Research Article| Volume 13, ISSUE 2, P519-526, February 2016

Download started.


Negative concordance pattern in bipolar and unipolar recordings: An additional mapping criterion to localize the site of origin of focal ventricular arrhythmias

Published:November 06, 2015DOI:


      The relevance of the temporal relationship between a unipolar electrogram (UEGM) and a bipolar electrogram (BEGM) in determining the site of origin (SOO) of focal arrhythmias has been largely demonstrated.


      We sought to demonstrate that a negative concordance in the initial forces of these EGMs is also helpful in predicting the SOO of premature ventricular contractions (PVCs).


      Mapping and radiofrequency (RF) ablation were performed in 41 patients with symptomatic PVCs in the absence of structural heart disease. Simultaneous recordings of the minimally filtered (0.5–500 Hz) UEGM and filtered BEGM (30–500 Hz) were analyzed at 247 mapping sites, where RF was attempted. EGMs of 63 mechanically induced PVCs were separately analyzed as a validation group. All ablation sites had a QS pattern in the UEGM. Acute PVC suppression was defined as a complete disappearance of ventricular ectopic beats after a 60-second pulse of RF.


      RF ablation obtained PVC suppression (RF+) in 33 of 247 sites (13.3%). A negative concordance pattern (NCP) during the initial 20 ms of both UEGM and BEGM was observed in 31 of 33 (94%) RF+ sites compared with 10 of 214 (4%)RF− sites (P < .0001). The NCP criterion demonstrated to be an additional powerful predictor of acute RF success with sensitivity, specificity, positive predictive value, and negative predictive value of 94%, 95%, 76%, and 99%, respectively. Similarly to RF+ sites, the NCP was observed in 60 of 63 sites (95.2%) in the mechanical PVC group.


      An NCP in both UEGM and BEGM may be an additional criterion that helps to localize the SOO of focal ventricular arrhythmias.


      BEGM (bipolar electrogram), Bip (first peak (positive or negative) of the bipolar electrogram), ECG (electrocardiogram/electrocardiographic), NCP (negative concordance pattern), NPV (negative predictive value), PPV (positive predictive value), PVC (premature ventricular contraction), RF (points where radiofrequency was delivered without suppression of PVC's), RF+ (radiofrequency-induced complete premature ventricular contraction suppression), ROC (receiver operating characteristic), SOO (site of origin), UEGM (unipolar electrogram), UNIon (onset of the unipolar electrogram), UNIS (rapid negative deflection of the unipolar electrogram)


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Heart Rhythm
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Josephson M.E.
        Clinical Cardiac Electrophysiology: Techniques and Interpretations.
        3rd ed. Lippincott Williams & Wilkins, Philadelphia, PA2002
        • De Bakker J.M.T.
        • Hauer R.N.W.
        • Simmers T.A.
        Activation mapping: unipolar versus bipolar recording.
        in: Zipes D.P. Jalife J. Cardiac Electrophysiology: From Cell to Bedside. 2nd ed. W.B. Saunders, Philadelphia, PA1995: 1068
        • Spach M.S.
        • Barr R.C.
        • Serwer G.A.
        • Kootsey J.M.
        • Johnson E.A.
        Extracellular potentials related to intracellular action potentials in the dog Purkinje system.
        Circ Res. 1972; 30: 505-519
        • Hoffman B.F.
        • Cranefield P.F.
        • Lepeschkin E.
        • Surawicz B.
        • Herrlich H.C.
        Comparison of cardiac monophasic action potentials recorded by intracellular and suction electrodes.
        Am J Physiol. 1959; 196: 1297-1301
        • Paul T.
        • Moak J.P.
        • Morris C.
        • Garson Jr, A.
        Epicardial mapping: how to measure local activation?.
        Pacing Clin Electrophysiol. 1990; 13: 285-292
        • Delacretaz E.
        • Soejima K.
        • Gottipaty V.K.
        • Brunckhorst C.B.
        • Friedman P.L.
        • Stevenson W.G.
        Single catheter determination of local electrogram prematurity using simultaneous unipolar and bipolar recordings to replace the surface ECG as a timing reference.
        Pacing Clin Electrophysiol. 2001; 24: 441-449
        • Biermann M.
        • Shenasa M.
        • Borggrefe M.
        • Hindricks G.
        • Haverkamp W.
        • Breithardt G.
        The interpretation of cardiac electrograms.
        in: Shenasa M. Borggrefe M. Breithardt G. Cardiac Mapping. 2nd ed. Blackwell/Futura, Elmsford2003: 15-41
        • Stevenson W.G.
        • Soejima K.
        Recording techniques for clinical electrophysiology.
        J Cardiovasc Electrophysiol. 2005; 16: 1017-1022
        • Gallagher J.J.
        • Kasell J.
        • Sealy W.C.
        • Pritchett E.L.
        • Wallace A.G.
        Epicardial mapping in the Wolff-Parkinson-White syndrome.
        Circulation. 1978; 57: 854-866
        • Man K.C.
        • Daoud E.G.
        • Knight B.P.
        • Bahu M.
        • Weiss R.
        • Zivin A.
        • Souza S.J.
        • Goyal R.
        • Strickberger S.A.
        • Morady F.
        Accuracy of the unipolar electrogram for identification of the site of origin of ventricular activation.
        J Cardiovasc Electrophysiol. 1997; 8: 974-979
        • Stinnett-Donnelly J.M.
        • Thompson N.
        • Habel N.
        • Petrov-Kondratov V.
        • Correa de Sa D.D.
        • Bates J.H.
        • Spector P.S.
        Effects of electrode size and spacing on the resolution of intracardiac electrograms.
        Coron Artery Dis. 2012; 23: 126-132
        • Brunckhorst C.B.
        • Delacretaz E.
        • Soejima K.
        • Maisel W.H.
        • Friedman P.L.
        • Stevenson W.G.
        Impact of changing activation sequence on bipolar electrogram amplitude for voltage mapping of left ventricular infarcts causing ventricular tachycardia.
        J Interv Card Electrophysiol. 2005; 12: 137-141
        • Tada H.
        • Oral H.
        • Sticherling C.
        • Chough S.P.
        • Baker R.L.
        • Wasmer K.
        • Kim M.H.
        • Pelosi Jr, F.
        • Michaud G.F.
        • Knight B.P.
        • Strickberger S.A.
        • Morady F.
        Electrogram polarity and cavotricuspid isthmus block during ablation of typical atrial flutter.
        J Cardiovasc Electrophysiol. 2001; 12: 393-399
        • Yamane T.
        • Shah D.C.
        • Jaïs P.
        • Hocini M.M.
        • Deisenhofer I.
        • Choi K.J.
        • Macle L.
        • Clémenty J.
        • Haïssaguerre M.
        Electrogram polarity reversal as an additional indicator of breakthroughs from the left atrium to the pulmonary veins.
        J Am Coll Cardiol. 2002; 39: 1337-1344
        • Restivo M.
        • Gough W.B.
        • el-Sherif N.
        Ventricular arrhythmias in the subacute myocardial infarction period: high resolution activation and refractory patterns of reentrant rhythms.
        Circ Res. 1990; 66: 1310-1327
        • Gardner P.I.
        • Ursell P.C.
        • Fenoglio Jr, J.J.
        • Wit A.L.
        Electrophysiologic and anatomic basis for fractionated electrograms recorded from healed myocardial infarcts.
        Circulation. 1985; 72: 596-611