identifying the origin of vt : ecg correlation and entrainment
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Identifying the Origin of VT Identifying the Origin of VT ::
ECG Correlation and EntrainmentECG Correlation and Entrainment
Yan Yao, MD, PhD
Arrhythmia CenterFuwai Heart Hospital-Cardiovascular Institute
Chinese Academy of Medical SciencesBeijing, China
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Activation of Right Ventricle (RV) during Sinus Rhythm
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Activation of Left Ventricle (LV) during Sinus Rhythm
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Frontal versus Horizontal Planes
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Normal QRS Vector in Three Dimensions
Emanuel Stein
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Lead Grouping According to the Region They Covered
Inferior
LateralLateral
LateralLateral
LateralLateral
Septal & Posterior
Anterior
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The Most Common Clinical VT Types
Idiopathic VT:– Ventricular Outflow Tract (VOT) VT:
RVOT VT;LVOT VT;
– Idiopathic Left VT:Fascicular LVT;Basal LVT;
Structural VT:– Ischemic VT;– ARVC VT;– Bundle Branch Reentrant (BBR) VT;– Others (DCM, HCM, Chaga, et al.);
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1, RVOT VT1, RVOT VTThe most common VT type;ECG features: LBBB + Inferior QRS axis;
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Anatomic ConsiderationsPA is superior, anterior and leftward of Aorta.RVOT is adjacent to Aortic cusp.
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Common Patterns of Outflow Tract VTs
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ECG in Localizing RVOT VT
Jadonath: Am Heart J 1995;130:1107
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Utility of ECG in Localizing RVOT VTUtility of ECG in Localizing RVOT VT
Jadonath: Am Heart J 1995;130:1107
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AblHBE
HBE
Abl
RAO 30 LAO 45
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FW1 FW2 FW3Site 1 Site 2 Site 2-3 Site 3
Septal
Free Wall
Free Wall Origin:-later precordial transition
- QRS duration -notching in II, III, avF-lower amplitude in II, III, avF
ANT
Septal Origin:Post (1) Ant (3)lead I: positive to negative for both FW and septum
Post Ant
RV Coronal View
RVOT VT ECG Patterns
PV
II
VV11
IIII
IIIIII
AvRAvR
AvLAvL
AvFAvF
VV22
VV33
VV44
VV55
VV66
Post Ant
POST
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The Value of Lead I in Localizing RVOT VT Origin
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Para-Hisian RVOT VT
Yamauchi Y. J Cardiovasc Electrophysiol, 2005; 16:1041
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Yamauchi Y. J Cardiovasc Electrophysiol, 2005; 16:1041
Para-Hisian RVOT VT
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Multiple Origins in RVOTMultiple Origins in RVOT
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Large substrate (42x38mm)
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2, LVOT VT2, LVOT VTECG features: -Inferior QRS axis;
-Broad R in lead V1(duration >40% of QRS,and amplitude >30%));-Early transition ( <V3);
LCC
Abl
HBE
LAO45
VT with LCC origin
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Left Coronary Cusp VT
Kanagartnam: JACC 2001;37:1408
most leftward cusp rS in lead I;broad R in lead V1
perfect pacemap
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Ouyang F: JACC 2002;39:500
Outflow Tract and Aortic Cusp VT
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Spatial Relationship of LCC & RVOT Anterior Septal Origins
RAO 30
LAO 45
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Anatomical Relationship BetweenRVOT and LVOT
Ouyang F: JACC 2002;39:500
TV
MV
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12
3
PV
TV
typical RVOT locations
LVOT: Mitral-Aortic Continuity
RVOT inflow
LV epicardium
Mitral annulus
AVMV
MVMV
TVTV
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VT/VPC Originating from the Junction of the Left & Right Coronary Sinus of Valsalva
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Yamada T: Heart Rhythm 2008;5:184
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3, Idipathic LV Basal VT
ECG Patterns:ECG Patterns:–– The The ratio of QRS complexes in leads II / III:ratio of QRS complexes in leads II / III:
>1 for septal-parahisian (S-P) and lateral mitralannular (MA) sites;≤1 for aortomitral continuity (AMC), superior MA, and superolateral MA locations;
–– MedialMedial sites (SP/AMC) sites (SP/AMC) vsvs laterallateral sites sites ((superolateralsuperolateral and lateral MA):and lateral MA):
narrower QRS complexes (134±24 msec vs.182±18 msec; P<0.05)initial negative lead V1 and predominantly positive forces in lead I (amplitude 0.59±0.27 mV vs. 0.16±0.34 mV; P <0.05).
Dixit S. Heart Rhythm 2005;2:485
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LV Anterior Basal VT
Ao
MVA
LAO 45
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LVOT VT from Aorto-Mitral Continuity
Site of Successful Ablation
“RBBB” in V1
early precordialtransition by V3
R/s in lead I
RAO LAO
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Comparison of ECG Patterns of LVVT: Medial vs Lateral LV Sites
Dixit S. Heart Rhythm 2005;2:485
QRS width(msec)
Initial negative force in lead V1
Early precordialtransition
Amplitude in lead I
(mV)
Medial basal LV sites (S-P & AMC) 134 ± 28 * 20/24 *
(85%)24/24 * (100%)
0.59 ±0.27*
Lateral basal LV sites (Sup-Lat & Lat MA) 182 ± 18 0/22 0/22 0.16 ± 34
Septal-parahisia
nAMC Superior
MASuperolateral MA
Lateral MA
Lead I R or Rs Rs or rs rs or rS rS or QS rS or rs
Lead V1 QS or Qr qR R or Rs R or Rs R or Rs
Precordialtransition
Early None None None None or late
Ratio of lead II/III
>1 ≤1 ≤1 ≤1 >1
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HISAbove AVA-M ContinuitySuperior MVSupero-Lat MVLateral MV
Medial to Lateral:- R to r/s in lead I - LBB to RBB in V1- wider QRS LV Posterior View
AVAVMVMV
LV Basal VT ECG Patterns
II
VV11
IIII
IIIIII
AvRAvR
AvLAvL
AvFAvF
VV22
VV33
VV44
VV55
VV66
Epicardial:qR in lead I
-RBB in V1- wider QRS
qR in V1:AMC
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Kumagai K, JCE 2005, 16:1029-1036
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Basal LV VT with poster-lateral MVA origin
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4, Fascicular VT:posterior fascicle origin
ECG features:RBBB + Left RBBB + Left axis deviation;axis deviation;
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RF on
Typical Ablation Target
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4, Fascicular VT:anterior fascicle origin
ECG features: RBBB + Right axis deviation
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Left Para-Hisian VTECG features: narrow QRS with similar morphology of sinus rhythm;
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Target site: 3mm below the distal portion of His bundle
RF on
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5, Ischemic VT
Reentrant mechanism;The ECG only reflect the location of exit.
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Basal VT
Summary of Specific Regions of VT Origin
Septal VT
Anterior Infarction Inferior Infarction
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Current Mapping Strategy to Ischemic VT
Substrate Mapping
(CARTO, ESI array/NavX)
Entrainment Mapping
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Entrainment Mapping
PPI VT CL
S S S S S
Stimulate with a CL that 20-30ms shorter than spontaneous VT at the site with MDP recorded:1,QRS identical with VT in12 leads;2,Stim-QRS is about equal with MDP-QRS (±10 ms); 3,Post pacing interval (PPI) is equal with the CL of VT (±10 ms);
Pacing at the common pathway of reentrant:1+2+3;Pacing at out loop: fusion + 3;Pacing outside of reentrant circuit: different morphology & PPI;Pacing at bystander:1+prolonged 2&3;
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MDP & Entrainment
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47 yro male with prior MI(inferior、posterior wall history.2 years history of VT after CABG;UCG: LVED 65mm , LVEF 40%.
Ischemic VT Case
Sinus Rhythm Clinical VT
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The earliest potential was 14 ms earlier that ECG;
Mapping in RV
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Entrainment mapping failed.
Mapping in RV
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Mapping in LV
The earliest potential was 28 ms earlier that ECG;;
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Mapping in LV
Concealed entrainment ,S-QRS:24ms;VTCL 356ms;PPI 372ms
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6, VT with Epicardail Origin
ECG features: significantly longer pseudo-delta wave (≥ 34 ms) , intrinsicoid deflection and RS complex duration compared to VT with endocardial origin.
Identification of Epicardial Origin of VT
Sensitivity Specificity
Pseudo-delta wave ≥ 34 ms 83% 95%
intrinsicoid deflection ≥ 85 ms 87% 90%
RS complex duration ≥ 121 ms 76% 85%
Berruezo A. Circulation 2004;109:1842
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65 yro male;Post-MI and PTCA+CABG; Incessant VT for 1 month;Irrigation ablation at endocardialwith 50 Watts terminated VT after 60 sec.
54ms
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Lim H, PACE 2006
Epicardiacmapping of VTwith isolated noncompaction of ventricular myocardium
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7, ARVC VT
ECG features: LBBB + S or s wave in any of the inferior leads.
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ARVC VT 40yr/M with history of presyncope
281ms
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VT 1 (210bpm) terminated
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VFL induced (CL 201ms)
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Fast VT terminated
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ARVC VTs with Multiple Exits
36 36 yroyro male with male with history of syncope.history of syncope.
CL 254ms
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Simple Steps for VT Origin Identification
V1
LBBB RBBB
Inferior Leads(II/III/avF)
R S or s
RVOT RVIT(ARVC ?)
R
LVOT or LV Basal VT
Fascicular VT
Structural VT