Origin Of Outflow Tract Ventricular Arrhythmias Research Articles

Diagnostic value of ECG characteristics in precordial leads V1-V3 for the diagnosis of the origin of outflow tract ventricular arrhythmias with a lead V3 precordial transition

Abstract Funding Acknowledgements Type of funding sources: None. Background and Purpose. To distinguish the origin of outflow tract ventricular arrhythmias (OTVAs) with a V3 precordial transition is still a challenge. To date, numerous diagnostic algorithms have been described, mainly by analysis of leads V1 and V2, while a complete study of lead V3 has never been conducted. Methods. The ECG characteristics of 45 patients (Pts) with a left bundle branch block pattern OTVAs (LVOT 51.1%, RVOT 48.9%) who underwent successful catheter ablation were retrospectively analyzed. The region where the radiofrequency delivery resulted in the persistent suppression of the arrhythmia was identified as the site of origin. For every duration or amplitude variable and for derivative indices, the comparison of means (U Mann Whitney or t-test), the determination of the AUC by ROC curves, and the correlation with BMI and BSA were performed. The odds ratio was calculated for every variable with an AUC ≥ 0.700. The three best results are described. Results. Pts with a LVOT origin were older (59.91 ± 10.48 vs 50.95 ± 15.48, p = 0.027) and predominantly males (82.6% vs 54.5%, p = 0.042) but they shared similar BMI (24.74 ± 2.76 vs 24.09 ± 2.94, p = 0.45) and BSA (1.83 ± 0.12 vs 1.77 ± 0.16, p = 0.157). In leads V1 – V2 the duration but not the amplitude of the R wave showed a significant correlation with the BSA; no variable, with the exception of the S wave amplitude, exhibited an AUC ≥ 0.700. Criteria based on the prevalence of the R wave in those leads were very specific but not sensitive as a V1 – V2 duration index ≥ 50% and a V1 – V2 amplitude ratio ≥ 30% were present only in 13.04 and 26.08% respectively of patients with a LVOT origin. No measurement in lead V3 showed any correlation with auxological characteristics. The three best ECG variables were: 1) the V3 R wave duration index (R wave \ QRS duration); AUC 0.905, LVOT origin if ≥ 50%, OR 74.80 95% CI [7.97 – 701.48], p < 0.001; 2) the V3 R wave duration; AUC 0.900, LVOT origin if ≥ 80 msec, OR 47.25 95% CI [7.73 – 288.82], p < 0.001; 3) the V3 R wave percentage (amplitude of the R wave with respect to the global amplitude of the QRS, expressed as a percentage); AUC 0.888, LVOT origin if ≥ 50%, OR 36 95% CI [6.19 – 209.06], p < 0.001. Based on the V2 transition ratio calculation formula, we calculated the V3 transition ratio (AUC 0.843, LVOT origin if ≥ 1) which was very sensitive but less specific; OR 30 CI [3.32 – 270.37], p = 0.002. To multivariate analysis, only a V3 R wave percentage ≥ 50% proved to be an independent predictor of LVOT origin; OR 9 CI [2.08 – 38.78], p = 0.003, even if the criterion with the highest accuracy was a V3 duration index ≥ 50% (88.89%). Conclusions. Although it has been poorly analyzed in previous studies on the origin of OTVAs, the morphological characteristics of lead V3 seem to provide valid elements for the creation of diagnostic algorithms. Abstract Figure. Comparison of ECG characteristics

Distinguishing Ventricular Arrhythmias Originating from the Posterior Right Ventricular Outflow Tract, or Near the Right Coronary Cusp or Near the His-Bundle

Differentiation of outflow tract ventricular arrhythmias (OT-VAs) which originate from the posterior right ventricular outflow tract (RVOT), right coronary cusp (RCC) or near the His-bundle are still a challenge until now. This study was aimed to develop a stepwise electrocardiogram (ECG) algorithm to distinguish their locations. Seventy-five consecutive patients with VAs successfully ablated from the posterior RVOT (n = 57), near the His-bundle (n = 5) or RCC (n = 13) were enrolled in our study. Measurements with highest diagnostic performance were chosen to develop a diagnostic algorithm. Of all these ECG measurements, the R-wave amplitude in lead I and V2S/V3R index showed the best diagnostic performance to discriminate these anatomical sites. The optimal ECG discriminators were different combination of lead I and V2S/V3R index as follows: the posterior RVOT, Lead I R-wave amplitude <0.65 mV and V2S/V3R index>1.5 (96.2% sensitivity, 69.6% specificity); the near the His-bundle, lead I R-wave amplitude ≥0.65 mV and V2S/V3R index>1.5 (100% sensitivity, 70% specificity); RCC, lead I R-wave amplitude<0.65 mV and V2S/V3R index ≤1.5 (52.9% sensitivity, 93.1% specificity). Sequential algorithmic application of these criteria resulted in an overall accuracy of 83% in predicting site of OT-VA origin. A predominantly positive R-wave in lead I is seen in OT-VAs originated near the His-bundle. A stepwise ECG algorithm of combination with R-wave amplitude in lead I and V2S/V3R index could localize the origins of OT-VAs from the posterior RVOT, near the His-bundle and the RCC with a high accuracy.

How to use intracardiac echocardiography to guide catheter ablation of outflow tract ventricular arrhythmias

The anatomy of the ventricular outflow tracts and semilunar valves as it pertains to catheter ablation of outflow tract ventricular arrhythmias (OTVAs) has been described. 1 Asirvatham S.J. Correlative anatomy for the invasive electrophysiologist: outflow tract and supravalvar arrhythmia. J Cardiovasc Electrophysiol. 2009; 20: 955-968 Crossref PubMed Scopus (114) Google Scholar Assessment of semilunar valve and regional anatomy by fluoroscopy and angiography has limitations. Coronary arteries may be subject to damage from catheter ablation near the semilunar valves due to their proximity to sites of origin of OTVAs. Detailed intracardiac echocardiographic (ICE) views of the semilunar valves may be useful to understand the anatomy, catheter location, and coronary artery proximity and variations. 2 Enriquez A. Saenz L.C. Rosso R. et al. Use of intracardiac echocardiography in interventional cardiology: working with the anatomy rather than fighting it. Circulation. 2018; 137: 2278-2294 Crossref PubMed Scopus (104) Google Scholar We describe in detail the application of ICE for this purpose during catheter ablation of OTVAs.

236 Modified High Precordial Lead R-Wave Deflection Interval Accurately Predicts Left and Right-Sided Idiopathic Outflow Tract Ventricular Arrhythmias

Electrocardiogram (ECG) prediction algorithms for outflow tract ventricular arrhythmias (OTVA) using standard precordial lead configuration localise OTVA with variable accuracy. We evaluated if modifying ECG precordial leads to a higher intercostal position improved the accuracy of OTVA localisation. Patients undergoing OTVA catheter ablation were prospectively enrolled. Multiple indices were measured to develop an algorithm that differentiated RVOT and LVOT with high accuracy: the modified lead R-wave deflection interval (RWDI). The accuracy of the RWDI was compared to all ECG algorithms using a standard precordial ECG position. Finally, prospective validation of the modified lead RWDI was performed. 40 patients (31 females, mean age 51±18 years) had a successful catheter ablation for OTVA (RVOT 60%, LVOT 40%). The modified lead RWDI was significantly shorter in the RVOT group compared to the LVOT group (16.7±13.4ms vs 66.8±14.4ms, p<0.0005). Using a RWDI <40ms to predict a RVOT focus, the sensitivity and specificity of the modified lead RWDI were both 100% and area under the receiver operator characteristic curve was 1. This was superior to all previously published algorithms. In the validation cohort (n=16 patients), the sensitivity and specificity of the modified lead RWDI was 88% and 75%, respectively. In 2 patients with a failed RVOT ablation, the modified lead RWDI was >40ms, indicating a LVOT focus. The modified lead RWDI is a simple, easily interpretable algorithm that can differentiate a right or left-sided origin of OTVA with high accuracy.

NON-INVASIVE ELECTROANATOMICAL MAPPING FOR PREDICTING SITE OF ORIGIN OF OUTFLOW TRACT VENTRICULAR TACHCYARDIAS

Prediction of site of origin of ventricular arrhythmias (VA) prior to ablation is important for procedural prognostication, risk assessment and preparation. We used noninvasive electrocardiographic mapping (ECM) to identify the origin of outflow tract VAs (OTVA). We included patients with OTVA

Effectiveness of Radiofrequency Catheter Ablation of Outflow Tract Ventricular Arrhythmias in Children and Adolescents

Outflow tract ventricular arrhythmias (OTVAs) are common in children; however, experience is limited on their radiofrequency catheter ablation (RFCA). The purpose of this study was to assess the outcomes of mapping and ablation of pediatric OTVAs and to evaluate the role of ECG algorithms in distinguishing the origin of OTVAs. We compared retrospectively collected single-center data on 92 consecutive pediatric patients (58 male; age, 8.2±2.9 [range 3.6-18] years) who underwent RFCA for OTVAs from 2009 to 2015. Two independent and blinded observers analyzed ECG data. Of these children, 69 (75%) were of RVOT origin. RFCA was given up in 1 case, and the acute success rate was 92.3% (84/91), the 1-year follow-up recurrence rate was 8.3% (7/84) and the complications of the procedure were 2.2% (2/92). And 3D versus 2D mapping-guided RFCA was associated with significantly (p<0.05) higher acute success rate (96.1% [49/51] vs. 87.5% [35/40]), and lower X-ray exposure (742.5±323.1 vs. 1432.3±605.5mGycm2) and 1-year recurrence rate (4.1% [2/49] vs. 14.3% [5/35]). The positive predictive value of four types of ECG algorithms used in adults for LVOT origin was only 47.7-65.4%. In these cases, four identified as RVOT origin and two identified as LVOT origin by ECG underwent successful ablation on the other side of outflow tract finally. And these six children who underwent successful RFCA in both sides of outflow tract had no follow-up recurrence. OTVAs in children originate mostly from RVOT. RFCA can be used for ablation of pediatric OTVAs effectively and safely. In some cases, successful RFCA should be ablated in both sides of outflow tract. ECG-based prediction of OTVA origin as used in adults is limited in children.

Differentiating the origin of outflow tract ventricular arrhythmia using a simple, novel approach.

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. The purpose of this study was to assess a simple criterion for localization of OT-VAs during electrophysiology study. 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). 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. 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.