Endocardial VT
originating in the Superior / Basal Left Ventricle
• ECG recordings of epicardial VT in 7 pts (all right bundle branch block morphology) were compared to VT originating from corresponding endocardial sites in 6 pts
• ECGs were specifically analyzed for:
➢ 1) Peak deflection ratio (PDR): Ratio of time to 1st peak / nadir and QRS duration (QRSd) in leads II and V3
➢ 2) Lead V2: Ratio of R and S wave amplitude
➢ 3) Lead I: QRS morphology
- Bala, Dixit, et al. HRS 2006
Epicardial Sites
Endocardial Sites
9/14/2019
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1 2 3
T
V
PV
RV
1
2
33
2
1
Anterior
Posterior
S
e
p
t
u
m
Fre
e W
all
Typical Site(s) of Origin For RVOT Tachycardia
Site 1
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Site 2
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Site 3
I
II
III
aVRaVL
aVF
V1
V2
V3
V4
V5
V6
Site 1
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
aVR
Site 3
I
II
III
aVL
aVF
V1
V2
V3
V4
V5
V6
100 msec
1 mV
Localizing Basal LV VT
M VAV
Sup Septum
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
I
AMC
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Superior MA
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Sup-Lateral MA
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
I
II
III
aVR
aVL
aVF
V1
V2
V3
V4
V5
V6
Parahisian
107
59
121
232217
56
366
0
50
100
150
200
250
300
350
400
VT CAD VT
RVCM*
VT
LVCM
RVOT
VT
LVOT
VT
Idio LV
VT
Other
VT
UPENN VT Ablations 1999- 2008(1158 VT ablation procedures ) Distribution of Idiopathic VT:
PENN Experience
1999 – 2003
(N = 431)
2004 – 2008
(N = 705)
P Value
RVOT 103 (24%) 115 (16%) P < 0.01
LVOT 24 (6%) 95 (14%) P < 0.001
LV & RVOT 4 (1%) 10 (1%) P = NS
Fascicular VT 18 (4%) 30 (4%) P = NS
9/14/2019
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- Circulation 2006;113:1169 - Circulation 2006;113:1169
RVOT
Cusps
Basal
LV
VT PM
- Betensky, Gerstenfeld, et al, JACC 2011;57:2255
RVOT LVOT
Distinguishing RVOT from LVOT
Tachycardia: Lead V2 Transition Ratio
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