1. Prevalence and ECG Features of Outflow Tract Arrhythmias With a Precordial Transitional Zone in Lead V4 Successfully Eliminated From the Coronary Cusp Region
Tatsuya Hayashi, MD; Pasquale Santangeli, MD, PhD; Fermin Garcia, MD; Jackson Liang, DO; Daniele Muser, MD; Simon Castro, MD; Rajeev Pathak, MD; Silvia Magnani, MD; Michael Riley, MD, PhD Mathew Hutchinson, MD; Gregory Supple, MD; David Lin, MD; David Frankel, MS; Robert Schaller, DO; David Callans, MD; Erica Zado, PA-C, Francis Marchlinski, MD
Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, PA
INTRODUCTION
RESULTS
Representative Case of CC Ablation
Cut off of the V3 Transition index
ECG measurements of the Sinus Rhythm
0.8257
0.8078
1.0339
1.1605
1.0487
1.1171
・Catheter ablation of idiopathic outflow tract ventricular arrhythmias (OT-VAs) with a precordial transitional zone in lead V4 (V4-transition) is typically successful from the right ventricular outflow tract (RVOT).
・A total 5 patients (10%) had earlier activation site in CC compared in RVOT, and were successfully ablated from the CC region (mean age 47±13 years, 3 females).
・Out of these 5 cases, 3 (60%) were successfully ablated from the right CC, and 2 (40%) from junction between the right and left CC.
Pacemap in RVOT
(poor)
PM in RCC
(good with pacing delay)
Activation in RCC
(Success Site)
Total (N=51)
CC (N=5)
RVOT (N=46)
p Value
V2 R amplitude (mV)
0.40±0.21
0.34±0.10
0.41±0.22
0.5083
S amplitude (mV)
1.00±0.41
1.05±0.34
1.00±0.42
0.7929
V3 R amplitude (mV)
0.65±0.35
0.57±0.21
0.66±0.37
0.6071
0.75±0.35
1.22±0.22
0.70±0.33
0.0010
V4 R amplitude (mV)
1.16±0.57
1.11±0.36
1.17±0.59
0.8329
0.43±0.24
0.67±0.15
0.40±0.23
0.0141
Transition zone in lead V4
32(63%)
5(100%)
27(59%)
0.1435
Transition zone beforeV4
18(35%)
0(0%)
18(39%)
0.1477
PVC Ⅰ Ⅰ Ⅱ Ⅱ Ⅲ Ⅲ
aVR
aVR
aVL
AIMS
aVF
aVL V1
aVF V2 V1
All cases with successful ablation from CC had sinus rhythm transitional zone in V4 (i.e., equal to the VA) (100%), compared to 27 (59%) of the control patients.
・ We report the prevalence and ECG features of OT-VAs with a V4-transition which were successfully ablated from the coronary cusp (CC) region. V3 V2 V4
Area under the curve=0.942
Clinical Characteristics V3 V5 V6 V4
Total (N=51)
CC (N=5)
RVOT (N=46)
p Value
Age (y.o.)
47±13
44±19
0.6645
female
32(63%)
3(60%)
29(63%)
1.0000
BMI (kg/m2)
28.7±6.6
31.8±8.9
28.3±6.3
0.2751
EF (%)
61±5
57±2
0.0504
symptom
51(100%)
5(100%)
46(100%) -
Syncope or pre-syncope
6(18%)
1(20%)
5(11%)
0.4799
VT/NSVT
15(29%)
2(40%)
13(30%)
0.6239
VAs burden(%)
20±15
39±19
18±13
0.0148 HT
6(12%)
4(9%)
0.0993
DLP
2(4%)
0(0%) DM
Previous session in other institute
7(14%) V5
ABL d
Algorithm To Predict the Successful Ablation from CC region V6
ABL p
METHODS
ECG Index to Predict the Success Site
(CC vs RVOT)
ECG measurements of the VAs
・We studied 51 consecutive patients (mean age 47±13 years, 32 females) who underwent successful catheter ablation of OT-VAs with a V4- transition. All patients had structurally normal heart according to standard TTE and/or MRI, and a normal QRS in sinus rhythm (no bundle branch and fascicular block). 　　　　　　　　　　　　　　　　　　　　　　　　　　　　 ・ ECG characteristics of the sinus QRS and OT-VA were analyzed and compared according to published criteria. In addition, the V2 and the V3 transition ratio was calculated by computing the percentage R-wave during VA (R/R+S) divided by the percentage R-wave in sinus rhythm (R/R+S).
Sinus Transition zone before V4
V3 Transition index <0.8
RVOT ablation
Yes No
CC ablation
Total (N=51)
CC (N=5)
RVOT (N=46)
p Value
V2 transition index
0.38±0.39
0.21±0.34
0.40±0.39
0.3082
V3 transition index
0.67±0.32
1.19±0.29
0.61±0.27
<0.0001
V2S/V3R index
4.5±2.9
2.85±0.65
4.73±2.95
0.1652
V3S/V4R index
1.61±0.94
0.67±0.21
1.72±0.93
0.0157
V2 R/S index
0.12±0.14
0.06±0.08
0.13±0.14
0.2741
V3 R/S index
0.42±023
0.58±0.19
0.41±0.23
0.1090
Total (N=51)
CC (N=5)
RVOT (N=46)
p Value
VAs QRS duration (ms)
149±17
146±17
0.6941
MDI
0.47±0.13
0.63±0.06
0.44±0.12
0.0007
I R amplitude (mv)
0.20±0.17
0.25±0.18
0.19±0.17
0.4671
I S amplitude (mv)
0.10±0.13
0.12±0.11
0.10±0.14
0.7209
II R amplitude (mv)
1.48±0.42
1.90±0.30
1.43±0.41
0.0151
III R amplitude (mv)
1.45±0.49
1.86±0.40
1.41±0.48
0.0492
III/II R amplitude ratio
0.97±0.14
0.97±0.13
0.97±0.15
0.9262
aVR Q amplitude (mv)
0.72±0.20
0.90±0.15
0.70±0.19
0.0332
aVL Q amplitude (mv)
1.02±0.58
0.91±0.28
0.67±0.33
0.1130
aVL/aVR Q amplitude ratio
1.05±0.37
1.02±0.60
0.9049
aVF R amplitude (mv)
1.46±0.44
1.86±0.32
1.42±0.43
0.0311
V1 R amplitude (mv)
0.10±0.11
0.03±0.06
0.1351
V1 S amplitude (mv)
1.20±0.47
0.97±0.35
1.23±0.48
0.2494
V2 R amplitude (mv)
0.23±0.22
0.10±0.16
0.25±0.23
0.1826
V2 S amplitude (mv)
1.97±0.76
1.68±0.32
2.00±0.79
0.3802
V2R deflection interval (ms)
22±15
11±18
23±15
0.0898
V2R duration (ms)
33±21
17±26
34±20
0.0833
V2S duration (ms)
112±23
111±38
112±21
V3 R amplitude (mv)
0.49±0.22
0.62±0.22
0.48±0.22
0.1815
V3 S amplitude (mv)
1.33±0.54
1.08±0.29
1.36±0.55
0.2778
V3R deflection interval (ms)
45±14
47±23
45±13
0.8055
V3R duration (ms)
63±18
73±29
62±16
0.1992
V3S duration (ms)
80±18
52±20
83±15
0.0001
V4 R amplitude (mv)
0.99±0.48
1.74±0.60
0.90±0.39
<0.0001
V4S amplitude (mv)
0.14±0.20
0.12±0.27
0.8089
V4R deflection interval (ms)
69±23
84±37
67±21
0.1089
V4 R duration (ms)
121±38
119±50
121±37
0.9031
V4 S duration (ms)
22±30
6±13
23±31
0.2212
V5 R amplitude (mv)
1.30±0.54
2.14±0.82
1.21±0.42
V6 R amplitude (mv)
1.30±0.47
1.84±0.74
1.23±0.40
0.0052
sensitivity
100%
specificity
82%
PPV
38%
NPV
Accuracy
84%
Multivariate Analysis
Distribution of the Success Site
CONCLUSIONS
Univariate (P value)
Multivariate (P value)
MDI
0.0007
0.9834
II R amplitude
0.0151
0.9999
III R amplitude
0.0492
0.9987
aVR Q amplitude
0.0332
aVF R amplitude
0.0311
1.0000
V3 Transition Index
<0.0001
V3S/V4R Index
0.0157
0.9994
V3 S duration
0.0001
V4 R amplitude
V5 R amplitude
0.9991
V6 R amplitude
0.0052 AP lt
NCC : Non-coronary cusp
RCC : Right-coronary cusp
LCC : Left-coronary cusp
R-L J : Right-Left coronary cusp junction
LCC
RCC
NCC
RVOT 5 15 3 4 2
R-L J V3
a: R amplitude in sinus rhythm
b: S amplitude in sinus rhythm
c: R amplitude in VAs
d: S amplitude in VAs a b c d e f
sinus
VAs g
Transition Index
=(c/c+d) / (a/a+b)
e: R duration in VAs
f : S duration in VAs
g: R deflection interval in VAs
(from onset of QRS to top of R)
・OT-VAs with a V4-transition can be successfully eliminated from the coronary cusp region in up to 10% of cases.
・ Sinus rhythm transitional zone in V4 (i.e., equal to the VA), and the V3 transition index can help to identify the successful ablation site for those VAs.
The authors declare no relevant disclosures