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      Electrocardiographic landmarks of idiopathic ventricular arrhythmia origins

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      Journal: Heart
      Publisher: BMJ

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          Abstract

          Idiopathic ventricular arrhythmias occur in the absence of underlying structural heart disease and less commonly in the presence of coexistent, but mechanistically unrelated, myocardial scar. These arrhythmias originate from several anatomical sites in both ventricles, with a predilection in outflow tract structures. The 12-lead surface ECG is the initial mapping tool, which is widely used to identify their origin. Specific features can predict the site of idiopathic ventricular arrhythmias, thus differentiating right from left ventricular, as well as endocardial from epicardial origins. In this review, we aim to analyse electrocardiographic landmarks for determination of idiopathic ventricular arrhythmia sources, with specific emphasis on pertinent caveats and anatomical relationships.

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          Mapping and ablation of idiopathic ventricular fibrillation.

          Fernando Cruz-Guilloty, Nilay Shah, Angelo Paola … (2002)
          Ventricular fibrillation is the main mechanism of sudden cardiac death. The feasibility of eliminating recurrent episodes by catheter ablation has not been reported. Twenty-seven patients without known heart disease (13 men, 14 women, 41+/-14 years of age) were studied after being resuscitated from recurrent (10+/-12) episodes of primary idiopathic ventricular fibrillation; 23 had received a defibrillator. The first initiating beat of ventricular fibrillation had an identical electrocardiographic morphology and coupling interval (297+/-41 ms) to preceding isolated premature beats typically noted in the aftermath of resuscitation. These triggers were localized by mapping the earliest electrical activity and ablated by local radiofrequency delivery. Outcome was assessed by Holter and defibrillator memory interrogation. Premature beats were elicited from the Purkinje conducting system in 23 patients: from the left ventricular septum in 10, from the anterior right ventricle in 9, and from both in 4. The interval from the Purkinje potential to the following myocardial activation varied from 10 to 150 ms during premature beat but was 11+/-5 ms during sinus rhythm, indicating location at peripheral Purkinje arborization. The premature beats originated from the right ventricular outflow tract muscle in 4 patients. The accuracy of mapping was confirmed by acute elimination of premature beats during local radiofrequency delivery. During a follow-up of 24+/-28 months, 24 patients (89%) had no recurrence of ventricular fibrillation without drug. Primary idiopathic ventricular fibrillation is a syndrome characterized by dominant triggers from the distal Purkinje system. These sources can be eliminated by focal energy delivery.
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            The V(2) transition ratio: a new electrocardiographic criterion for distinguishing left from right ventricular outflow tract tachycardia origin.

            David Lin, J. Park, Fernanda Garcia … (2011)
            We sought to develop electrocardiography (ECG) criteria for distinguishing left ventricular outflow tract (LVOT) from right ventricular outflow tract (RVOT) origin in patients with idiopathic outflow tract ventricular tachycardia (OTVT) and lead V(3) R/S transition. Several ECG criteria have been proposed for differentiating left from right OTVT origin; ventricular tachycardias (VTs) with left bundle branch block and V(3) transition remain a challenge. We analyzed the surface ECG pattern of patients with OTVT with a precordial transition in lead V(3) who underwent successful catheter ablation. Sinus and VT QRS morphologies were measured in limb and precordial leads with electronic calipers. The V(2) and V(3) transition ratios were calculated by computing the percentage R-wave during VT (R/R+S)(VT) divided by the percentage R-wave in sinus rhythm (R/R+S)(SR). We retrospectively analyzed ECGs from 40 patients (mean age 44 ± 14 years, 21 female) with outflow tract premature ventricular contractions (PVCs)/VT. Patients with structural heart disease, paced rhythms, and bundle branch block during sinus rhythm were excluded. The V(2) transition ratio was significantly greater for LVOT PVCs compared with RVOT PVCs (1.27 ± 0.60 vs. 0.23 ± 0.16; p < 0.001) and was the only independent predictor of LVOT origin. In 21 prospective cases, a V(2) transition ratio ≥0.60 predicted an LVOT origin with 91% accuracy. A PVC precordial transition occurring later than the sinus rhythm transition excluded an LVOT origin with 100% accuracy. The V(2) transition ratio is a novel electrocardiographic measure that reliably distinguishes LVOT from RVOT origin in patients with lead V(3) precordial transition. This measure might be useful for counseling patients and planning an ablation strategy. Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.
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              Idiopathic ventricular arrhythmias originating from the moderator band: Electrocardiographic characteristics and treatment by catheter ablation.

              Mouhannad Sadek, Daniel Benhayon, Ravi Sureddi … (2015)
              The moderator band (MB) can be a source of premature ventricular contractions (PVCs), monomorphic ventricular tachycardia (VT), and idiopathic ventricular fibrillation (IVF).
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                Author and article information

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                Stylianos Tzeis: (View ORCID Profile)
                Journal
                Title: Heart
                Abbreviated Title: Heart
                Publisher: BMJ
                ISSN (Print): 1355-6037
                ISSN (Electronic): 1468-201X
                Publication date Created: June 26 2019
                Publication date Created: July 2019
                Publication date (Print): July 2019
                Publication date (Electronic): May 15 2019
                Volume: 105
                Issue: 14
                Pages: 1109-1116
                Article
                DOI: 10.1136/heartjnl-2019-314748
                SO-VID: 2816fd2d-47f6-459a-8560-737a473a4c14
                Copyright © © 2019
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