[PDF] - Surface ECG Recognition / 1200 Localization of Idiopathic PDF Document

SLIDE 1

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 85 808 761 1199 233 1216

200 400 600 800 1000 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 A V 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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Free Wall Septum

3 2 1 3 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 Wall Septum

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

2 1 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 1.16 R 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.

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Activation n in RVO VOT LBI PVCs with transition ≥ V4 Mapping in the Right Cusp LBI PVC Pace Map

Distance 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

riginating 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 Cardiol2019;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 Cardiol2019;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 - <1.45 Successful Unsuccessful Anatomic Distance <13.5mm Abularach et al Heart Rhythm. 2012;9:865-873 9pts 7pts Other clues:

<5 ms difference

in activation

 Output better

PM match

Ablation from Adjacent Sites

Clue for Successful ablation – Better PM Match with High Output Pacing (Index of Anatomical Proximity)

Santangeli and Marchlinski. Heart Rhythm 2015. In Press

>20 mA ≤20 mA

AIV LCC LV endo RVOT

Targeting the inaccessible area of LV summit from antero-septal RVOT

Frankel et al, Circulation A&E, 2014;7:984

RAO LAO

Frankel et al, Circulation A&E, 2014;7:984

Targeting the inaccessible area of LV summit from antero-septal RVOT

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Septal - Parahisian AMC Sup MA Sup Lat MA Lat MA

1 2 4 5 3

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 arrhythmogenic by design?

Developmentally the outflow tract (OFT) is derived from the second heart field

which is molecularly and phenotypically different from the first heart field that gives rise to the left ventricle.

The prenatal OFT remains undifferentiated and slowly conducting until it is

incorporated into the RVOT; it is devoid of Tbx5 (which is required for expression of Cx40) and has no Cx43 expression.

Remnants of the embryonic OFT phenotype and expression profile in the adult

RVOT may determine its electrophysiologic characteristics and vulnerability to arrhythmias.

There is heterogeneity over the apex to base axis of the heart and fate based

mapping studies in the chicken heart show that cells located initially in the A V canal and OFT will become part of the base of ventricles.

Proximity of Outflow Tract Structures

RVOT & Cusps

LCC RVOT LCC RVOT

Cusps & GCV

LCC GCV LCC GCV

Basal LV & GCV

GCV Basal LV GCV Basal LV

Epicardial ablation of LV Summit VT: PENN experience

Over 10 year period, 86 patients

with LV summit VT ablated.

In the majority (n=63; 73%) the VT

was successfully ablated from adjacent structures.

In remaining 23 patients, epicardial

ablation was attempted in 14 and was successful in only 5.

Presence of ≥2 of the previous ECG

criteria predicted epicardial success with 100% sensitivity and 72% specificity.

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

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Outflow Tract Tachycardia: Unique Features

Mechanism: Triggered rhythm (DAD mediated)
Focal site of origin
Absence of structural heart disease
Morphology of clinical arrhythmia can be mimicked by

pace-mapping

Pace mapping can be used to develop ECG criteria for

localizing site(s) of origin of clinical tachycardias

Electro-anatomic mapping facilitates accurate catheter

localization and pace mapping

V A I II III aVR V6 aVL aVF V5 V4 V3 V2 V1 CSPi CSD

A B

LV RVA

VT Originating From The Epicardium

Clinical PVC: LBBB, Inferior Axis, Small R wave in lead V1

QRS Duration (msec) PDR in Lead II PDR in Lead V3 PDR  0.55 in Lead II

r V3

R / S < 1 in Lead V2

QS morphology in Lead I

EPI VT 19751 0.530.17* 0.510.12 6/7 (88%)* 6/7 (88%)*

7/7 (100%)*

ENDO VT 17421 0.460.09 0.370.08

* p < 0.05

ECG Characteristics of Epicardial versus Endocardial VT

Bala, Dixit, et al. HRS 2006

Differentiating Epicardial from Endocardial location in the Anterior LV required ≥ 2 of the 3 pre-specified criteria

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E.C.G. Criteria for Distinguishing Epicardial from Endocardial VT

riginating in the Superior / Basal Left Ventricle
ECG recordings of epicardial VT in 7

pts (all right bundle branch block morphology) were compared to VT

riginating from corresponding

endocardial sites in 6 pts

ECGs were specifically analyzed for:

➢ 1) Peak deflection ratio (PDR): Ratio of time to 1st peak / nadir and QRS duration (QRSd) in leads II and V3 ➢ 2) Lead V2: Ratio of R and S wave amplitude ➢ 3) Lead I: QRS morphology

Bala, Dixit, et al. HRS 2006

Epicardial Sites Endocardial Sites

Coronary Sinus AIV LCC NCC RCC

R V O T

LVOT

1st RF Lesion……………………………

E.C.G. Criteria for Distinguishing Epicardial from Endocardial VT

riginating in the Superior / Basal Left Ventricle
ECG recordings of epicardial VT in 7

pts (all right bundle branch block morphology) were compared to VT

riginating from corresponding

endocardial sites in 6 pts

ECGs were specifically analyzed for:

➢ 1) Peak deflection ratio (PDR): Ratio of time to 1st peak / nadir and QRS duration (QRSd) in leads II and V3 ➢ 2) Lead V2: Ratio of R and S wave amplitude ➢ 3) Lead I: QRS morphology

Bala, Dixit, et al. HRS 2006

Epicardial Sites Endocardial Sites

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1 2 3 T V PV

RV

1 2 3 3 2 1 Anterior Posterior S e p t u m Free Wall

Typical Site(s) of Origin For RVOT Tachycardia

Site 1

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Site 2

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Site 3

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Site 1

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 aVR

Site 3

I II III aVL aVF V1 V2 V3 V4 V5 V6 100 msec 1 mV

Localizing Basal LV VT

M V A V Sup Septum

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 I

AMC

II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Superior MA

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Sup-Lateral MA

I II III aVR aVL aVF V1 V2 V3 V4 V5 V6 I II III aVR aVL aVF V1 V2 V3 V4 V5 V6

Parahisian

107 59 121 232 217 56 366 50 100 150 200 250 300 350 400

VT CAD VT RVCM* VT LVCM RVOT VT LVOT VT Idio LV VT Other VT

UPENN VT Ablations 1999- 2008

(1158 VT ablation procedures )

Distribution of Idiopathic VT: PENN Experience

1999 – 2003 (N = 431) 2004 – 2008 (N = 705) P Value RVOT

103 (24%) 115 (16%) P < 0.01

LVOT

24 (6%) 95 (14%) P < 0.001

LV & RVOT

4 (1%) 10 (1%) P = NS

Fascicular VT

18 (4%) 30 (4%) P = NS

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Circulation 2006;113:1169
Circulation 2006;113:1169

RVOT Cusps Basal LV VT PM

Betensky, Gerstenfeld, et al, JACC 2011;57:2255

RVOT LVOT