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Ablation of Wide QRS Complex Tachycardias in Structurally · PDF file 2019. 10. 10. · Surface ECG Recognition / Localization of Idiopathic Ventricular Arrhythmias ... Distinguishing

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Text of Ablation of Wide QRS Complex Tachycardias in Structurally · PDF file 2019. 10....

  • 9/14/2019

    1

    Surface ECG Recognition /

    Localization of Idiopathic Ventricular

    Arrhythmias

    Sanjay Dixit, M.D.

    Professor, University of Pennsylvania School of Medicine

    Director, Cardiac Electrophysiology, Philadelphia V.A.M.C.

    45 144

    238 85

    808761

    1199

    233

    1216

    0

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    800

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    1200

    1400

    ICM ARVC/D LVCM Idio RV Idio LV ILVT Pap VF trig Other

    UPENN PVC / VT Ablations 1999-2018

    (N = 4729)

    40%

    Outflow Tract and Basal Interventricular Septal Region:

    Common sites of origin for idiopathic VAs

    MV TV

    PV

    AV

    - Heart model figure courtesy Samuel Asirvatham, MD

    Anteroseptal Sup. RVOT

    Aortic Cusp Region

    Aorto-Mitral Continuity

    Superior Basal Epicardium

    Superior & lateral MA

    Infero-basal septum

    Infero-basal Crux

    Outflow Tract Tachycardias: Typical ECG Manifestations I

    II

    III

    aVR

    V6

    aVL

    aVF

    V5

    V4

    V3

    V2

    V1

    I

    II

    III

    aVR

    V6

    aVL

    aVF

    V5

    V4

    V3

    V2

    V1

    I

    II

    III

    aVR

    V6

    aVL

    aVF

    V5

    V4

    V3

    V2

    V1

    - Inferiorly

    directed axis

    - Left or Right

    Bundle branch

    Block pattern

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    Influence of Cardiac Orientation on Unique ECG

    Manifestations of Outflow Tract Tachycardias:

    Morphology in lead V1 & Precordial Transition

    RVOT

    AV

    MV

    RC LC

    NC

    MV

    AV

    PV

    aVR

    RVFW

    aVF

    V1

    V6

    II

    I

    III

    aVL

    RV Septal RCC LV Septal LCC AMC

    Position of ECG Leads V1 & V2:

    Localization of Outflow Tract Tachycardia

    - Anter, Dixit et al, Heart Rhythm 2012;9:697

    Change in position:

    Leads V1 and V2

    Anterior RVOT Left-Right Cusp

    Influence of Cardiac Orientation on Unique ECG

    Manifestations of Outflow Tract Tachycardias:

    Morphology in limb lead I

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    3

    Free Wall

    Septum

    3 2 13 2 1

    PV

    aVF

    V2

    V3

    V4

    V5

    V6

    II

    I

    III

    aVR

    aVL

    V1

    aVF

    V2

    V3

    V4

    V5

    V6

    II

    I

    III

    aVR

    aVL

    V1

    Free WallSeptum

    1 2

    3

    1 2

    3

    Superior RVOT

    - Dixit S et al, J Cardiovasc Electrophysiol. 2003;13(1):1-7

    Position of ECG Lead I:

    Localization of Outflow Tract Tachycardia

    - Anter, Dixit et al, Heart Rhythm 2012;9:697

    RVOT

    Right Coronary Cusp

    I

    II

    III

    aVR

    V6

    aVL

    aVF

    V5

    V4

    V3

    V2

    V1

    Left Coronary Cusp

    I

    II

    III

    aVR

    V6

    aVL

    aVF

    V5

    V4

    V3

    V2

    V1

    21 3

    Aortic Cusp Region The V2 Transition Ratio: A New ECG Criterion for Distinguishing LV From RV Outflow Tachycardia Origin

    I

    II

    III

    R

    L

    F

    I

    II

    III

    R

    L

    F

    V1

    V2

    V3

    V4

    V5

    V6

    V1

    V2

    V3

    V4

    V5

    V6

    Patient 1 Patient 2

    Betensky … Gerstenfeld. JACC 2011;57:2255-62

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    RVOT (n=18) LVOT (n=18)

    TRANSITION RATIO =

    (R/R+S)VT (R/R+S)SR

    0.29 1.16R S

    R S

    V1

    V2

    V3

    V4

    V5

    V6

    V1

    V2

    V3

    V4

    V5

    V6

    Results – V2 Transition Ratio

    0.6

    RCC

    NCC

    The V2 Transition Ratio: A New ECG Criterion for

    Distinguishing LV From RV Outflow Tachycardia Origin

    I

    II

    III

    R

    L

    F

    I

    II

    III

    R

    L

    F

    V1

    V2

    V3

    V4

    V5

    V6

    V1

    V2

    V3

    V4

    V5

    V6

    RVOT LVOT

    Betensky … Gerstenfeld. JACC 2011;57:2255-62

    Patient 1 Patient 2

    Summary – ECG Criteria OT PVCs

    LBB/inferior, precordial xition = V4 RVOT

    LBB/inferior, precordial xition ≤ V2 Ao cusp

    LBB/inferior, precordial xition = V3 V2 ratio

    LBB/inferior, precordial xition ≥V5 *Consider ARVC

    *Hoffmayer et al. JACC 2011;58:831-838.

    http://files.abstractsonline.com/CTRL/FF/0/330/A04/FB0/4F6/9A9/3DA/DD1/306/321/D1/g7049_1.jpg

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    Activation in RVOT LBI PVCs with transition ≥ V4 Mapping in the Right CuspLBI PVC Pace MapDistance between earliest RVOT & Cusp location: 1cm

    LV Summit: Anatomic Correlates

    GCV AIV

    LCC

    NCC RCC

    R V O

    T

    LVOT

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    LV Summit VT: ECG Manifestations

    I

    II

    III

    aVR

    V1

    aVL

    aVF

    V6

    I

    II

    III

    aVR

    V1

    aVL

    aVF

    V6

    I

    II

    III

    aVR

    V1

    aVL

    aVF

    V6

    LV Summit VT: ECG Manifestations

    I

    II

    III

    aVR

    V1

    aVL

    aVF

    V6

    I

    II

    III

    aVR

    V1

    aVL

    aVF

    V6

    PERCUTANEOUS EPICARDIAL ABLATION OF VENTRICULAR ARRHYTHMIAS

    ARISING FROM THE LEFT VENTRICULAR SUMMIT: OUTCOMES AND ECG

    PREDICTORS OF SUCCESS

    ECG Features associated

    with successful epicardial

    ablation of LV summit

    VT:

    1. Q wave ratio in leads

    aVL/aVR >1.85.

    2. R/S wave ratio in lead V1

    >2.

    3. Lack of initial “q” wave

    in lead V1.

    - Santangeli, Dixit et al, Circulation A&E, 2015;8:337

    Localizing idiopathic ventricular arrhythmias

    originating from the inferior basal septal region

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    ECG features of VAs originating from the basal infero-septal LV

    - Jackson L, Dixit S et al. J Am Coll Cardiol 2019;5:833-42

    ECG features to differentiate VAs originating from

    infero-basal LV endocardium Vs infero-basal crux region

    - Jackson L, Dixit S et al. J Am Coll Cardiol 2019;5:833-42

    ECG features of VAs originating from the slow pathway region

    - Briceno D, Dixit S et al. Heart Rhythm Journal 2019;16:1421

    MV TV

    PV

    AV

    Inferior lead discordance in idiopathic ventricular arrhythmias

    - Enriquez A et al. JCE 2017;28:1179-1186

    SPR Region Mod. Band AL Pap Muscle

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    ECG localization of VAs arising from the outflow

    tract region and inferior basal septum: Summary

    • Although these arrhythmias originate from narrow zones, they manifest distinct ECG morphologies.

    • Careful analysis of 12 lead ECG can help in successful localization of the site of origin of these arrhythmias.

    • To facilitate accurate ECG localization attention should be paid to lead placement, precordial transition patterns, patient’s body habitus and age.

    Other Challenges to ECG

    Localization of Outflow Tract

    Tachycardias MV

    TV

    AV

    AV

    MV TV

    PV A. B.

    Influence of Age on Cardiac Orientation in

    the Thoracic Cavity

    - Maeda S, Lin D et al.

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    - Timmermans, et al., Circulation 2003

    RVOT VT Originating Above Pulmonic Valve

    - Bala et al, Heart Rhythm 2010;7:312

    VT Above The Right / Left Coronary Cusp Margin

    VPD/VT from GCV/AIV – Accessible Area

    I

    I I III

    aV R aV L

    aV

    F V1

    V6

    QS in lead

    1

    Rs in V1

    Santangeli, Marchlinski et al. Card EP Clinic. 2015 In Press

    CS

    Os

    LCC

    RCC NCC

    AIV

    NCC

    RCC

    LCC AIV

    CS

    Os

    The Inaccessible Area Ablation from Adjacent Structures

    LCC, LV Endo, RVOT

    LCC

    LV Endo

    RVOT

    W.A. McAlpine Collection-UCLA Cardiac Arrhythmia Center (with

    permission)

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    Ablation from LCC or Adjacent Endocardium of VT

    Source Near the AIV (Earliest site/best PM) -16pts

    Clue for Successful ablation – Anatomical Proximity

    ECG clue - Q wave ratio aVL/aVR -

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    Septal - ParahisianAMCSup MASup Lat MALat MA

    1 2 4 53

    M V

    AV

    3

    1

    2 4

    5

    Inferior

    Superior

    Lateral Septal

    200 msec

    I

    II

    III

    aVR

    V6

    aVL

    aVF

    V5

    V4

    V3

    V2

    V1

    I

    II

    III

    aVR

    V6

    aVL

    aVF

    V5

    V4

    V3

    V2

    V1

    PA View

    - Heart Rhythm, 2005

    Is the outflow tract region arrhythmoge