Localization of precise origin of PVC and VT

: ECG anatomic correlation

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삼성서울병원
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 RVOT/LVOT Tachycardia

• ages of 30~50 yrs

• More frequent in women
• LBBB-like complex with tall R-waves in the inferior leads.
• 70~90% of VT patients with a structurally normal heart.
• Arrhythmia episodes
: rare or frequent isolated PVCs, bursts of nonsustained VT, or sustained
tachycardia often facilitated by catecholamines.
: Exercise/emotion induced
• Symptoms: ranging from none to palpitations, lightheadedness, dyspnea,
presyncope, or syncope.
• Sustained or nonsustained episodes occur in response to burst pacing
facilitated by the infusion of isoproterenol, atropine or aminophylline
suggest that the triggered activity by delayed afterdepolarizations
(DAD) rather than reentry is the mechanism.

• Termination in response to verapamil, adenosine and enhanced vagal

tone which lead to decreased stimulated intracellular calcium levels.

• Termination of VT by adenosine
diagnostic of a cyclic adenosine monophosphate (cAMP) dependent
mechanism mediated by triggered activity dependent on DAD

• Prognosis is almost benign

• A malignant variant : relatively early triggered beats in the vulnerable
period of the repolarization phase resulted in VF.
Correlative Anatomy of Outflow Tract

A supravalvular portion of the aorta is a unique site for arrhythmia origin

where the arrhythmogenic substrate for atrial arrhythmias, ventricular
arrhythmias, and accessory pathways may all be located.
Relationship between RVOT and LVOT
Ventricular Outflow Tract Tachycardia
ECG recognition of outflow tract tachycardia location

• Frontal plane axis

• Precordial QRS transition
• QRS width
• complexity of the QRS in the inferior leads
Anatomic Considerations

1. The RVOT is anterior and to the left of the LVOT.

• Simultaneous mapping on the posterior RVOT and the anterior wall

of the LVOT should be performed to identify the true earliest site of
origin.
• The top of RVOT may be crescent shaped, with the posteroseptal
region directed rightward and the anteroseptal region directed leftward.
Anatomic Considerations

1. The RVOT is anterior and to the left of the LVOT.

• The anteroseptal aspect of RVOT is located in close proximity to the
LV epicardium, adjacent to the AIV and the LAD.
• The posteroseptal aspect of RVOT is adjacent to the region of the
RCC, and the anterior septal surface is adjacent to the anterior margin
of the RCC or the medial aspect of the LCC.
ECG-Anatomic correlation
• RVOT tachycardia shows LBBB morphology with inferior axis (R waves in II,III,aVF)
and QS complexes in aVR and aVL.

• Lead V1 : negative (LBBB morphology)

• Origin of arrhythmia in the posterior RVOT or origin near or above the pulmonic
valve (left side of the body) gives rise to an initial R wave in lead V1.
• R wave in lead V1 : clue to the potential anatomic sites of origin

Asirvatham SJ. J Cardiovasc Electrophysiol. 2009;20:955

R wave in lead V1 : clue to the potential anatomic sites of origin

• Anterior RVOT (1) : a typical LBBB morphology in lead V1

• (2), (3) : between the posterior RVOT and the anterior right coronary cusp (RCC) of the
aortic valve. A small but variable R wave is seen in lead V1.
• (4) : more posteriorly in the region of the left coronary cusp (LCC)/aortic mitral
continuity(AMC) /noncoronary cusp(NCC) characterized with a distinct R wave in V1.
• Even more posterior and leftward origin (the posterior mitral annulus) : RBBB morphology.

Asirvatham SJ. J Cardiovasc Electrophysiol. 2009;20:955

Lead I
• The focus near or above the pulmonic valve (leftward in the body): typically
all negative (QS complex)
• Origin on the right side of the RVOT (free wall): positive lead I
• Origin either in the anterior or posterior portion of the RVOT : biphasic pattern
Leads aVR and aVL (Both leads are superior leads.)

• Outflow tract VT (right or left) in a superior location : negative (QS complexes)

deflections in aVL and aVR
• Peri-His bundle region in the RVOT (most rightward and inferior portion)
: lead aVL (a left-sided lead) becomes isoelectric or slightly positive,
lead aVR (a right-sided lead) remains negative
• Suprapulmonary VT (anatomic location of the site in the left side of the body)
: greater amplitude negatively in the aVL compared to aVR
Leads II, III, and aVF
• All outflow tract arrhythmias show a positive deflection in leads II, III, aVF.
• The ratio of positivity (R-wave amplitude) : a clue to the site of origin.

• Suprapulmonary valve arrhythmia : a taller R wave in lead III than in II.

(the anatomic leftward location of the PV and lead III being an inferior
and rightward lead)
• The left main coronary artery is just posterior to the PV closely related to the overlying LAA base.
• Epicardial fat between the right atrial appendage, aortic valve and around the right coronary artery.
• The aortocaval ganglia is located between the nearly adjacent ascending aorta and SVC.
LBBB morphologies with right inferior axis
: VT arising from the anterior septal side of the RVOT,
from the right or left coronary cusp, and
from the pulmonary artery.

- R-wave progression : LV or the aortic cusp

- R waves in V1 and V2 and a transition by lead V3
: left-sided outflow tract VT,
- Later transitions at V3 and V4 : RVOT or the pulmonary artery
Monomorphic ventricular tachycardia with LBBB morphology and an
inferior axis : DDx of RVOT and ASC origin

A Total QRS duration(ms)

B R-wave duration (ms)
C R-wave amplitude (mV)
D S-wave amplitude (mV) Ouyang F. J Am Coll Cardiol 2002;39:500
 RVOT Localization
QRS: Free wall vs Septal

• QRS duration  140 msec

• QRS notching in inferior leads
• Lead V3 R/S ratio  1

Dixit . JCE 2003;14:1

Joshi . JCE 2005;16suppl:S52
 RVOT Localization
Lead I: Anterior vs Posterior

Dixit . JCE 2003;14:1

Joshi . JCE 2005;16suppl:S52
 - RVOT vs LVOT
(QRS transition V3-V4)
FW RVOT – transition V4-V5
Septal RVOT – transition V3-V4
RCC – transition V2-V3
LCC – transition V1-V2

- Free wall vs Septum

Free Wall – notching in QRS in II, III, aVF
– QRS  140ms

- Anterior vs posterior RVOT site

Anterior : Site 3 – lead I negative
(more leftward)
Site 2 – lead I biphasic
Site 1 – lead I positive
(more rightward)

site 1 (posterior/right), site 2 (mid), and site 3 (anterior/left)

 VT with LBBB morphology and inferior axis

RV OT PA LVOT ASV LV epi CS Total

Ito S 55(69%) 7(9%) 11(14%) 7(9%) 80
Tanner 20(61%) 1(3%) 5(15%) 2(6%) 2(6%) 3(9%) 33
Sekiguchi Y 92(72%) 24(19%) 11(9%) 148
Iwai S 100(82%) 22(18%) 122

267(70%) 25(7%) 58(15%) 12(3%) 383 (100%)

Ito S. J Cardiovasc Electrophysiol. 2003;14:1280

Tanner H. J Am Coll Cardiol 2005;45:418
Sekiguchi Y. J Am Coll Cardiol 2005;45:887
Iwai S. J Cardiovasc Electrophysiol, Vol. 2006;17:1
Anatomic Considerations

1. The RVOT is anterior and to the left of the LVOT.

(Simultaneous mapping on the posterior RVOT and the anterior wall of the LVOT should be performed to
identify the true earliest site of origin.)

2. Myocardium extends above the semilunar valves into the great arteries.

• Myocardial sleeves commonly extend fairly symmetrically crossing each

of the 3 pulmonary valve cusps. The extension can vary from a few mm
up to more than 2 cm into the pulmonary artery.

• Extensions proceed more leftward and superiorly into the PA

; EKG shows a strong right inferior access
negative in lead I, large R waves in II, III, aVF,
deep QS complexes in aVR and aVL,
S wave being deeper in aVL than in aVR
Anatomic Considerations

1. The RVOT is anterior and to the Left of the LVOT.

(Simultaneous mapping on the posterior RVOT and the anterior wall of the LVOT should be performed to
identify the true earliest site of origin.)

2. Myocardium extends above the semilunar valves into the great arteries.

• Myocardial sleeves commonly extend fairly symmetrically crossing each of

the 3 pulmonary valve cusps. The extension can vary from a few mm up to
more than 2 cm into the pulmonary artery.
•

• Myocardial extensions above aortic valve

• RCC frequently exhibits myocardial sleeves.
• LCC, because of its partial continuity of the anterior leaflet of the valve,
has not been demonstrated to have ventricular myocardial extensions.
• The NCC at its junction of the RCC may have sleeves of ventricular
myocardium.
• Because of these complex extensions and interface with the subvalvular
ventricular myocardium, the arrhythmia may have variable exits.
Anatomic Considerations

3. Because of the anatomic proximity and continuity of the outflow tracts,

the best location to map or ablate an arrhythmia in the RVOT may be from
the supravalvular LVOT or vice versa.
proximity of the posterior RVOT and anterior aortic valve cusps

posterior RVOT

anterior aortic cusps

Early precordial transition zone (RS ratios ≥1 in leads V1 or V2) usually
arise from the LVOT (basal septum or aortic commissures) or LV epicardium.
LVOT VT
1. VT from RCC : transition V2-V3
VT from LCC : transition V1-V2
2. R-wave duration index ≥50% and R/S ratio ≥30% in lead V1 or V2

A Total QRS duration(ms)

B R-wave duration (ms)
C R-wave amplitude (mV)
D S-wave amplitude (mV)
Ouyang F. J Am Coll Cardiol 2002;39:500
Chun KRJ. Herz 2007;32:226
40% (73/181) R wave duration index 60% (100/167) ≥50%
27% (0.51/1.86) R/S amplitude ratio 46% (0.98/2.13) ≥30%

Chun KRJ. Herz 2007;32:226

Bala R. Marchlinski FE. Heart Rhythm 2007;4:366
LVOT VT

1. VT from RCC : transition V2-V3

VT from LCC : transition V1-V2

2. R-wave duration index ≥50% and R/S ratio ≥30% in lead V1 or V2

• Aging may draw the aortic valve down in a vertical tilt in relation to the pulmonic
valve.
• RCC tachycardias can exhibit a QRS complex in lead II > lead III and a
biphasic (positive/negative) complex in lead aVL.
• The LCC remains superior and exhibits a positive QRS in the frontal plane axis.

• In young patients with a vertical heart, the QRS complex in lead I may be
negative in and around both the LCC and RCC regions.
• In patients with a horizontal heart, the area surrounding the aortic valve will be
directed rightward relative to the LV apex/lateral wall, and a positive QRS
complex in lead I can be seen.
ECG of Ventricular Outflow Tract Tachycardia

V1,V2: LVOT V4~V6: RVOT

Ito S. J Cardiovasc Electrophysiol. 2003;14:1280

• Aortography reveals major anatomic landmarks in the aortic root in LAO and RAO.
• The mapping catheter is located underneath the LCC.
• RF energy should be delivered under continuous fluoroscopy to avoid coronary artery injury.
(aortic cusp: 55 °C, 15~30 W, 120 s; LVOT below the aortic valve: 55 °C, 30~40 W, 120 s).
• Before application of RF energy at epicardial sites (irrigated tip flow rate 17 ml/min, 43 °C,
20~30 W, 110 s), a coronary angiogram should be performed.
Ventricular arrhythmias originating from the RCC/LCC commissure

unique ECG
• QS morphology in lead V1 with notching on
the downward deflection
• precordial transition at lead V3
• presence of late potentials in sinus rhythm at
the site of successful ablation

• 37 patients (16%) of 233 RV/LV OT tachycardia

: aortic cusp region
• 19 (51%) of 37 patients: RCC–LCC commissure
• 15 (79%) of 19 patients : a notch on the downward
deflection of the QS complex in lead V1
• 4 patients : a “w” pattern in lead V1
• 16 of 19 patients: the precordial transition
occurred by lead V3
• 3 patients transition occurred by lead V4
• 8 of 19 patients : late potential

• 13 (26%) of 50 patients from septal RVOT

: QS in lead V1 with a notch
• 3 of 13 septal RVOT patients: the precordial
transition occurred by lead V3
• Late potential : not seen in septal RVOT

Bala R. Marchlinski FE. Heart Rhythm 2010;7:312

Ventricular arrhythmias originating from the RCC/LCC commissure
RCC–LCC commissure septal RVOT (50
(19 patients) patients)
QS in lead V1 with a notch 15 (79%) patients 13 (26%) patients p<0.01
4 patients : a “w” pattern in V1

Precordial transition by lead V3 13 (87%) of 15 patients with notch in V1 3 of 13 (23%) patients p<0.01
with notch in V1

Late potential in sinus rhythm at the 8 (42%) of 19 patients 0 p<0.01

site of successful ablation

combination of a notch pattern in V1, 8 (42%) of 19 patients 0 p<0.01

precordial transition at lead V3, and the late
potentials

Bala R. Marchlinski FE. Heart Rhythm 2010;7:312

• The AMC (aorto–mitral continuity) on the endocardium
qR complex in V1
Rs/rs complex in I

• VT originating further leftward across the anterior mitral annulus : the R wave
in lead I diminishes and a broad, positive R wave is seen in lead V1.
 Idiopathic Epicardial LV VT
• Perivascular sites of origin
• Catecholamine enhanced, adenosine sensitive
• 5~10% of idiopathic VT

Daniels DV. Circulation. 2006;113:1659

 ECG of Idiopathic Epicardial LV VT

• Precordial MDI >0.55 reliably identified EPI VT.

MDI : the maximum deflection index

TMD: time to maximum deflection in precordial lead

Daniels DV. Circulation. 2006;113:1659

 LV epicardial VT

• Typical QS complex in lead I

• Characteristic pattern break from leads V1~V3, with relative negativity in V2
• delayed pattern of initial QRS activation
Bala R. Marchlinski FE. Heart Rhythm 2007;4:366
LVOT Epicardial VT

pseudo-delta wave (widening of the initial QRS complex)

Chun KRJ. Herz 2007;32:226

Idiopathic RV arrhythmias not from the outflow tract
but from the body of RV

29 VT from the body of RV

Most VTs originate from the RV free wall.
50% from the TVA region. Herendael HV. Marchlinski FE. Heart Rhythm 2011;8:511
Idiopathic RV arrhythmias not from the outflow tract
Apical versus basal or valvular site of origin :
• precordial R-wave transition
• polarity in the inferior leads
• amplitude of R wave in lead II
• S wave in lead aVR

Herendael HV. Marchlinski FE. Heart Rhythm 2011;8:511

 Take Home Messages
• Anatomic relationship between RVOT and LVOT
: RVOT is anterior and to the left of the LVOT
• ECG recognition of outflow tract tachycardia location
• R wave in lead V1 : clue to the potential anatomic sites of origin
• Precordial QRS transition: RVOT vs LVOT (RCC, LCC)
• Lead I : right vs left side of RVOT site
QRS width: free wall vs septum of RVOT
Leads aVR and aVL : peri-His bundle region and suprapulmonary VT
Leads II, III, and aVF: suprapulmonary VT
• R-wave duration index ≥50% and R/S ratio ≥30% in lead V1 or V2 :
LVOT (RCC, LCC)
• Precordial MDI >0.55, delayed pattern of initial QRS activation,
pseudo-delta wave : epicardial LV VT