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Right bundle branch block ventricular tachycardia in arrhythmogenic right ventricular cardiomyopathy more commonly originates from the right ventricle: Criteria for identifying chamber of origin

  • Author Footnotes
    1 Dylan F. Marchlinski and Dr Cory M. Tschabrunn are co-first authors.
    Dylan F. Marchlinski
    Footnotes
    1 Dylan F. Marchlinski and Dr Cory M. Tschabrunn are co-first authors.
    Affiliations
    Cardiac Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
    Search for articles by this author
  • Author Footnotes
    1 Dylan F. Marchlinski and Dr Cory M. Tschabrunn are co-first authors.
    Cory M. Tschabrunn
    Footnotes
    1 Dylan F. Marchlinski and Dr Cory M. Tschabrunn are co-first authors.
    Affiliations
    Cardiac Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
    Search for articles by this author
  • Erica S. Zado
    Affiliations
    Cardiac Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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  • Pasquale Santangeli
    Affiliations
    Cardiac Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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  • Francis E. Marchlinski
    Correspondence
    Address reprint requests and correspondence: Dr Francis E. Marchlinski, Cardiac Electrophysiology Section, Hospital of the University of Pennsylvania, 3400 Spruce St, 9 Founders Pavilion, Philadelphia, PA 19104.
    Affiliations
    Cardiac Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
    Search for articles by this author
  • Author Footnotes
    1 Dylan F. Marchlinski and Dr Cory M. Tschabrunn are co-first authors.
Published:September 01, 2020DOI:https://doi.org/10.1016/j.hrthm.2020.08.016

      Background

      Right bundle branch block (RBBB) ventricular tachycardia (VT) morphology is a criterion for left ventricular (LV) involvement in arrhythmogenic right ventricular cardiomyopathy (ARVC).

      Objective

      The purpose of this study was to determine the frequency and chamber of origin of RBBB VT in patients with ARVC and VT.

      Methods

      We studied 110 consecutive patients with VT who met the diagnostic International Task Force criteria for ARVC and underwent VT mapping/ablation. Patients with ≥1 RBBB VT were identified. Right ventricular (RV) origin of the RBBB VT was determined based on standard mapping criteria and elimination with ablation.

      Results

      Nineteen patients (17%) had 26 RBBB VTs. Eleven of these 19 patients (58%) had 16 RBBB VTs from the RV, and 9 patients (47%) had 10 RBBB VTs originating from the LV, with 1 patient demonstrating both. RBBB VT from RV most commonly (13/16 RBBB VTs) had an early precordial QRS transition (V2 or V3), with superiorly and typically leftward directed frontal plane axis, consistent with exit from dilated RV adjacent to inferior LV septum, whereas all 10 VTs from LV had RBBB morphology with positive R waves to V5 or V6 and rightward axis in 6 VTs characteristic of basal lateral origin.

      Conclusion

      In patients with ARVC and VT presenting for VT ablation, RBBB VT occurs in 17% of cases, with most RBBB VTs (62%) originating from the RV and not indicative of LV origin. Precordial R-wave transition and frontal plane axis can be used to identify the anticipated chamber of origin of RBBB VT.

      Keywords

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      References

        • Marchlinski F.E.
        • Zado E.
        • Dixit S.
        • et al.
        Electroanatomic substrate and outcome of catheter ablative therapy for ventricular tachycardia in setting of right ventricular cardiomyopathy.
        Circulation. 2004; 110: 2293-2298
        • Sen-Chowdhry S.
        • Syrris P.
        • Prasad S.K.
        • et al.
        Left-dominant arrhythmogenic cardiomyopathy: an under-recognized clinical entity.
        J Am Coll Cardiol. 2008; 52: 2175-2187
        • Corrado D.
        • van Tintelen P.J.
        • McKenna W.J.
        • et al.
        Arrhythmogenic right ventricular cardiomyopathy: evaluation of the current diagnostic criteria and differential diagnosis.
        Eur Heart J. 2020; 41: 1414-1429
        • Marcus F.I.
        • McKenna W.J.
        • Sherrill D.
        • et al.
        Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia: proposed modification of the task force criteria.
        Circulation. 2010; 121: 1533-1541
        • Josephson M.E.
        • Horowitz L.N.
        • Waxman H.L.
        • et al.
        Sustained ventricular tachycardia: role of the 12-lead electrocardiogram in localizing site of origin.
        Circulation. 1981; 64: 257-272
        • Barold S.S.
        • Narula O.S.
        • Javier R.P.
        • Linhart J.W.
        • Lister J.W.
        • Samet P.
        Significance of right bundle-branch block patterns during pervenous ventricular pacing.
        Br Heart J. 1969; 31: 285-290
        • Tzeis S.
        • Andrikopoulos G.
        • Weigand S.
        • et al.
        Right bundle branch block-like pattern during uncomplicated right ventricular pacing and the effect of pacing site.
        Am J Cardiol. 2016; 117: 935-939
        • Tschabrunn C.M.
        • Marchlinski F.E.
        Ventricular tachycardia mapping and ablation in arrhythmogenic right ventricular cardiomyopathy/dysplasia: lessons learned.
        World J Cardiol. 2014; 6: 959-967
        • Santangeli P.
        • Zado E.S.
        • Supple G.E.
        • et al.
        Long-term outcome with catheter ablation of ventricular tachycardia in patients with arrhythmogenic right ventricular cardiomyopathy.
        Circ Arrhythm Electrophysiol. 2015; 8: 1413-1421
        • Marchlinski F.E.
        • Callans D.J.
        • Gottlieb C.D.
        • Zado E.
        Linear ablation lesions for control of unmappable ventricular tachycardia in patients with ischemic and nonischemic cardiomyopathy.
        Circulation. 2000; 101: 1288-1296
        • Garcia F.C.
        • Bazan V.
        • Zado E.S.
        • Ren J.F.
        • Marchlinski F.E.
        Epicardial substrate and outcome with epicardial ablation of ventricular tachycardia in arrhythmogenic right ventricular cardiomyopathy/dysplasia.
        Circulation. 2009; 120: 366-375
        • Cano O.
        • Hutchinson M.
        • Lin D.
        • et al.
        Electroanatomic substrate and ablation outcome for suspected epicardial ventricular tachycardia in left ventricular nonischemic cardiomyopathy.
        J Am Coll Cardiol. 2009; 54: 799-808
        • Gerstenfeld E.P.
        • Dixit S.
        • Callans D.J.
        • Rajawat Y.
        • Rho R.
        • Marchlinski F.E.
        Quantitative comparison of spontaneous and paced 12-lead electrocardiogram during right ventricular outflow tract ventricular tachycardia.
        J Am Coll Cardiol. 2003; 41: 2046-2053
        • Hsia H.H.
        • Callans D.J.
        • Marchlinski F.E.
        Characterization of endocardial electrophysiological substrate in patients with nonischemic cardiomyopathy and monomorphic ventricular tachycardia.
        Circulation. 2003; 108: 704-710
        • 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
        • Valles E.
        • Bazan V.
        • Marchlinski F.E.
        ECG criteria to identify epicardial ventricular tachycardia in nonischemic cardiomyopathy.
        Circ Arrhythm Electrophysiol. 2010; 3: 63-71
        • Kuo L.
        • Han Y.
        • Mui D.
        • et al.
        Diagnostic specificity of basal inferoseptal triangular late gadolinium enhancement for identification of cardiac sarcoidosis.
        JACC Cardiovasc Imaging. 2019; 12: 2574-2576