Advertisement

Conduction patterns of idiopathic arrhythmias from the endocardium and epicardium of outflow tracts: New insights with noninvasive electroanatomic mapping

      Background

      Idiopathic arrhythmias commonly arise from the septal right ventricular outflow tract (RVOT), sinuses of Valsalva (SoV), and great cardiac vein (GCV). Predicting the exact site of origin is important for preparation for catheter ablation.

      Objective

      The purpose of this study was to examine the diagnostic value of noninvasive electroanatomic mapping (NIEAM) to differentiate between septal RVOT, SoV, and GCV origin and compare it to that of 12-lead electrocardiography (ECG).

      Methods

      NIEAM maps (CardioInsight, Medtronic) were generated during spontaneous ventricular premature depolarizations (VPDs) and threshold pacing from septal RVOT, SoV, and GCV. Origin prediction using NIEAM was compared to algorithmic ECG criteria (maximal deflection index; V2 transition ratio) and subjective ECG evaluation.

      Results

      Sixty NIEAMs (18 spontaneous VPDs and 42 pace-maps) from 31 patients (age 56 ± 16 years) were analyzed. NIEAM showed distinct conduction patterns, best visualized at the base of the heart: septal RVOT VPDs propagate toward the tricuspid annulus, depolarizing the septum from inferior to superior; SoV VPDs engage the superior septum early; and GCV VPDs move laterally along the mitral annulus, depolarizing the heart from left to right. Activation of the lateral mitral annulus >60.50 ms and the superior basal septum <22.5 ms from onset predicts RVOT and SoV origin, respectively, in 100% of cases. NIEAM was superior to maximum deflection index in predicting GCV origin (100% vs 42.2% accuracy) and superior to V2 transition ratio in predicting SoV origin (100% vs 75.9% accuracy).

      Conclusion

      Arrhythmias arising from the outflow tracts follow distinct propagation patterns depending on the origin. A 2-step algorithm using activation timing by NIEAM yields 100% diagnostic accuracy in predicting origin.

      Keywords

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

      Purchase one-time access:

      Academic and Personal
      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:

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

      References

        • Lin D.
        • Ilkhanoff L.
        • Gerstenfeld E.
        • et al.
        Twelve-lead electrocardiographic characteristics of the aortic cusp region guided by intracardiac echocardiography and electroanatomic mapping.
        Heart Rhythm. 2008; 5: 663-669
        • Obel O.A.
        • d'Avila A.
        • Neuzil P.
        • Saad E.B.
        • Ruskin J.N.
        • Reddy V.Y.
        Ablation of left ventricular epicardial ouflow tract tachycardia from the distal great cardiac vein.
        J Am Coll Cardiol. 2006; 48: 1813-1817
        • Yamada T.
        • McElderry H.T.
        • Doppalapudi H.
        • et al.
        Idiopathic ventricular arrhythmias originating from the left ventricular summit: anatomic concepts relevant to ablation.
        Circ Arrhythm Electrophysiol. 2010; 3: 616-623
        • Mountantonakis S.E.
        • Frankel D.S.
        • Tschabrunn C.M.
        • et al.
        Ventricular arrhythmias from the coronary venous system: Prevalence, mapping, and ablation.
        Heart Rhythm. 2015; 12: 1145-1153
        • Yarlagadda R.K.
        • Iwai S.
        • Stein K.M.
        • et al.
        Reversal of cardiomyopathy in patients with repetitive monomorphic ventricular ectopy originating from the right ventricular outflow tract.
        Circulation. 2005; 112: 1092-1097
        • Takemoto M.
        • Yoshimura H.
        • Ohba Y.
        • et al.
        Radiofrequency catheter ablation of premature ventricular complexes from right ventricular outflow tract improves left ventricular dilation and clinical status in patients without structural heart disease.
        J Am Coll Cardiol. 2005; 45: 1259-1265
        • Bogun F.
        • Crawford T.
        • Reich S.
        • et al.
        Radiofrequency ablation of frequent, idiopathic premature ventricular complexes: comparison with a control group without intervention.
        Heart Rhythm. 2007; 4: 863-867
        • Baman T.S.
        • Lange D.C.
        • Ilg K.J.
        • et al.
        Relationship between burden of premature ventricular complexes and left ventricular function.
        Heart Rhythm. 2010; 7: 865-869
        • Mountantonakis S.E.
        • Frankel D.S.
        • Gerstenfeld E.P.
        • et al.
        Reversal of outflow tract ventricular premature depolarization-induced cardiomyopathy with ablation: effect of residual arrhythmia.
        Heart Rhythm. 2011; 8: 1608-1614
        • Cakulev I.
        • Sahadevan J.
        • Arrude M.
        • et al.
        Confirmation of novel noninvasive high-density electrocardiographic mapping with electrophysiology study: implications for therapy.
        Circ Arrhythm Electrophysiol. 2013; 6: 68-75
        • Jamil-Copley S.
        • Bokan R.
        • Kojodjojo P.
        • et al.
        Noninvasive electrocardiographic mapping to guide ablation of outflow tract ventricular arrhythmias.
        Heart Rhythm. 2014; 11: 587-594
        • Erkapic D.
        • Greiss H.
        • Pajitnev D.
        • et al.
        Clinical impact of a novel three-dimensional electrocardiographic imaging for non-invasive mapping of ventricular arrhythmias—a prospective randomized trial.
        Europace. 2015; 17: 591-597
        • Wissner E.
        • Revishvili A.
        • Metzner A.
        • et al.
        Noninvasive epicardial and endocardial mapping of premature ventricular contractions.
        Europace. 2017; 19: 843-849
        • Bazan V.
        • Bala R.
        • Garcia F.C.
        • et al.
        Twelve-lead ECG features to identify ventricular tachycardia arising from the epicardial right ventricle.
        Heart Rhythm. 2006; 3: 1132-1139
        • Bazan V.
        • Gerstenfeld E.P.
        • Garcia F.C.
        • et al.
        Site-specific twelve-lead ECG features to identify an epicardial origin for left ventricular tachycardia in the absence of myocardial infarction.
        Heart Rhythm. 2007; 4: 1403-1410
        • Betensky B.P.
        • Park R.E.
        • Marchlinski F.E.
        • et al.
        The V(2) transition ratio: a new electrocardiographic criterion for distinguishing left from right ventricular outflow tract tachycardia origin.
        J Am Coll Cardiol. 2011; 57: 2255-2262
        • Efimova E.
        • Dinov B.
        • Acou W.J.
        • et al.
        Differentiating the origin of outflow tract ventricular arrhythmia using a simple, novel approach.
        Heart Rhythm. 2015; 12: 1534-1540
        • Xie S.
        • Kubala M.
        • Liang J.J.
        • et al.
        Lead I R-wave amplitude to differentiate idiopathic ventricular arrhythmias with left bundle branch block right inferior axis originating from the left versus right ventricular outflow tract.
        J Cardiovasc Electrophysiol. 2018; 29: 1515-1522