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Zhang W, Huang K, Qu J, Su G, Li X, Kong Q, Jiang H. A novel ECG algorithm to differentiate between ventricular arrhythmia from right versus left ventricular outflow tract. J Cardiovasc Med (Hagerstown) 2023; 24:853-863. [PMID: 37724483 DOI: 10.2459/jcm.0000000000001559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
AIM The aim of this study was to evaluate the accuracy of the diagnostic criteria for determining the origin of outflow tract ventricular arrhythmia (OTVA) and develop an ECG algorithm to predict its origin. METHOD We analyzed the ECGs of 100 patients with OTVA who underwent successful ablation. The QRS complex was measured during sinus rhythm and ventricular arrhythmia. After the ECG algorithm was developed, it was validated in an additional 100 patients from two different hospitals. RESULTS In this retrospective study, among the parameters without restrictions in the transition lead, the V2S/V3R index (AUC = 0.96) was significantly better in predicting ventricular arrhythmia originating from the right ventricular outflow tract (RVOT). Further, the larger initial r wave surface area (ISA) in V1 and V2 (AUC = 0.06) was significantly better in predicting ventricular arrhythmias originating from the left ventricular outflow tract (LVOT). Among the parameters with the transition lead in V3, the V2S/V3R index (AUC = 0.82) was significantly better in predicting VAs originating from the RVOT. On the contrary, the V3 R-wave deflection interval (AUC = 0.19) was significantly better in predicting ventricular arrhythmias originating from the LVOT. The algorithm combining the V2S/V3R index and the larger ISA in V1 and V2 could predict OTVA origin with an accuracy of 95.00%, a sensitivity of 87.18%, a specificity of 100.00%, a positive predictive value (PPV) of 100.00%, and a negative predictive value (NPV) of 92.42%. In the validation study, the algorithm exhibited excellent accuracy (95.00%) and AUC (AUC = 0.95), with a sensitivity of 94.12%, a specificity of 95.45%, a PPV of 91.43%, and an NPV of 96.92%. CONCLUSION Our developed algorithm can reliably predict OTVA origin without restrictions in the transition lead.
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Affiliation(s)
- Wei Zhang
- Department of Cardiology, Chest Hospital, Tianjin University
- Tianjin Key Laboratory of Cardiovascular Emergency and Critical Care, Tianjin Municipal Science and Technology Bureau, Tianjin
| | - Kui Huang
- Department of Cardiology, Chest Hospital, Tianjin University
- Tianjin Key Laboratory of Cardiovascular Emergency and Critical Care, Tianjin Municipal Science and Technology Bureau, Tianjin
| | - Jun Qu
- Department of Cardiology, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai
| | - Guoying Su
- Department of Cardiology, Central Hospital Affiliated to Shandong First Medical University (Previous Name: Jinan Central Hospital Affiliated to Shandong University), Jinan, Shangdong, China
| | - Xinyun Li
- Department of Cardiology, Central Hospital Affiliated to Shandong First Medical University (Previous Name: Jinan Central Hospital Affiliated to Shandong University), Jinan, Shangdong, China
| | - Qingzan Kong
- Department of Cardiology, Central Hospital Affiliated to Shandong First Medical University (Previous Name: Jinan Central Hospital Affiliated to Shandong University), Jinan, Shangdong, China
| | - Hua Jiang
- Department of Cardiology, Chest Hospital, Tianjin University
- Tianjin Key Laboratory of Cardiovascular Emergency and Critical Care, Tianjin Municipal Science and Technology Bureau, Tianjin
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Romero J, Gamero M, Alviz I, Grushko M, Diaz JC, Lorente M, Gabr M, Toquica CC, Krishnan S, Velasco A, Lin A, Natale A, Zou F, Di Biase L. Catheter Ablation of Left Ventricular Summit Arrhythmias from Adjacent Anatomic Vantage Points. Card Electrophysiol Clin 2023; 15:31-37. [PMID: 36774134 DOI: 10.1016/j.ccep.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Idiopathic ventricular arrhythmias (VA), particularly left ventricular outflow tract (LVOT) VA accounts for up to 10% of all VAs referred for ablative therapy. In addition to being infrequent, its intricate anatomy and its pathophysiology make catheter ablation (CA) of these arrhythmias a challenge even for experts. In this scenario, detailed right ventricular outflow tract as well as LVOT electroanatomic mapping including epicardial mapping are essential. In this article, we will emphasize our approach toward the CA technique used for LVOT VA, particularly IVS and/or LVS VA originating from intramural foci, along with its acute and long-term efficacy and safety.
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Affiliation(s)
- Jorge Romero
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Maria Gamero
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Isabella Alviz
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Michael Grushko
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Juan Carlos Diaz
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Marta Lorente
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mohamed Gabr
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Suraj Krishnan
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Alejandro Velasco
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Aung Lin
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Fengwei Zou
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
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3
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Shimojo M, Inden Y, Yanagisawa S, Suzuki N, Tsurumi N, Watanabe R, Nakagomi T, Okajima T, Suga K, Tsuji Y, Murohara T. A novel practical algorithm using machine learning to differentiate outflow tract ventricular arrhythmia origins. J Cardiovasc Electrophysiol 2023; 34:627-637. [PMID: 36651347 DOI: 10.1111/jce.15823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/04/2023] [Accepted: 01/10/2023] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Diagnosis of outflow tract ventricular arrhythmia (OTVA) localization by an electrocardiographic complex is key to successful catheter ablation for OTVA. However, diagnosing the origin of OTVA with a precordial transition in lead V3 (V3TZ) is challenging. This study aimed to create the best practical electrocardiogram algorithm to differentiate the left ventricular outflow tract (LVOT) from the right ventricular outflow tract (RVOT) of OTVA origin with V3TZ using machine learning. METHODS Of 498 consecutive patients undergoing catheter ablation for OTVA, we included 104 patients who underwent ablation for OTVA with V3TZ and identified the origin of LVOT (n = 62) and RVOT (n = 42) from the results. We analyzed the standard 12-lead electrocardiogram preoperatively and measured 128 elements in each case. The study population was randomly divided into training group (70%) and testing group (30%), and decision tree analysis was performed using the measured elements as features. The performance of the algorithm created in the training group was verified in the testing group. RESULTS Four measurements were identified as important features: the aVF/II R-wave ratio, the V2S/V3R index, the QRS amplitude in lead V3, and the R-wave deflection slope in lead V3. Among them, the aVF/II R-wave ratio and the V2S/V3R index had a particularly strong influence on the algorithm. The performance of this algorithm was extremely high, with an accuracy of 94.4%, precision of 91.5%, recall of 100%, and an F1-score of 0.96. CONCLUSIONS The novel algorithm created using machine learning is useful in diagnosing the origin of OTVA with V3TZ.
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Affiliation(s)
- Masafumi Shimojo
- Department of Cardiovascular Research and Innovation, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Satoshi Yanagisawa
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Noriyuki Suzuki
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Naoki Tsurumi
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Ryo Watanabe
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Toshifumi Nakagomi
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Takashi Okajima
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Kazumasa Suga
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yukiomi Tsuji
- Department of Cardiovascular Research and Innovation, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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4
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Zhu X, Chen S, Ma K, Chen Z, Chen C, Jiang Z. AInterventricular septum angle obtained from cardiac computed tomography for origin differentiation of outflow tract ventricular arrhythmia between left and right. Pacing Clin Electrophysiol 2022; 45:1279-1287. [DOI: 10.1111/pace.14593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Xiaomei Zhu
- Department of Radiology the First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital) Nanjing China
| | - Shumin Chen
- Department of Cardiology the First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital) Nanjing China
| | - Kefan Ma
- Department of Radiology the First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital) Nanjing China
| | - Zenghong Chen
- Department of Cardiology the First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital) Nanjing China
| | - Chun Chen
- Department of Cardiology the First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital) Nanjing China
| | - Zhixin Jiang
- Department of Cardiology the First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital) Nanjing China
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5
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Gabriels JK, Abdelrahman M, Nambiar L, Kim J, Ip JE, Thomas G, Liu CF, Markowitz SM, Lerman BB, Cheung JW. Reappraisal of electrocardiographic criteria for localization of idiopathic outflow region ventricular arrhythmias. Heart Rhythm 2021; 18:1959-1965. [PMID: 34375724 DOI: 10.1016/j.hrthm.2021.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/20/2021] [Accepted: 08/01/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Electrocardiographic (ECG) criteria have been proposed to localize the site of origin of outflow region ventricular arrhythmias (VAs). Many factors influence the QRS morphology of VAs and may limit the accuracy of these criteria. OBJECTIVE The purpose of this study was to assess the accuracy of ECG criteria that differentiate right from left outflow region VAs and localize VAs within the aortic sinus of Valsalva (ASV). METHODS One hundred one patients (mean age 52 ± 16 years; 55 [54%] women) undergoing catheter ablation of right ventricular outflow tract (RVOT) or ASV VAs with a left bundle branch block, inferior axis morphology were studied. ECG measurements including V2 transition ratio, transition zone index, R-wave duration index, R/S amplitude index, V2S/V3R index, V1-3 QRS morphology, R-wave amplitude in the inferior leads were tabulated for all VAs. Comparisons were made between the predicted site of origin using these criteria and the successful ablation site. RESULTS Patients had successful ablation of 71 RVOT and 38 ASV VAs. For the differentiation of RVOT from ASV VAs, the positive predictive values and negative predictive values for all tested ECG criteria ranged from 42% to 75% and from 71% to 82%, respectively, with the V2S/V3R index having the largest area under the curve of 0.852. Morphological QRS criteria in leads V1 through V3 did not localize ASV VAs. The maximum R-wave amplitude in the inferior leads was the sole criterion demonstrating a significant difference between right ASV, right-left ASV commissure, and left ASV sites. CONCLUSION ECG criteria for differentiating right from left ventricular outflow region VAs and for localizing ASV VAs have a limited accuracy.
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Affiliation(s)
- James K Gabriels
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - Mohamed Abdelrahman
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - Lakshmi Nambiar
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - Jiwon Kim
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - James E Ip
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - George Thomas
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - Christopher F Liu
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - Steven M Markowitz
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - Bruce B Lerman
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - Jim W Cheung
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York.
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Mariani MV, Piro A, Della Rocca DG, Forleo GB, Pothineni NV, Romero J, Di Biase L, Fedele F, Lavalle C. Electrocardiographic Criteria for Differentiating Left from Right Idiopathic Outflow Tract Ventricular Arrhythmias. Arrhythm Electrophysiol Rev 2021; 10:10-16. [PMID: 33936738 PMCID: PMC8076969 DOI: 10.15420/aer.2020.10] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Idiopathic ventricular arrhythmias are ventricular tachycardias or premature ventricular contractions presumably not related to myocardial scar or disorders of ion channels. Of the ventricular arrhythmias (VAs) without underlying structural heart disease, those arising from the ventricular outflow tracts (OTs) are the most common. The right ventricular outflow tract (RVOT) is the most common site of origin for OT-VAs, but these arrhythmias can, less frequently, originate from the left ventricular outflow tract (LVOT). OT-VAs are focal and have characteristic ECG features based on their anatomical origin. Radiofrequency catheter ablation (RFCA) is an effective and safe treatment strategy for OT-VAs. Prediction of the OT-VA origin according to ECG features is an essential part of the preprocedural planning for RFCA procedures. Several ECG criteria have been proposed for differentiating OT site of origin. Unfortunately, the ECG features of RVOT-VAs and LVOT-VAs are similar and could possibly lead to misdiagnosis. The authors review the ECG criteria used in clinical practice to differentiate RVOT-VAs from LVOT-VAs.
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Affiliation(s)
- Marco V Mariani
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Italy
| | - Agostino Piro
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Italy
| | | | | | | | - Jorge Romero
- Department of Cardiology, Montefiore Medical Center, New York, NY, US
| | - Luigi Di Biase
- Department of Cardiology, Montefiore Medical Center, New York, NY, US
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Italy
| | - Carlo Lavalle
- Department of Cardiovascular, Respiratory, Nephrology, Anaesthesiology and Geriatric Sciences, Sapienza University of Rome, Italy
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7
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Zheng J, Fu G, Abudayyeh I, Yacoub M, Chang A, Feaster WW, Ehwerhemuepha L, El-Askary H, Du X, He B, Feng M, Yu Y, Wang B, Liu J, Yao H, Chu H, Rakovski C. A High-Precision Machine Learning Algorithm to Classify Left and Right Outflow Tract Ventricular Tachycardia. Front Physiol 2021; 12:641066. [PMID: 33716788 PMCID: PMC7947246 DOI: 10.3389/fphys.2021.641066] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 01/18/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction Multiple algorithms based on 12-lead ECG measurements have been proposed to identify the right ventricular outflow tract (RVOT) and left ventricular outflow tract (LVOT) locations from which ventricular tachycardia (VT) and frequent premature ventricular complex (PVC) originate. However, a clinical-grade machine learning algorithm that automatically analyzes characteristics of 12-lead ECGs and predicts RVOT or LVOT origins of VT and PVC is not currently available. The effective ablation sites of RVOT and LVOT, confirmed by a successful ablation procedure, provide evidence to create RVOT and LVOT labels for the machine learning model. Methods We randomly sampled training, validation, and testing data sets from 420 patients who underwent successful catheter ablation (CA) to treat VT or PVC, containing 340 (81%), 38 (9%), and 42 (10%) patients, respectively. We iteratively trained a machine learning algorithm supplied with 1,600,800 features extracted via our proprietary algorithm from 12-lead ECGs of the patients in the training cohort. The area under the curve (AUC) of the receiver operating characteristic curve was calculated from the internal validation data set to choose an optimal discretization cutoff threshold. Results The proposed approach attained the following performance: accuracy (ACC) of 97.62 (87.44–99.99), weighted F1-score of 98.46 (90–100), AUC of 98.99 (96.89–100), sensitivity (SE) of 96.97 (82.54–99.89), and specificity (SP) of 100 (62.97–100). Conclusions The proposed multistage diagnostic scheme attained clinical-grade precision of prediction for LVOT and RVOT locations of VT origin with fewer applicability restrictions than prior studies.
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Affiliation(s)
- Jianwei Zheng
- Computational and Data Science, Chapman University, Orange, CA, United States
| | - Guohua Fu
- Department of Cardiology, Ningbo First Hospital of Zhejiang University, Hangzhou, China
| | - Islam Abudayyeh
- Department of Cardiology, Loma Linda University, Loma Linda, CA, United States
| | - Magdi Yacoub
- Harefield Heart Science Center, Imperial College London, London, United Kingdom
| | | | | | | | - Hesham El-Askary
- Computational and Data Science, Chapman University, Orange, CA, United States.,Department of Environmental Sciences, Faculty of Science, Alexandria University, Alexandria, Egypt
| | - Xianfeng Du
- Department of Cardiology, Ningbo First Hospital of Zhejiang University, Hangzhou, China
| | - Bin He
- Department of Cardiology, Ningbo First Hospital of Zhejiang University, Hangzhou, China
| | - Mingjun Feng
- Department of Cardiology, Ningbo First Hospital of Zhejiang University, Hangzhou, China
| | - Yibo Yu
- Department of Cardiology, Ningbo First Hospital of Zhejiang University, Hangzhou, China
| | - Binhao Wang
- Department of Cardiology, Ningbo First Hospital of Zhejiang University, Hangzhou, China
| | - Jing Liu
- Department of Cardiology, Ningbo First Hospital of Zhejiang University, Hangzhou, China
| | - Hai Yao
- Zhejiang Cachet Jetboom Medical Devices Co., Ltd., Hangzhou, China
| | - Huimin Chu
- Department of Cardiology, Ningbo First Hospital of Zhejiang University, Hangzhou, China
| | - Cyril Rakovski
- Computational and Data Science, Chapman University, Orange, CA, United States
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8
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Zheng J, Fu G, Abudayyeh I, Yacoub M, Chang A, Feaster WW, Ehwerhemuepha L, El-Askary H, Du X, He B, Feng M, Yu Y, Wang B, Liu J, Yao H, Chu H, Rakovski C. A High-Precision Machine Learning Algorithm to Classify Left and Right Outflow Tract Ventricular Tachycardia. Front Physiol 2021. [PMID: 33716788 DOI: 10.6084/m9.figshare.c.4668086.v2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Introduction Multiple algorithms based on 12-lead ECG measurements have been proposed to identify the right ventricular outflow tract (RVOT) and left ventricular outflow tract (LVOT) locations from which ventricular tachycardia (VT) and frequent premature ventricular complex (PVC) originate. However, a clinical-grade machine learning algorithm that automatically analyzes characteristics of 12-lead ECGs and predicts RVOT or LVOT origins of VT and PVC is not currently available. The effective ablation sites of RVOT and LVOT, confirmed by a successful ablation procedure, provide evidence to create RVOT and LVOT labels for the machine learning model. Methods We randomly sampled training, validation, and testing data sets from 420 patients who underwent successful catheter ablation (CA) to treat VT or PVC, containing 340 (81%), 38 (9%), and 42 (10%) patients, respectively. We iteratively trained a machine learning algorithm supplied with 1,600,800 features extracted via our proprietary algorithm from 12-lead ECGs of the patients in the training cohort. The area under the curve (AUC) of the receiver operating characteristic curve was calculated from the internal validation data set to choose an optimal discretization cutoff threshold. Results The proposed approach attained the following performance: accuracy (ACC) of 97.62 (87.44-99.99), weighted F1-score of 98.46 (90-100), AUC of 98.99 (96.89-100), sensitivity (SE) of 96.97 (82.54-99.89), and specificity (SP) of 100 (62.97-100). Conclusions The proposed multistage diagnostic scheme attained clinical-grade precision of prediction for LVOT and RVOT locations of VT origin with fewer applicability restrictions than prior studies.
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Affiliation(s)
- Jianwei Zheng
- Computational and Data Science, Chapman University, Orange, CA, United States
| | - Guohua Fu
- Department of Cardiology, Ningbo First Hospital of Zhejiang University, Hangzhou, China
| | - Islam Abudayyeh
- Department of Cardiology, Loma Linda University, Loma Linda, CA, United States
| | - Magdi Yacoub
- Harefield Heart Science Center, Imperial College London, London, United Kingdom
| | | | | | | | - Hesham El-Askary
- Computational and Data Science, Chapman University, Orange, CA, United States.,Department of Environmental Sciences, Faculty of Science, Alexandria University, Alexandria, Egypt
| | - Xianfeng Du
- Department of Cardiology, Ningbo First Hospital of Zhejiang University, Hangzhou, China
| | - Bin He
- Department of Cardiology, Ningbo First Hospital of Zhejiang University, Hangzhou, China
| | - Mingjun Feng
- Department of Cardiology, Ningbo First Hospital of Zhejiang University, Hangzhou, China
| | - Yibo Yu
- Department of Cardiology, Ningbo First Hospital of Zhejiang University, Hangzhou, China
| | - Binhao Wang
- Department of Cardiology, Ningbo First Hospital of Zhejiang University, Hangzhou, China
| | - Jing Liu
- Department of Cardiology, Ningbo First Hospital of Zhejiang University, Hangzhou, China
| | - Hai Yao
- Zhejiang Cachet Jetboom Medical Devices Co., Ltd., Hangzhou, China
| | - Huimin Chu
- Department of Cardiology, Ningbo First Hospital of Zhejiang University, Hangzhou, China
| | - Cyril Rakovski
- Computational and Data Science, Chapman University, Orange, CA, United States
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9
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Wang J, Miao C, Yang G, Xu L, Xing R, Jia Y, Zhang R, Wang Y, Huang L, Liu S. Lead I R-wave amplitude to distinguish ventricular arrhythmias with lead V 3 transition originating from the left versus right ventricular outflow tract. Clin Cardiol 2020; 44:100-107. [PMID: 33300652 PMCID: PMC7803356 DOI: 10.1002/clc.23511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/02/2020] [Accepted: 11/02/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The electrophysiology algorithm for localizing left or right origins of outflow tract ventricular arrhythmias (OT-VAs) with lead V3 transition still needs further investigation in clinical practice. HYPOTHESIS Lead I R-wave amplitude is effective in distinguishing the left or right origin of OT-VAs with lead V3 transition. METHODS We measured lead I R-wave amplitude in 82 OT-VA patients with lead V3 transition and a positive complex in lead I who underwent successful catheter ablation from the right ventricular outflow tract (RVOT) and left ventricular outflow tract (LVOT). The optimal R-wave threshold was identified, compared with the V2 S/V3 R index, transitional zone (TZ) index, and V2 transition ratio, and validated in a prospective cohort study. RESULTS Lead I R-wave amplitude for LVOT origins was significantly higher than that for RVOT origins (0.55 ± 0.13 vs. 0.32 ± 0.15 mV; p < .001). The area under the curve (AUC) for lead I R-wave amplitude as assessed by receiver operating characteristic (ROC) analysis was 0.926, with a cutoff value of ≥0.45 predicting LVOT origin with 92.9% sensitivity and 88.2% specificity, superior to the V2 S/V3 R index, TZ index, and V2 transition ratio. VAs in the LVOT group mainly originated from the right coronary cusp (RCC) and left and right coronary cusp junction (L-RCC). In the prospective study, lead I R-wave amplitude identified the LVOT origin with 92.3% accuracy. CONCLUSION Lead I R-wave amplitude provides a useful and simple criterion to identify RCC or L-RCC origin in OT-VAs with lead V3 transition.
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Affiliation(s)
- Jue Wang
- Department of Cardiology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chenglong Miao
- Department of Cardiology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Guangmin Yang
- Department of Joint Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lu Xu
- Department of Cardiology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ru Xing
- Department of Cardiology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yan Jia
- Department of Cardiology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ruining Zhang
- Department of Cardiology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yanwei Wang
- Department of Cardiology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Liu Huang
- Department of Cardiology, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Suyun Liu
- Department of Cardiology, Second Hospital of Hebei Medical University, Shijiazhuang, China
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10
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Sáenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Europace 2020; 21:1143-1144. [PMID: 31075787 DOI: 10.1093/europace/euz132] [Citation(s) in RCA: 219] [Impact Index Per Article: 54.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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Bradfield JS. Redefining Optimal Targets for Intramural Ventricular Arrhythmias. JACC Clin Electrophysiol 2020; 6:1349-1352. [DOI: 10.1016/j.jacep.2020.06.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 06/26/2020] [Indexed: 10/23/2022]
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12
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Bella PD, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. J Interv Card Electrophysiol 2020; 59:145-298. [PMID: 31984466 PMCID: PMC7223859 DOI: 10.1007/s10840-019-00663-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, IN, USA
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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Choe WS, Lee SR, Cha MJ, Choi EK, Oh S. Differentiation of the right versus left outflow tract ventricular arrhythmias using local activation time at the His bundle electrogram. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2020. [DOI: 10.1186/s42444-020-00023-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Although multiple algorithms based on surface electrocardiographic criteria have been introduced to localize idiopathic ventricular arrhythmia (VA) origins from the outflow tract (OT), their diagnostic accuracy and clinical usefulness remain limited. We evaluated whether local activation time of the His bundle region could differentiate left and right ventricular OT VA origins in the early stage of electrophysiology study.
Methods
We studied 30 patients who underwent catheter ablation for OT VAs with a left bundle branch block pattern and inferior axis QRS morphology. The interval between the local V signal on the mapping catheter placed in the RVOT and His bundle region (V(RVOT)-V(HB) interval) and the interval from QRS complex onset to the local V signal on the His bundle region (QRS-V(HB) interval) were measured during VAs.
Results
The V(RVOT)-V(HB) and QRS-V(HB) intervals were significantly shorter in patients with LVOT VAs. The area under the curve (AUC) for the V(RVOT)-V(HB) interval by receiver operating characteristic analysis was 0.865. A cutoff value of ≤ 50 ms predicted an LVOT origin of VA with sensitivity, specificity, and positive and negative predictive values of 100%, 62.5%, 40%, and 100%, respectively. The QRS-V(HB) interval showed similar diagnostic accuracy (AUC, 0.840), and a cutoff value of ≤ 15 ms predicted an LVOT origin of VA with a sensitivity, specificity, and positive and negative predictive values of 100%, 70.8%, 45.2%, and 100%, respectively.
Conclusion
The V(RVOT)-V(HB) and QRS-V(HB) intervals could differentiate left from right OT origins of VA with high sensitivity and negative predictive values.
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Liao H, Wei W, Tanager KS, Miele F, Upadhyay GA, Beaser AD, Aziz Z, Nayak HM, Ozcan C, Nishimura T, Jiang R, Shatz D, Husain AN, Tung R. Left ventricular summit arrhythmias with an abrupt V 3 transition: Anatomy of the aortic interleaflet triangle vantage point. Heart Rhythm 2020; 18:10-19. [PMID: 32707175 DOI: 10.1016/j.hrthm.2020.07.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/15/2020] [Accepted: 07/16/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND While early precordial electrocardiographic (ECG) characteristics are useful to differentiate left-sided from the right-sided outflow tract ventricular arrhythmia (OTVA), few patterns predict an origin from the septal margin of the left ventricular (LV) summit. OBJECTIVE The purpose of this study was to report mapping and ablation characteristics of a new ECG pattern with left bundle branch morphology and an abrupt R-wave transition in lead V3 (ATV3). METHODS Over a 3-year period, 78 consecutive patients (mean age 57±15 years; 35% female) with OTVA were referred for mapping and ablation. Twenty patients (26%) exhibited an ATV3 pattern, of whom 65% failed prior ablation. RESULTS Ninety-two percent of patients with ATV3 that underwent simultaneous epicardial and endocardial mapping demonstrated an intramural or epicardial site of origin. Eighty percent of OTVA with ATV3 was eliminated by ablation from the vantage point of the interleaflet triangle below the right-left coronary junction. The ATV3 pattern showed higher sensitivity, specificity, predictive value, and accuracy than validated ECG criteria (notch or "w" pattern in lead V1, qrS pattern in leads V1 through V3, and pattern break V2) for predicting successful ablation in the region of the anterior LV ostium. At 12±11 months, freedom from ventricular arrhythmia recurrence was 89% and 82% in the ATV3 and control groups, respectively. CONCLUSION ATV3 is a simple and distinct ECG pattern indicative of a site of origin from the septal margin of the LV summit. The right-left aortic interleaflet triangle vantage point was effective to eliminate OTVA with ATV3 that overwhelmingly exhibited the earliest activation from the epicardium or mid-myocardium. Test characteristics for ATV3 were superior to ECG patterns validated for the anterior LV ostium.
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Affiliation(s)
- Hongtao Liao
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Academy of Medical Sciences, Guangzhou, P.R. China; Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Wei Wei
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Academy of Medical Sciences, Guangzhou, P.R. China
| | - Kevin S Tanager
- Department of Pathology, Department of Medicine, Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Frank Miele
- Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Gaurav A Upadhyay
- Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Andrew D Beaser
- Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Zaid Aziz
- Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Hemal M Nayak
- Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Cevher Ozcan
- Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Takuro Nishimura
- Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Ruhong Jiang
- Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Dalise Shatz
- Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Aliya N Husain
- Department of Pathology, Department of Medicine, Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Roderick Tung
- Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Academy of Medical Sciences, Guangzhou, P.R. China; Section of Cardiology, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois.
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15
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Rangaswamy VV, Yalagudri S, Saggu DK, Subramanian M, Sridevi C, Narasimhan C. Clinical and electrophysiological characteristics of ventricular arrhythmias arising from pulmonary cusps. J Arrhythm 2020; 36:471-477. [PMID: 32528574 PMCID: PMC7280010 DOI: 10.1002/joa3.12347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/04/2020] [Accepted: 03/10/2020] [Indexed: 11/09/2022] Open
Abstract
Introduction Ventricular arrhythmias (VAs) have been successfully ablated from the pulmonary sinus cusps establishing pulmonary artery (PA) as a distinct site of arrhythmic foci. The aim of the present study was to determine the clinical presentation, electrocardiographic, and ablation characteristics of PA‐VAs. Methods Thirty consecutive patients with right ventricular outflow tract (RVOT)‐type VAs were included in this retrospective study. Three‐dimensional electroanatomic mapping was performed in all patients. Mapping was performed initially in RVOT, and later within the PA. Mapping was performed in the PA if there was no early activation, unsatisfactory pace‐map, or ablation in RVOT were unsuccessful. All PA‐VAs were mapped and ablated by looping the catheter in a reverse U fashion. Results Among 30 patients, 8 (26.6%) patients VAs were successfully ablated within PA. Electrocardiography (ECG) revealed that the QRS duration was significantly wider in the PA‐VAs group compared to the RVOT‐VAs group (155 ± 14.14 vs 142.40 ± 8.12 ms, P < .01). Mapping by reversed U method of PA‐VAs revealed earlier activation (55 ± 9.66 vs 12.00 ± 8.61 ms, P < .01) in PA compared to RVOT. An isolated discrete prepotential was present at the successful site in 50% (n = 4). Conclusion Pulmonary artery‐VAs are an important subset of VA originating from the outflow tract. They have a wider baseline QRS duration compared to RVOT‐VAs. Presence of a prepotential aids in the identification of a successful ablation site. Mapping utilizing the reversed U method can help in localization and successful ablation of PA‐VAs.
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Arani A, Fazelifar AF, Amanpour B, Heidarali M. Importance of great cardiac vein signal in the differentiation of premature ventricular contraction origins in right and left ventricular outflow tracts. Res Cardiovasc Med 2020. [DOI: 10.4103/rcm.rcm_23_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Electrocardiographic features, mapping and ablation of idiopathic outflow tract ventricular arrhythmias. J Interv Card Electrophysiol 2019; 57:207-218. [PMID: 31650457 DOI: 10.1007/s10840-019-00617-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 08/27/2019] [Indexed: 01/01/2023]
Abstract
PURPOSE Idiopathic outflow tract ventricular arrhythmias are ventricular tachycardias or premature ventricular contractions presumably not related to myocardial scar or disorders of ion channels. These arrhythmias have focal origin and display characteristic electrocardiographic features. The purpose of this article is to review the state of the art of diagnosis and treatment of idiopathic outflow tract ventricular arrhythmias. METHODS We systematically reviewed scientific literature about idiopathic outflow tract ventricular arrhythmias selecting the most relevant papers on this topic. RESULTS The right ventricle outflow tract is the most common site of origin for outflow tract ventricular arrhythmias, but also left ventricle outflow tract can harbour these arrhythmias. Outflow tract ventricular arrhythmias are generally benign and may require treatment if they are symptomatic, incessant or give rise to cardiomyopathy. Radiofrequency catheter ablation is an effective and safe therapeutic strategy. A successful procedure requires a thorough preoperative analysis of the 12-lead electrocardiogram of the spontaneous arrhythmia combined with a detailed electroanatomical mapping and intracardiac echocardiography. CONCLUSIONS Idiopathic outflow tract arrhythmias are frequent in daily clinical practice and can be successfully eliminated through discrete radiofrequency catheter ablation with low rates of complications.
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Cheng D, Ju W, Zhu L, Chen K, Zhang F, Chen H, Yang G, Li X, Li M, Gu K, Han B, Fan J, Lin Y, Cao K, Kojodjojo P, Yang B, Chen M. V 3R/V 7 Index: A Novel Electrocardiographic Criterion for Differentiating Left From Right Ventricular Outflow Tract Arrhythmias Origins. Circ Arrhythm Electrophysiol 2019; 11:e006243. [PMID: 30571180 DOI: 10.1161/circep.118.006243] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Several algorithms have been proposed to predict the origin of outflow tract (OT) ventricular arrhythmias (VAs) using standard 12-lead ECG. However, the additive value of right precordial and posterior leads is unknown. METHODS Standard 12-lead ECG, right precordial leads ECG (V3R, V4R, V5R) and posterior leads ECG (V7, V8, V9) were recorded and analyzed in a development cohort of consecutive patients undergoing OT-VAs ablation at a single center. These findings informed the development of a novel algorithm incorporating right precordial and posterior leads to discriminate between left ventricular OT (LVOT) and right ventricular OT (RVOT) foci. The performance of this novel algorithm which includes the V3R/V7 index was prospectively tested in a validation cohort of consecutive patients undergoing OT-VA ablation at 4 centers and compared with published algorithms. The location of the foci was determined by the successful ablation site. RESULTS One hundred ninety-one patients were recruited, of which 94 formed the validation cohort (mean age of 45.7±15.6, 39% male, 79% RVOT foci). During OT-VAs, a QS pattern in lead V3R and an S wave in lead V7 were exclusively recorded in RVOT and LVOT foci, respectively. The V3R/V7 index of LVOT origin was significantly greater than that of RVOT (1.05±0.83 versus 0.28±0.23, P<0.001). The V3R/V7 index ≥0.85 predicted an LVOT origin with 87% sensitivity and 96% specificity. In the prospective evaluation, when the V3R/V7 index ≥0.85, an RVOT origin could be excluded with 98.6% accuracy. The area under the curve of V3R/V7 index (0.954) was larger than that of previously reported ECG criteria, including V2S/V3R (0.896), V2 transition ratio (0.792), and transition zone index (0.666). This novel index was also accurate in both patients without obvious LVOT or RVOT origins and subgroups with cardiac rotation or lead V3 R/S transition. CONCLUSIONS The V3R/V7 index is a novel and accurate ECG criterion that predicts OT-VAs origin.
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Affiliation(s)
- Dian Cheng
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, China (D.C., W.J., L.Z., K.C., F.Z., H.C., G.Y., X.L., M.L., K.G., K.C., B.Y., M.C.)
| | - Weizhu Ju
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, China (D.C., W.J., L.Z., K.C., F.Z., H.C., G.Y., X.L., M.L., K.G., K.C., B.Y., M.C.)
| | - Lili Zhu
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, China (D.C., W.J., L.Z., K.C., F.Z., H.C., G.Y., X.L., M.L., K.G., K.C., B.Y., M.C.)
| | - Kanghui Chen
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, China (D.C., W.J., L.Z., K.C., F.Z., H.C., G.Y., X.L., M.L., K.G., K.C., B.Y., M.C.)
| | - Fengxiang Zhang
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, China (D.C., W.J., L.Z., K.C., F.Z., H.C., G.Y., X.L., M.L., K.G., K.C., B.Y., M.C.)
| | - Hongwu Chen
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, China (D.C., W.J., L.Z., K.C., F.Z., H.C., G.Y., X.L., M.L., K.G., K.C., B.Y., M.C.)
| | - Gang Yang
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, China (D.C., W.J., L.Z., K.C., F.Z., H.C., G.Y., X.L., M.L., K.G., K.C., B.Y., M.C.)
| | - Xiaorong Li
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, China (D.C., W.J., L.Z., K.C., F.Z., H.C., G.Y., X.L., M.L., K.G., K.C., B.Y., M.C.)
| | - Mingfang Li
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, China (D.C., W.J., L.Z., K.C., F.Z., H.C., G.Y., X.L., M.L., K.G., K.C., B.Y., M.C.)
| | - Kai Gu
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, China (D.C., W.J., L.Z., K.C., F.Z., H.C., G.Y., X.L., M.L., K.G., K.C., B.Y., M.C.)
| | - Bing Han
- Division of Cardiology, Xuzhou Central Hospital, China (B.H.)
| | - Jie Fan
- Division of Cardiology, First People's Hospital of Yunnan Province, Kunming, China (J.F.)
| | - Yazhou Lin
- Division of Cardiology, Fujian Provincial Hospital, China (Y.L.)
| | - Kejiang Cao
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, China (D.C., W.J., L.Z., K.C., F.Z., H.C., G.Y., X.L., M.L., K.G., K.C., B.Y., M.C.)
| | - Pipin Kojodjojo
- Division of Cardiology, National University Hospital, Singapore (P.K.)
| | - Bing Yang
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, China (D.C., W.J., L.Z., K.C., F.Z., H.C., G.Y., X.L., M.L., K.G., K.C., B.Y., M.C.)
| | - Minglong Chen
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, China (D.C., W.J., L.Z., K.C., F.Z., H.C., G.Y., X.L., M.L., K.G., K.C., B.Y., M.C.)
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19
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Di C, Wan Z, Tse G, Letsas KP, Liu T, Efremidis M, Li J, Lin W. The V 1-V 3 transition index as a novel electrocardiographic criterion for differentiating left from right ventricular outflow tract ventricular arrhythmias. J Interv Card Electrophysiol 2019; 56:37-43. [PMID: 31478158 DOI: 10.1007/s10840-019-00612-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 08/12/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The aim of this study was to develop a new electrocardiographic criterion for differentiating the origin of outflow tract ventricular arrhythmias (OT-VAs) with precordial transition in lead V3. METHODS A total of 147 consecutive patients with OT-VAs displaying precordial transition in lead V3 who underwent successful catheter ablation in the right ventricular outflow tract (RVOT) (n = 118) or left ventricular outflow tract (LVOT) (n = 29) were included in this study. The V1-V3 transition index was defined as the sum of S-wave amplitude in lead V1 and V2 during premature ventricular contractions (PVCs) divided by the S-wave amplitude during sinus rhythm (SR), respectively, minus the sum of R-wave amplitude in lead V1, V2, and V3 during PVCs divided by the R-wave amplitude during SR, respectively, i.e., [(SPVC/SSR)V1 + (SPVC/SSR)V2] - [(RPVC/RSR) V1 + (RPVC/RSR)V2 + (RPVC/RSR)V3]. RESULTS The V1-V3 transition index was significantly higher for RVOT origins than for LVOT origins (1.25 ± 2.48 vs. - 3.94 ± 3.11; P < 0.001). Receiver operating characteristic (ROC) analysis revealed an area under the curve (AUC) of 0.931 for the V1-V3 transition index, and a cutoff value of > - 1.60 predicted a RVOT origin with a 93% sensitivity and 86% specificity. With respect to AUC and accuracy, the V1-V3 transition index was superior to any previously proposed ECG indices for differentiating left from right OT-VAs. In 37 prospective cases, the new index was able to predict the site of a RVOT origin with 95% accuracy (35 of 37 cases). CONCLUSIONS The V1-V3 transition index is a useful novel ECG criterion for distinguishing left from right OT-VAs with precordial transition in lead V3.
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Affiliation(s)
- Chengye Di
- First Department of Cardiology, TEDA International Cardiovascular Hospital, Tianjin, People's Republic of China
| | - Zheng Wan
- Cardiovascular Center, Tianjin Medical University General Hospital, Tianjin, People's Republic of China
| | - Gary Tse
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China.,Li Ka Shing Institute of Health Sciences, Chinese University of Hong Kong, Hong Kong, SAR, People's Republic of China
| | - Konstantinos P Letsas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, 10676, Athens, Greece
| | - Tong Liu
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, Tianjin, People's Republic of China
| | - Michael Efremidis
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, 10676, Athens, Greece
| | - Jianming Li
- Department of Cardiovascular Division, Minneapolis Veterans Affairs Medical Center, University of Minnesota, Minneapolis, MN, USA
| | - Wenhua Lin
- First Department of Cardiology, TEDA International Cardiovascular Hospital, Tianjin, People's Republic of China.
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Busch S, Eckardt L, Sommer P, Meyer C, Bonnemeier H, Thomas D, Neuberger HR, Tilz RR, Steven D, von Bary C, Kuniss M, Voss F, Estner HL. [Premature ventricular contractions and tachycardia in a structurally normal heart : Idiopathic PVC and VT]. Herzschrittmacherther Elektrophysiol 2019; 30:212-224. [PMID: 30767064 DOI: 10.1007/s00399-019-0607-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 01/21/2019] [Indexed: 06/09/2023]
Abstract
Premature ventricular contractions (PVC) are a common, often incidental and mostly benign finding. Treatment is indicated in frequent and symptomatic PVC or in cases of worsening of left ventricular function. Idiopathic ventricular tachycardia (VT) is mostly found in patients with a structurally healthy heart. These PVC/VT usually have a focal origin. The most likely mechanism is delayed post-depolarization. Localization of the origin is based on the creation of an activation map with or without combination of pace mapping. Idiopathic PVC/VT are most frequently located on the outflow tracts of the right and left ventricles, including the aortic root. Other typical locations include the annulus of the tricuspid or mitral valve, papillary muscles and Purkinje fibers. Catheter ablation is an alternative to antiarrhythmic medication in symptomatic monomorphic PVC/VT. The success rate is good whereby mapping and ablation can often represent a challenge. This article is the fifth part of a series dedicated to specific advanced training in the field of special rhythmology and invasive electrophysiology. It describes the pathophysiological principles, types and typical findings that can be obtained during an electrophysiological investigation.
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Affiliation(s)
- Sonia Busch
- II. Med. Klinik, Klinik für Kardiologie, Angiologie, Pneumologie, Klinikum Coburg, Ketschendorfer Str. 33, 96450, Coburg, Deutschland.
| | - Lars Eckardt
- Klinik für Kardiologie II - Rhythmologie, Universitätsklinikum Münster, Münster, Deutschland
| | - Philipp Sommer
- Klinik für Elektrophysiologie/Rhythmologie, Herz- und Diabeteszentrum Nordrhein-Westfalen, Bad Oeynhausen, Deutschland
| | - Christian Meyer
- Klinik für Kardiologie mit Schwerpunkt Elektrophysiologie, Universitäres Herzzentrum Hamburg, Hamburg, Deutschland
| | - Hendrik Bonnemeier
- Klinik für Innere Medizin III, Kardiologie, Angiologie, Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel, Deutschland
| | - Dierk Thomas
- Department of Cardiology, Medical University Hospital, Heidelberg, Deutschland
- HCR (Heidelberg Center for Heart Rhythm Disorders), Heidelberg, Deutschland
- partner site Heidelberg/Mannheim, DZHK (German Center for Cardiovascular Research), Heidelberg, Deutschland
| | | | - Roland Richard Tilz
- Medizinische Klinik II (Kardiologie, Angiologie, Intensivmedizin) - Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein (UKSH), Lübeck, Deutschland
| | - Daniel Steven
- Herzzentrum, Abteilung für Elektrophysiologie, Uniklinik Köln, Köln, Deutschland
| | - Christian von Bary
- Medizinische Klinik I, Rotkreuzklinikum München - Akademisches Lehrkrankenhaus der Technischen Universität München, München, Deutschland
| | - Malte Kuniss
- Abteilung für Kardiologie, Kerckhoff-Klinik GmbH, Bad Nauheim, Deutschland
| | - Frederic Voss
- Innere Medizin 3, Krankenhaus der Barmherzigen Brüder Trier, Trier, Deutschland
| | - Heidi L Estner
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Ludwig-Maximilians-Universität München (LMU München), München, Deutschland
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Heart Rhythm 2019; 17:e2-e154. [PMID: 31085023 PMCID: PMC8453449 DOI: 10.1016/j.hrthm.2019.03.002] [Citation(s) in RCA: 179] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Indexed: 01/10/2023]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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22
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Di Biase L, Romero J, Zado ES, Diaz JC, Gianni C, Hranitzki PM, Sanchez JE, Mohanty S, Al-Ahmad A, Mohanty P, Trivedi C, Della Rocca D, Santangeli P, Burkhardt JD, Garcia FC, Marchlinski FE, Natale A. Variant of ventricular outflow tract ventricular arrhythmias requiring ablation from multiple sites: Intramural origin. Heart Rhythm 2019; 16:724-732. [DOI: 10.1016/j.hrthm.2018.11.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Indexed: 10/27/2022]
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23
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Qin F, Zhao Y, Bai F, Ma Y, Sun C, Liu N, Li B, Li Y, Liu C, Liu Q, Zhou S. Coupling interval variability: A new diagnostic method for distinguishing left from right ventricular outflow tract origin in idiopathic outflow tract premature ventricular contractions patients with precordial R/S transition at lead V3. Int J Cardiol 2018; 269:126-132. [DOI: 10.1016/j.ijcard.2018.07.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2018] [Revised: 07/04/2018] [Accepted: 07/06/2018] [Indexed: 11/26/2022]
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Koutbi L, Maille B, Peyrol M, Hourdain J, Salaun E, Deharo JC, Franceschi F. High-density mapping for catheter ablation of premature ventricular complexes originating from left ventricular papillary muscles: A case series. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:1071-1077. [PMID: 29947109 DOI: 10.1111/pace.13417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 04/27/2018] [Accepted: 04/27/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE Ablation of premature ventricular complexes (PVCs) originating from left-sided papillary muscles is challenging. We tested a new approach by performing high-density mapping of PVC. METHODS AND RESULTS We used a 20-pole deflectable spiral catheter during ablation procedures in four consecutive patients. Three presented with mitral valve prolapse, one with dilated cardiomyopathy. PVC burden was 24 ± 13%. The procedures lasted 182 ± 55.4 minutes, including 10 ± 3.2 minutes of radiofrequency. In all patients, mapping evidenced internal primary activation relative to the left ventricle shell (mean distance 21.3 ± 5.1 mm). Endocavitary prematurity was -38.3 ± 4.8 ms. Primary ablation success was achieved for all patients. CONCLUSIONS High-density mapping of the papillary muscles in the left ventricle using a spiral catheter may be feasible. We identified the PVC foci away from the left ventricular shell. This consolidates the assumption for the origin of these ectopic beats at the junction between the chordae tendineae and the papillary muscles.
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Affiliation(s)
- Linda Koutbi
- Department of Cardiology, Assistance Publique - Hôpitaux de Marseille (APHM), Aix-Marseille University, Timone Hospital, France
| | - Baptiste Maille
- Department of Cardiology, Assistance Publique - Hôpitaux de Marseille (APHM), Aix-Marseille University, Timone Hospital, France.,UMR MD2, Aix Marseille University (AMU), Marseille, France
| | - Michael Peyrol
- Department of Cardiology, Assistance Publique - Hôpitaux de Marseille (APHM), Aix-Marseille University, North Hospital, France
| | - Jérôme Hourdain
- Department of Cardiology, Assistance Publique - Hôpitaux de Marseille (APHM), Aix-Marseille University, Timone Hospital, France
| | - Erwan Salaun
- Department of Cardiology, Assistance Publique - Hôpitaux de Marseille (APHM), Aix-Marseille University, Timone Hospital, France
| | - Jean-Claude Deharo
- Department of Cardiology, Assistance Publique - Hôpitaux de Marseille (APHM), Aix-Marseille University, Timone Hospital, France.,UMR MD2, Aix Marseille University (AMU), Marseille, France
| | - Frédéric Franceschi
- Department of Cardiology, Assistance Publique - Hôpitaux de Marseille (APHM), Aix-Marseille University, Timone Hospital, France.,UMR MD2, Aix Marseille University (AMU), Marseille, France
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He Z, Liu M, Yu M, Lu N, Li J, Xu T, Zhu J, O'Gara MC, O'Meara M, Ye H, Tan X. An electrocardiographic diagnostic model for differentiating left from right ventricular outflow tract tachycardia origin. J Cardiovasc Electrophysiol 2018; 29:908-915. [PMID: 29608235 DOI: 10.1111/jce.13493] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 03/12/2018] [Accepted: 03/21/2018] [Indexed: 02/05/2023]
Abstract
INTRODUCTION Although several electrocardiographic (ECG) algorithms have been proposed for differentiating the origins of outflow tract ventricular arrhythmias, the most optimal one has not been agreed on. The purpose of this study was to establish an ECG diagnostic model based on the previous ECG algorithms. METHODS AND RESULTS The following ECG diagnostic model, Y=-1.15×( TZ )-0.494×(V2S/V3R), was developed by standard 12-lead ECG algorithms in 488 patients with idiopathic premature ventricular contractions or ventricular tachycardia with a left bundle branch block pattern and inferior axis QRS morphology. Binary logistic regression analysis was performed to establish the ECG diagnostic model. The ECG diagnostic model consisted of two ECG algorithms-the transition zone (TZ) index and V2S/V3R index. The area under the curve by receiver operating characteristic curve analysis for the ECG diagnostic model was 0.88, with a cut-off value of ≥ -0.76 predicting a left ventricular outflow tract (LVOT) origin with a sensitivity of 82% and a specificity of 86%, which was higher than other ECG algorithms in this study. The predictive accuracy of the ECG diagnostic model was also the best among all ECG algorithms in patients with a lead V3 precordial transition. This model was tested prospectively in 207 patients with a sensitivity of 90%, a specificity of 87%, and Youden index of 0.77. CONCLUSIONS A highly accurate ECG diagnostic model for correctly differentiating LVOT origin from right ventricular outflow tract origin was developed.
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Affiliation(s)
- Zhuoqiao He
- Department of Cardiology, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Ming Liu
- Department of Cardiology, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
- Cardio-Pulmonary Function Department, Wuhan Asia Heart Hospital, Wuhan, Hubei, China
| | - Min Yu
- Department of Cardiology, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Nan Lu
- Department of Cardiology, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Jia Li
- Department of Cardiology, Wuhan Asia Heart Hospital, Wuhan, Hubei, China
| | - Tan Xu
- Department of Cardiology, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Jinxiu Zhu
- Department of Cardiology, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Mary Clare O'Gara
- Department of Nursing, Shantou University Medical College, Shantou, Guangdong, China
| | - Michael O'Meara
- Department of Information Technology, Shantou University Medical College, Shantou, Guangdong, China
| | - Hong Ye
- Department of Cardiology, Wuhan Asia Heart Hospital, Wuhan, Hubei, China
| | - Xuerui Tan
- Department of Cardiology, The First Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
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Liu Z, Liu X, Ren L, Yin X, Han H, Wang Y, Deng W, Jia Y, Fang P, Yang X. Recurrence after successful catheter ablation for ventricular arrhythmia from the aortic root. Acta Cardiol 2018; 73:29-39. [PMID: 28691870 DOI: 10.1080/00015385.2017.1324658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The mechanism underlying recurrence after successful ablation of ventricular arrhythmias (VAs) was unclear. Spectrum analysis can help to identify near-field activation. The purpose of this study was to quantify the changes of near-field activation in response to ablation at the VAs origin in the aortic root (AR-VAs) and to assess its relationship with late ablation outcome. METHODS AND RESULTS Patients who underwent acutely successful ablation for AR-VAs were analysed. Ventricular electrograms acquired before and after ablation at VAs origin were subjected to spectrum analysis. The area under the curve of the high frequency component (HFC, 50-200 Hz) and the low frequency component (LFC, 0-50 Hz) was measured. The proportion of HFC to the frequency spectrum of 0-200 Hz was defined as the HFC ratio (HFCR). The reduction of HFC and HFCR in response to ablation was defined as HFC pre-post and HFCR pre-post, respectively. Documentation of VAs with the same morphology after an acute successful procedure was defined as recurrence. Fifty-six patients were analysed, and VAs recurred in 17 patients. HFCR pre-post, HFC pre-post, and HFC pre-ablation were significantly higher in patients without recurrence. And HFCR pre-post has the highest predictive value (area under the receiver-operating characteristic curve: 0.975). A HFCR pre-post of 1.0% differentiated two groups (sensitivity = 84.6%, specificity = 100%). Higher HFCR pre-post was correlated with shorter VAs termination time (correlation coefficient = -0.399, p = .009). CONCLUSIONS HFCR pre-post can quantify the near-field activation change during ablation. Incomplete destruction to the VAs foci could underlie recurrence after successful ablation.
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Affiliation(s)
- Zheng Liu
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xiaoqin Liu
- Department of Cardiology, Beijing Jishuitan Hospital, Peking University, Beijing, People’s Republic of China
| | - Lan Ren
- Department of Cardiology, Beijing Jishuitan Hospital, Peking University, Beijing, People’s Republic of China
| | - Xiandong Yin
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Hao Han
- Department of Cardiology, Beijing Jishuitan Hospital, Peking University, Beijing, People’s Republic of China
| | - Yuxin Wang
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Wenning Deng
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yuhe Jia
- Arrhythmia Center, Fuwai Hospital, Beijing, People’s Republic of China
| | - Pihua Fang
- Arrhythmia Center, Fuwai Hospital, Beijing, People’s Republic of China
| | - Xinchun Yang
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, People's Republic of China
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Longo D, Poliserpi C, Toscano Quilon F, Díaz Uberti P, López C, García-Niebla J, Ramella I. Diagnostical mistakes in ablation procedures associated with a high placement of the leads V1–V3. J Electrocardiol 2017; 50:433-436. [DOI: 10.1016/j.jelectrocard.2017.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Indexed: 10/20/2022]
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Wang C, Zhang Y, Hong F, Huang Y. Pulmonary artery: A pivotal site for catheter ablation in idiopathic RVOT ventricular arrhythmias. Pacing Clin Electrophysiol 2017; 40:803-807. [PMID: 28585685 DOI: 10.1111/pace.13131] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 05/13/2017] [Accepted: 05/26/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Chunmiao Wang
- Department of Cardiology; the First Affiliated Hospital of Anhui Medical University; Hefei China
| | - Yawen Zhang
- Department of Cardiology; the First Affiliated Hospital of Anhui Medical University; Hefei China
| | - Fangde Hong
- Department of Cardiology; the First Affiliated Hospital of Anhui Medical University; Hefei China
| | - Ying Huang
- Department of Cardiology; the First Affiliated Hospital of Anhui Medical University; Hefei China
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29
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Conventional mapping and ablation of focal ventricular tachycardias in the healthy heart. Herzschrittmacherther Elektrophysiol 2017; 28:187-192. [PMID: 28484842 DOI: 10.1007/s00399-017-0505-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 04/12/2017] [Indexed: 10/19/2022]
Abstract
Ventricular tachycardias (VT) in the healthy heart, also known as idiopathic VTs, often have a focal origin. Triggered activity due to delayed after-depolarization is the most likely mechanism of focal VTs. Localization of the site of origin of focal VTs is based on activation mapping with or without combination with pace mapping. The characteristic anatomic site of origin of idiopathic VTs is the right and left outflow tract. Other sites include the tricuspid and mitral annulus, the papillary muscles, and Purkinje fibers. Catheter ablation is indicated for monomorphic symptomatic VT and can be an alternative to antiarrhythmic drugs. Success rates are high, but mapping and ablation can be challenging. We review the main electrophysiological findings and the important clues for ablation of focal VTs. Specific considerations for each location are considered.
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30
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Miyazawa K, Ueda M, Kondo Y, Hayashi T, Nakano M, Ishimura M, Nakano M, Kobayashi Y. Rapid mapping and differentiation in ventricular outflow tract arrhythmia using non-contact mapping. J Interv Card Electrophysiol 2017; 49:41-49. [DOI: 10.1007/s10840-017-0250-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 03/29/2017] [Indexed: 11/24/2022]
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31
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Zhang F, Hamon D, Fang Z, Xu Y, Yang B, Ju W, Bradfield J, Shivkumar K, Chen M, Tung R. Value of a Posterior Electrocardiographic Lead for Localization of Ventricular Outflow Tract Arrhythmias: The V 4/V 8 Ratio. JACC Clin Electrophysiol 2017; 3:678-686. [PMID: 29759536 DOI: 10.1016/j.jacep.2016.12.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 12/13/2016] [Accepted: 12/22/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES This study sought to prospectively evaluate the value of a dedicated electrocardiographic posterior lead to create an anteroposterior ratio to localize premature ventricular complexes (PVCs) between the right ventricular outflow tract and left ventricular outflow tract for catheter ablation. BACKGROUND The anteroposterior relationship between the right and left outflow tract has not been explored for electrocardiographic localization of ventricular arrhythmia. METHODS Standard V5 and V6 leads were placed posteriorly and ablation was performed with activation mapping. The site of successful ablation was correlated with the ratio of the R-wave in V4 to the R-wave in V8. Normalization of the V4/V8 ratio to a V4/V8 index was achieved by dividing the V4/V8 ratio by sinus V4/V8. After determination of optimal cutoffs, comparison with V2 transition ratio and V2S/V3R was subsequently performed using receiver operating characteristic curves in a prospective validation cohort. RESULTS A total of 134 patients underwent ablation of PVCs with 2 modified posterior leads. PVCs successfully ablated from the left side had a statistically significantly higher V4/V8 ratio compared with right-sided PVCs (11.7 ± 10.6 vs. 2.3 ± 2.4, p < 0.001). At a cutoff of >3, the V4/V8 ratio had a sensitivity of 88% with a specificity of 77% for left-sided locations. At a cutoff of >2.28, the V4/V8 index had a sensitivity of 67% with a specificity of 98%. In the prospective validation cohort (n = 40), the V4/V8 ratio exhibited the highest sensitivity of 75% with a negative predictive value of 89% compared with the V4/V8 index, V2 transition ratio, and V2S/V3R. The V4/V8 index had the highest specificity of 96% with positive predictive value of 89% compared to the other predictive ratios. When analyzing cases with a V3 transition, the V4/V8 index demonstrated 100% specificity and positive predictive value. CONCLUSIONS A simple modification of V5 to V8 posteriorly may provide incremental diagnostic value for localizing PVCs arising from the outflow tracts. Normalizing PVC localization criteria to the sinus rhythm results in the highest specificity when compared with other validated criteria.
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Affiliation(s)
- Fengxiang Zhang
- First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - David Hamon
- UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California
| | - Zhen Fang
- First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yan Xu
- First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Bing Yang
- First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weizhu Ju
- First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jason Bradfield
- UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California
| | - Minglong Chen
- First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Roderick Tung
- University of Chicago Medicine, Center for Arrhythmia Care, Heart and Vascular Center, Pritzker School of Medicine, Chicago, Illinois.
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32
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Balla C, Ali H, Cappato R. Ventricular tachycardia as the first manifestation of disease: an element with different clinical settings. J Cardiovasc Med (Hagerstown) 2017; 18 Suppl 1:e77-e82. [PMID: 28151771 DOI: 10.2459/jcm.0000000000000452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Cristina Balla
- aArrhythmia and Electrophysiology Research Center, IRCCS Humanitas Research Hospital, Rozzano, Milan bArrhythmia and Electrophysiology Unit II, Humanitas Gavazzeni Clinics, Bergamo cDepartment of Cardiology, SS. ma Annunziata Hospital, Azienda Unità Sanitaria Locale Ferrara, Cento, Ferrara, Italy
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33
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Brandt M, Brunckhorst CB. [Not Available]. PRAXIS 2017; 106:275-276. [PMID: 28253813 DOI: 10.1024/1661-8157/a002616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Marius Brandt
- 1 Klinik für Kardiologie, Universitäres Herzzentrum Zürich, Universitätsspital Zürich
| | - Corinna B Brunckhorst
- 1 Klinik für Kardiologie, Universitäres Herzzentrum Zürich, Universitätsspital Zürich
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34
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New electrocardiographic criteria for predicting successful ablation of premature ventricular contractions from the right coronary cusp. Int J Cardiol 2016; 224:199-205. [DOI: 10.1016/j.ijcard.2016.09.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 08/23/2016] [Accepted: 09/15/2016] [Indexed: 11/20/2022]
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35
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Wissner E, Saguner AM, Metzner A, Chmelesky M, Tsyganov A, Deiss S, Maurer T, Kuck KH. Radiofrequency ablation of premature ventricular contractions originating from the aortomitral continuity localized by use of a novel noninvasive epicardial and endocardial electrophysiology system. HeartRhythm Case Rep 2016; 2:255-257. [PMID: 28491682 PMCID: PMC5419758 DOI: 10.1016/j.hrcr.2016.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Erik Wissner
- Stereotaxis Laboratory, Asklepios Klinik St Georg, Hamburg, Germany
| | - Ardan M Saguner
- Stereotaxis Laboratory, Asklepios Klinik St Georg, Hamburg, Germany
| | - Andreas Metzner
- Stereotaxis Laboratory, Asklepios Klinik St Georg, Hamburg, Germany
| | - Mikhail Chmelesky
- Federal Almazov North-West Medical Research Centre, Saint Petersburg, Russia.,EP Solutions SA, Yverdon-les-Bains, Switzerland
| | | | - Sebastian Deiss
- Stereotaxis Laboratory, Asklepios Klinik St Georg, Hamburg, Germany
| | - Tilman Maurer
- Stereotaxis Laboratory, Asklepios Klinik St Georg, Hamburg, Germany
| | - Karl-Heinz Kuck
- Stereotaxis Laboratory, Asklepios Klinik St Georg, Hamburg, Germany
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LIU ZHENG, JIA YUHE, REN LAN, FANG PIHUA, ZHOU GONGBU, HE JIA, ZHANG SHU. Multiple Intercostal Space Electrocardiogram Allows Accurate Localization of Outflow Tract Ventricular Arrhythmia Origin. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2015; 39:173-81. [PMID: 26549840 DOI: 10.1111/pace.12781] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 10/07/2015] [Accepted: 10/28/2015] [Indexed: 11/26/2022]
Affiliation(s)
- ZHENG LIU
- Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing People's Republic of China
| | - YU-HE JIA
- Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing People's Republic of China
| | - LAN REN
- Department of Cardiology; Beijing Jishuitan Hospital; Beijing People's Republic of China
| | - PI-HUA FANG
- Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing People's Republic of China
| | - GONG-BU ZHOU
- Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing People's Republic of China
| | - JIA HE
- Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing People's Republic of China
| | - SHU ZHANG
- Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases; Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing People's Republic of China
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Tanawuttiwat T, Nazarian S, Calkins H. The role of catheter ablation in the management of ventricular tachycardia. Eur Heart J 2015; 37:594-609. [DOI: 10.1093/eurheartj/ehv421] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 08/07/2015] [Indexed: 12/11/2022] Open
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Maeda S, Chik WW, Han Y, Liang JJ, Squara F, Arkles JS, Sadek MM, Santangeli P, Frankel DS, Zado ES, Takebayashi S, Dixit S, Callans DJ, Marchlinski FE, Lin D. Effects of Age-Related Aortic Root Anatomic Changes on Left Ventricular Outflow Tract Pace-Mapping Morphologies: A Cardiac Magnetic Resonance Imaging Validation Study. J Cardiovasc Electrophysiol 2015; 26:994-999. [PMID: 25991070 DOI: 10.1111/jce.12712] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 04/27/2015] [Accepted: 05/04/2015] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Outflow tract ventricular arrhythmias (OT VAs) are common and catheter ablation is an effective treatment option. We sought to investigate the relationship between age-related anatomic aortic root changes and QRS morphology during left ventricular outflow tract (LVOT) pace-mapping using cardiac magnetic resonance (CMR) imaging. METHODS AND RESULTS Fifty-one patients undergoing CMR imaging were divided into 3 groups based on age (<40, 40-60, >60 years). We measured the angle of the aortic root, the aorta to ventricular septal angle, the distance between the right coronary cusp (RCC) and left coronary cusp (LCC), and the distance between the ascending and descending aorta. Additionally, we evaluated the QRS morphologies obtained during pace-mapping from the LVOT. In older patients, LCC was more superior to the RCC (P < 0.01). Age was positively correlated with the aortic root angle (r2 = 0.481, P < 0.01) as well as the distances between the ascending and descending aorta at a level below the arch (r2 = 0.569, P < 0.01). In older patients, LVOT pace-mapping (performed in 16 patients) demonstrated higher maximal R-wave amplitude, and was greater when pacing from the LCC versus the RCC in lead III (1.8 ± 0.7 vs. 1.0 ± 0.5 mV, P = 0.02). CONCLUSION The anatomy of the aortic root changes with age, and age-related aortic root changes may affect the QRS morphology during pace-mapping. Understanding the potential anatomic changes that accompany aging is important to maximize the efficacy of catheter ablation of OT VAs.
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Affiliation(s)
- Shingo Maeda
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - William W Chik
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yuchi Han
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jackson J Liang
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fabien Squara
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey S Arkles
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mouhannad M Sadek
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pasquale Santangeli
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David S Frankel
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erica S Zado
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Satoshi Takebayashi
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sanjay Dixit
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David J Callans
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis E Marchlinski
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Lin
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Scanavacca M, Lara S, Hardy C, Pisani CF. How To Identify & Treat Epicardial Origin Of Outflow Tract Tachycardias. J Atr Fibrillation 2015; 7:1195. [PMID: 27957159 DOI: 10.4022/jafib.1195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 02/13/2015] [Accepted: 03/15/2015] [Indexed: 11/10/2022]
Abstract
The right ventricle outflow tract (RVOT) is the most common site of origin of idiopathic ventricular arrhythmias. The typical outflow tract arrhythmias pattern on ECG is an inferior axis deviation and left bundle branch block when originated on the RVOT and right bundle branch block morphology when originated on the left ventricular outflow tract (LVOT). There are several ECG tricks for different locations of origin. An increased Maximum Deflection Index (MDI) suggests epicardial origin of arrhythmia. In general the result of ablation is very good, but sometimes there are difficult and unsuccessful procedures. The origin in the aortic cusps and epicardium are the reason for failure in some cases. When they are epicardial, the arrhythmias can be accessed by the venous system or by subxiphoid epicardial mapping.
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Affiliation(s)
- Mauricio Scanavacca
- Arrhythmia Clinical Unit - Heart Institute - University of São Paulo Medical School
| | - Sissy Lara
- Arrhythmia Clinical Unit - Heart Institute - University of São Paulo Medical School
| | - Carina Hardy
- Arrhythmia Clinical Unit - Heart Institute - University of São Paulo Medical School
| | - Cristiano F Pisani
- Arrhythmia Clinical Unit - Heart Institute - University of São Paulo Medical School
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Efimova E, Dinov B, Acou WJ, Schirripa V, Kornej J, Kosiuk J, Rolf S, Sommer P, Richter S, Bollmann A, Hindricks G, Arya A. Differentiating the origin of outflow tract ventricular arrhythmia using a simple, novel approach. Heart Rhythm 2015; 12:1534-40. [PMID: 25847476 DOI: 10.1016/j.hrthm.2015.04.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Numerous electrocardiographic (ECG) criteria have been proposed to identify localization of outflow tract ventricular arrhythmias (OT-VAs); however, in some cases, it is difficult to accurately localize the origin of OT-VA using the surface ECG. OBJECTIVE The purpose of this study was to assess a simple criterion for localization of OT-VAs during electrophysiology study. METHODS We measured the interval from the onset of the earliest QRS complex of premature ventricular contractions (PVCs) to the distal right ventricular apical signal (the QRS-RVA interval) in 66 patients (31 men aged 53.3 ± 14.0 years; right ventricular outflow tract [RVOT] origin in 37) referred for ablation of symptomatic outflow tract PVCs. We prospectively validated this criterion in 39 patients (22 men aged 52 ± 15 years; RVOT origin in 19). RESULTS Compared with patients with RVOT PVCs, the QRS-RVA interval was significantly longer in patients with left ventricular outflow tract (LVOT) PVCs (70 ± 14 vs 33.4±10 ms, P < .001). Receiver operating characteristic analysis showed that a QRS-RVA interval ≥49 ms had sensitivity, specificity, and positive and negative predictive values of 100%, 94.6%, 93.5%, and 100%, respectively, for prediction of an LVOT origin. The same analysis in the validation cohort showed sensitivity, specificity, and positive and negative predictive values of 94.7%, 95%, 95%, and 94.7%, respectively. When these data were combined, a QRS-RVA interval ≥49 ms had sensitivity, specificity, and positive and negative predictive values of 98%, 94.6%, 94.1%, and 98.1%, respectively, for prediction of an LVOT origin. CONCLUSION A QRS-RVA interval ≥49 ms suggests an LVOT origin. The QRS-RVA interval is a simple and accurate criterion for differentiating the origin of outflow tract arrhythmia during electrophysiology study; however, the accuracy of this criterion in identifying OT-VA from the right coronary cusp is limited.
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Affiliation(s)
- Elena Efimova
- Department of Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
| | - Borislav Dinov
- Department of Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
| | - Willem-Jan Acou
- Department of Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
| | - Valentina Schirripa
- Department of Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
| | - Jelena Kornej
- Department of Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
| | - Jedrzej Kosiuk
- Department of Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
| | - Sascha Rolf
- Department of Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
| | - Philipp Sommer
- Department of Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
| | - Sergio Richter
- Department of Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
| | - Andreas Bollmann
- Department of Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany
| | - Arash Arya
- Department of Electrophysiology, Heart Center, University of Leipzig, Leipzig, Germany.
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Percutaneous Epicardial Ablation of Ventricular Arrhythmias Arising From the Left Ventricular Summit. Circ Arrhythm Electrophysiol 2015; 8:337-43. [DOI: 10.1161/circep.114.002377] [Citation(s) in RCA: 112] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 01/16/2015] [Indexed: 11/16/2022]
Abstract
Background—
Percutaneous epicardial ablation of ventricular arrhythmias arising from the left ventricular summit is limited by the presence of major coronary vessels and epicardial fat. We report the outcomes of percutaneous epicardial mapping and ablation of ventricular arrhythmias arising from the left ventricular summit and the ECG features associated with successful ablation.
Methods and Results—
Between January 2003 and December 2012, a total of 23 consecutive patients (49±14 years; 39% men) with ventricular arrhythmias arising from the left ventricular summit underwent percutaneous epicardial instrumentation for mapping and ablation because of unsuccessful ablation from the coronary venous system and multiple endocardial LV/right ventricular sites. Successful epicardial ablation was achieved in 5 (22%) patients. In the remaining 18 (78%) cases, ablation was aborted for either close proximity to major coronary arteries or poor energy delivery over epicardial fat. The Q-wave amplitude ratio in aVL/aVR was higher in the successful group, with a ratio of >1.85 present in 4 (80%) patients in the successful group versus 2 (11%) in the unsuccessful group (
P
=0.008). The ratio of R/S wave in V1 was greater in the successful group, with 4 (80%) patients in the successful group having a R/S ratio of >2 in V1 versus 5 (28%) in the unsuccessful group (
P
=0.056). None of the patients in the successful group had an initial q wave in lead V1, as opposed to 6 (33%) in the unsuccessful group. The presence of at least 2 of the 3 ECG criteria above predicted successful ablation with 100% sensitivity and 72% specificity.
Conclusions—
Epicardial instrumentation for mapping and ablation of ventricular arrhythmias arising from the left ventricular summit is successful only in a minority of patients because of close proximity to major coronary arteries and epicardial fat. A Q-wave ratio of >1.85 in aVL/aVR, a R/S ratio of >2 in V1, and absence of q waves in lead V1 help identify appropriate candidates for epicardial ablation.
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Rillig A, Lin T, Ouyang F, Kuck KH, Tilz RR. Which Is The Appropriate Arrhythmia Burden To Offer RF Ablation For RVOT Tachycardias? J Atr Fibrillation 2014; 7:1157. [PMID: 27957135 DOI: 10.4022/jafib.1157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 02/12/2013] [Accepted: 02/12/2013] [Indexed: 12/14/2022]
Abstract
Premature ventricular complexes (PVCs) and ventricular tachycardia (VT) in patients with structurally normal hearts originate from the right ventricular outflow tract (RVOT) in the majority of cases. In the last few decades catheter ablation of these arrhythmias has been proven to be effective. RVOT VT/PVCs may cause disabling symptoms or arrhythmia induced cardiomyopathy. However, the PVC burden at which catheter ablation should be recommended is still controversial. What adds to the controversy is why some patients with only a low number of PVCs can be highly symptomatic and may even develop arrhythmia induced cardiomyopathy, whilst others may have a higher PVC/VT burden and remain asymptomatic and do not develop cardiomyopathy for a long period of time. Therefore, although catheter ablation of RVOT PVCs has high success and low complication rates, the time point of when ablation should be recommended is currently still under debate. This review discusses the treatment strategies and prognosis for RVOT tachycardias and focuses on the question of which arrhythmia burden is appropriate to offer RF ablation.
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Affiliation(s)
- Andreas Rillig
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Tina Lin
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Feifan Ouyang
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Karl-Heinz Kuck
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
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Kawamura M, Gerstenfeld EP, Vedantham V, Rodrigues DM, Burkhardt JD, Kobayashi Y, Hsia HH, Marcus GM, Marchlinski FE, Scheinman MM, Badhwar N. Idiopathic Ventricular Arrhythmia Originating From the Cardiac Crux or Inferior Septum. Circ Arrhythm Electrophysiol 2014; 7:1152-8. [DOI: 10.1161/circep.114.001704] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Idiopathic ventricular arrhythmia (VA) can arise from the epicardium near the posteroseptal region (cardiac crux). There are only 2 prior reports describing idiopathic VA from the cardiac crux. The purpose of this study was to characterize the clinical and the electrocardiographic features of idiopathic crux VA.
Methods and Results—
Crux VA was identified in 18 patients undergoing catheter ablation. We divided patients into 2 groups, those with VA originating from the apical crux (n=9) and the basal crux (n=9). We described the clinical and electrocardiographic characteristics of crux VA as well as the ablation results. Furthermore, we compared clinical features of crux VA with other sites of idiopathic VA. Fifteen crux VA patients (83%) had sustained ventricular tachycardia and 3 patients required implantable cardioverter defibrillator implantation because of syncope. All patients had a left superior axis and 16 patients had R>S wave in V2. In apical crux VA, all patients had a deep S wave in V6 and 8 patients (89%) had R>S wave in aVR. All apical crux patients underwent attempted ablation in the middle cardiac vein without success. In 4 of these patients, epicardial ablation with subxiphoid approach was performed successfully. All basal crux VA patients had either negative or isoelectric pattern in V1 and had R>S in V6. Patients had successful ablation within the middle cardiac vein.
Conclusions—
Apical versus basal crux VA is identified as a new category of idiopathic VA with distinctive electrocardiographic characteristics; ablation via the middle cardiac vein is effective for eliminating basal crux VA, whereas apical crux VA often requires a subxiphoid epicardial approach.
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Affiliation(s)
- Mitsuharu Kawamura
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
| | - Edward P. Gerstenfeld
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
| | - Vasanth Vedantham
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
| | - Derek M. Rodrigues
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
| | - J. David Burkhardt
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
| | - Youichi Kobayashi
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
| | - Henry H. Hsia
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
| | - Gregory M. Marcus
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
| | - Francis E. Marchlinski
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
| | - Melvin M. Scheinman
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
| | - Nitish Badhwar
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
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Trevisi N, Silberbauer J, Radinovic A, Bavila R, Sala S, Vergara P, Bella PD. New diagnostic criteria for identifying left-sided ventricular ectopy using non-contact mapping and virtual unipolar electrogram analysis. Europace 2014; 17:108-16. [DOI: 10.1093/europace/euu145] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Hutchinson MD. Redefining the golden ratio: a novel ECG tool for approaching outflow tract arrhythmias. J Cardiovasc Electrophysiol 2014; 25:754-5. [PMID: 24641268 DOI: 10.1111/jce.12408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Mathew D Hutchinson
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Bradfield JS, Homsi M, Shivkumar K, Miller JM. Coupling interval variability differentiates ventricular ectopic complexes arising in the aortic sinus of valsalva and great cardiac vein from other sources: mechanistic and arrhythmic risk implications. J Am Coll Cardiol 2014; 63:2151-2158. [PMID: 24657687 DOI: 10.1016/j.jacc.2014.02.551] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 02/05/2014] [Accepted: 02/17/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The objective of this study was to determine whether premature ventricular contractions (PVCs) arising from the aortic sinuses of Valsalva (SOV) and great cardiac vein (GCV) have coupling interval (CI) characteristics that differentiate them from other ectopic foci. BACKGROUND PVCs occur at relatively fixed CI from the preceding normal QRS complex in most patients. However, we observed patients with PVCs originating in unusual areas (SOV and GCV) in whom the PVC CI was highly variable. We hypothesized that PVCs from these areas occur seemingly randomly because of the lack of electrotonic effects of the surrounding myocardium. METHODS Seventy-three consecutive patients referred for PVC ablation were assessed. Twelve consecutive PVC CIs were recorded. The ΔCI (maximum - minimum CI) was measured. RESULTS We studied 73 patients (age 50 ± 16 years, 47% male). The PVC origin was right ventricular (RV) in 29 (40%), left ventricular (LV) in 17 (23%), SOV in 21 (29%), and GCV in 6 (8%). There was a significant difference between the mean ΔCI of RV/LV PVCs compared with SOV/GCV PVCs (33 ± 15 ms vs. 116 ± 52 ms, p < 0.0001). A ΔCI of >60 ms demonstrated a sensitivity of 89%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 94%. Cardiac events were more common in the SOV/GCV group versus the RV/LV group (7 of 27 [26%] vs. 2 of 46 [4%], p < 0.02). CONCLUSIONS ΔCI is more pronounced in PVCs originating from the SOV or GCV. A ΔCI of 60 ms helps discriminate the origin of PVCs before diagnostic electrophysiological study and may be associated with increased frequency of cardiac events.
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Affiliation(s)
- Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Mohamed Homsi
- Krannert Institute of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - John M Miller
- Krannert Institute of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
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Ghanbari H, Schmidt M, Machado C, Daccarett M. Catheter ablation of ventricular tachycardia in structurally normal hearts. Expert Rev Cardiovasc Ther 2014; 8:651-61. [DOI: 10.1586/erc.10.25] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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49
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Nakano M, Ueda M, Ishimura M, Kajiyama T, Hashiguchi N, Kanaeda T, Kondo Y, Hiranuma Y, Kobayashi Y. Estimation of the origin of ventricular outflow tract arrhythmia using synthesized right-sided chest leads. Europace 2013; 16:1373-8. [PMID: 24284987 DOI: 10.1093/europace/eut355] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS For successful ablation of ventricular outflow tract arrhythmia, estimation of its origin prior to the procedure can be useful. Morphology and lead placement in the right thoracic area may be useful for this purpose. Electrocardiography using synthesized right-sided chest leads (Syn-V3R, Syn-V4R, and Syn-V5R) is performed using standard leads without any additional leads. This study evaluated the usefulness of synthesized right-sided chest leads in estimating the origin of ventricular outflow tract arrhythmia. METHODS AND RESULTS This retrospective study included 63 patients in whom successful ablation of ventricular outflow tract arrhythmia was performed. Numbers of arrhythmias originating from the left ventricle, the septum of the right ventricle, and the free wall of the right ventricle were 11, 40, and 13, respectively. In one patient, two different left ventricular outflow tract origins were found. Electrocardiographic recordings from right-sided chest leads were divided into three types as follows: those in which an R > S concordance, a transitional zone, or an R < S concordance were detected. In all left arrhythmia cases, R > S concordance was observed. A transitional zone was evident in 34 of 40 cases of right ventricular outflow tract arrhythmia originating in the ventricular septum, and an R < S concordance was observed in 6 of the 40 cases. However, an R < S concordance was found in all cases of right ventricular outflow tract arrhythmia originating in the free wall. CONCLUSION Synthesized right-sided chest lead electrocardiography may be useful for estimating the origin of ventricular outflow tract arrhythmia.
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Affiliation(s)
- Masahiro Nakano
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Marehiko Ueda
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Masayuki Ishimura
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Takatsugu Kajiyama
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Naotaka Hashiguchi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Tomonori Kanaeda
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Yusuke Kondo
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Yasunori Hiranuma
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo-ku, Chiba 260-8670, Japan
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HUTCHINSON MATHEWD, GARCIA FERMINC. An Organized Approach to the Localization, Mapping, and Ablation of Outflow Tract Ventricular Arrhythmias. J Cardiovasc Electrophysiol 2013; 24:1189-97. [DOI: 10.1111/jce.12237] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2013] [Revised: 06/09/2013] [Accepted: 06/26/2013] [Indexed: 11/30/2022]
Affiliation(s)
- MATHEW D. HUTCHINSON
- Cardiovascular Division, Department of Medicine; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
| | - FERMIN C. GARCIA
- Cardiovascular Division, Department of Medicine; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
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