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      Assessment of a single monomorphic ventricular ectopy from the right ventricular outflow tract in standard and high resolution electrocardiogram

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          Abstract

          Introduction

          High-resolution electrocardiography (ECG-CREM) is a method based on digital electrocardiography. In order to facilitate the interpretation of the Crem records the technique of vectorcardiography was used. In comparison the origin of the ventricular premature complexes (VPCs) could be estimated based on a standard 12-lead electrocardiogram. The aim of the study was to assess the point of origin of the VPCs in ECG-CREM and correlate it with standard electrocardiography (ECG-Stand).

          Material and methods

          Our study included 26 patients (16 females, 10 males), aged 51-83 years (avg. 58.1 ±12.3), who presented with recurrent, during at least 6 months’ observation, VPCs. The point of origin of VPCs was compared in both methods.

          Results

          The performed analysis of collected ECG-Stand records revealed the presence of arrhythmogenic focal points in six different locations (1, 3, 5, 7, 8, 9). However, we did not affirm their presence in points 2,4,6. They were most commonly located in RVOT zones 8 (30.7%), 9 (23.0%), 5 (23.0%), and most seldom in zones 1, 3, 7 (7.6% each). In the simultaneous record of ECG-CREM with a single VPC it was confirmed that the FPb zone was activated the most frequently (40.0%); the next in relation to frequency were SD and ST (20.0%). Less frequent VPCs have their origin in Crem zones SP, FPa and SB (6.6%).

          Conclusions

          Electrocardiogram of high signal resolution (ECG-CREM) might be useful in recognition of the origin of ventricular premature complexes from RVOT.

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          Most cited references16

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          Repetitive monomorphic ventricular tachycardia originating from the aortic sinus cusp: electrocardiographic characterization for guiding catheter ablation.

          M Volkmer, Daniel S Y Ho, Jeffrey Burns … (2002)
          We sought to investigate the electrocardiographic (ECG) characteristics for guiding catheter ablation in patients with repetitive monomorphic ventricular tachycardia (RMVT) originating from the aortic sinus cusp (ASC). Repetitive monomorphic ventricular tachycardia can originate from the right ventricular outflow tract (RVOT) and ASC in patients with a left bundle branch block (LBBB) morphology and an inferior axis. Activation mapping and ECG analysis was performed in 15 patients with RMVT or ventricular premature contractions. The left main coronary artery (LMCA) was cannulated as a marker and for protection during radiofrequency delivery if RMVT originated from the left coronary ASC. During arrhythmia, the earliest ventricular activation was recorded from the superior septal RVOT in eight patients (group 1) and from the ASC in the remaining seven patients (group 2). The indexes of R-wave duration and R/S-wave amplitude were significantly lower in group 1 than in group 2 (31.8+/-13.5% vs. 58.3+/-12.1% and 14.9+/-9.9% vs. 56.7+/-29.5%, respectively; p < 0.01), despite similar QRS morphology. In five patients from group 2, RMVT originated from the left ASC, with a mean distance of 12.2+/-3.2 mm (range 7.3 to 16.1) below the ostium of the LMCA. In the remaining two patients, the RMVT origin was in the right ASC. All arrhythmias were successfully abolished. None of the patients had recurrence or complications during 9+/-3 months of follow-up. On the surface ECG, RMVT from the ASC has a QRS morphology similar to that of RVOT arrhythmias. The indexes of R-wave duration and R/S-wave amplitude can be used to differentiate between the two origins. Radiofrequency ablation can be safely performed within the left ASC with a catheter cannulating the LMCA.
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            Electrocardiographic characteristics of repetitive monomorphic right ventricular tachycardia originating near the His-bundle.

            Yasuhiro Yokoyama, Y. Yamauchi, Mitsuaki Isobe … (2005)
            Most idiopathic nonreentrant ventricular tachycardia (VT) and ventricular premature contractions (VPCs) arise from the right or left ventricular outflow tract (OT). However, some right ventricular (RV) VT/VPCs originate near the His-bundle region. The aim of this study was to investigate ECG characteristics of VT/VPCs originating near the His-bundle in comparison with right ventricular outflow tract (RVOT)-VT/VPCs. Ninety RV-VT/VPC patients underwent catheter mapping and radiofrequency ablation. ECG variables were compared between VT/VPCs originating from the RVOT and near the His-bundle. Ten patients had foci near the His-bundle (HIS group), with the His-bundle local ventricular electrogram preceding the QRS onset by 15-35 msec (mean: 22 msec) and His-bundle pacing produced a nearly identical ECG to clinical VT/VPCs. The HIS group R wave amplitude in the inferior leads (lead III: 1.0 +/- 0.6 mV) was significantly lower than that of the RVOT group (1.7 +/- 0.4 mV, P < 0.05). An R wave in aVL was present in 6 of 10 HIS group patients, while almost all RVOT group patients had a QS pattern in aVL. Lead I in HIS group exhibited significantly taller R wave amplitudes than RVOT group. HIS group QRS duration in the inferior leads was shorter than that of the RVOT group. Eight of 10 HIS group patients exhibited a QS pattern in lead V1 compared to 14 of 81 RVOT group patients. HIS group had larger R wave amplitudes in leads V5 and V6 than RVOT group. VT/VPCs originating near the His-bundle have distinctive ECG characteristics. Knowledge of the characteristic QRS morphology may facilitate catheter mapping and successful ablation.
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              Electrocardiographic patterns of superior right ventricular outflow tract tachycardias: distinguishing septal and free-wall sites of origin.

              Sanjay Dixit, Francis Marchlinski, David J Callans … (2002)
              The superior right ventricular outflow tract (RVOT) septum and free wall are common locations of origin for outflow tract ventricular tachycardias (VT). We hypothesized that (1) unique ECG morphologies of pace maps from septal and free-wall sites in the superior RVOT could be identified using magnetic electroanatomic mapping for accurate anatomical localization; and (2) this ECG information could help facilitate pace mapping and accurate VT localization. In 14 patients with structurally normal hearts who were undergoing ablation for outflow tract VT, a detailed magnetic electroanatomic map of RVOT was constructed in sinus rhythm, then pace mapping was performed from anterior, mid, and posterior sites along the septum and free wall of the superior RVOT. Pace maps were analyzed for ECG morphologies in limb leads and transition patterns in precordial leads. Monophasic R waves in inferior leads for septal sites were taller (1.7 +/- 0.4 mV vs 1.1 +/- 0.3 mV; P < 0.01) and narrower (158 +/- 21 msec vs 168 +/- 15 msec; P < 0.01) compared with free-wall sites; lacked "notching" (28.6% vs 95.2%; P < 0.05); and showed early precordial transition (by lead V4; 78.6% vs 4.8%; P < 0.05). A positive R wave in lead I also distinguished posterior from anterior septal and free-wall sites. Based on QRS morphology in limb leads and precordial transition pattern (early vs late), in a retrospective analysis, a blinded reviewer was able to accurately localize the site of origin of clinical arrhythmia (the successful ablation site on the magnetic electroanatomic map) in 25 of 28 patients (90%) with superior RVOT VT. Pace maps in the superior RVOT region manifest site-dependent ECG morphologies that can help in differentiating free-wall from septal locations and posterior from anterior locations. Despite overlap in QRS amplitude and duration, in the majority of patients a combination of ECG features can serve as a useful template in predicting accurately the site of origin of clinical arrhythmias arising from this region.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Arch Med Sci
                Journal ID (publisher-id): AMS
                Title: Archives of Medical Science : AMS
                Publisher: Termedia Publishing House
                ISSN (Print): 1734-1922
                ISSN (Electronic): 1896-9151
                Publication date (Print): October 2010
                Publication date (Electronic): 26 October 2010
                Volume: 6
                Issue: 5
                Pages: 713-718
                Affiliations
                [1 ]Department of Cardiology and Electrotherapy, Medical University of Gdansk, Poland
                [2 ]Department of Clinical Anatomy, Medical University of Gdansk, Poland
                [3 ]Noninvasive Cardiac Diagnostic Department, Medical University of Gdansk, Poland
                Author notes
                Corresponding author: Dariusz Kozłowski, MD, PhD, Department of Cardiology and Electrotherapy, Medical University of Gdansk, ul. Dębinki 7 80-211, Gdansk, Poland, Phone: +48 58 349 39 10. E-mail: dkozl@ 123456gumed.edu.pl
                Article
                Publisher ID: AMS-6-5-713
                DOI: 10.5114/aoms.2010.17086
                PMC ID: 3298340
                PubMed ID: 22419930
                SO-VID: 273e08c9-82cc-4856-9e93-0bc8e67b5f41
                Copyright © Copyright © 2010 Termedia & Banach
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License, permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 1 December 2008
                Date revision received : 12 February 2009
                Date accepted : 4 August 2010
                Categories
                Subject: Clinical Research

                ScienceOpen disciplines: Medicine
                Keywords: standard ecg,ventricular ectopy,rvot,high-resolution electrocardiography
                Data availability:
                ScienceOpen disciplines: Medicine
                Keywords: standard ecg, ventricular ectopy, rvot, high-resolution electrocardiography

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