qrs fragmentation

7/26/2019 QRS Fragmentation

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www.ipej.org 213

Review Article

Fragmented QRS: What Is The Meaning?

Yutaka Take, MD1,2, Hiroshi Morita, MD1,3

1Department of Cardiovasu!ar Mediine, "ka#ama $niversit# %raduate &hoo! of Mediine,Dentistr# and 'harmaeutia! &ienes, ())*++, "ka#ama, -apan2Department of Cardiovasu!ar Mediine, &akakiara Heart /nstitute of "ka#ama, ())*)+23,"ka#ama, -apan.3Department of Cardiovasu!ar Therapeutis, "ka#ama $niversit# %raduate &hoo! ofMediine, Dentistr# and 'harmaeutia! &ienes, ())*++, "ka#ama, -apan

0ddress for Correspondene Hiroshi Morita, Department of Cardiovasu!ar Mediine Cardiovasu!ar Therapeutis, "ka#ama $niversit# %raduate &hoo! of Mediine and Dentistr#,2**1 &hikata*Cho, "ka#ama Cit#, "ka#ama, ())*++, -apan.*mai! hmoritaat.oka#ama*u.a.jp

Abstract

4ragmented 56& 7f56&8 is a onvenient marker of m#oardia! sar eva!uated # 12*!eade!etroardiogram 7C%8 reording. f56& is defined as additiona! spikes within the 56&omp!e9. /n patients with C0D, f56& was assoiated with m#oardia! sar deteted # sing!e

photon emission tomograph# and was a preditor of ardia events. f56& was a!so a preditorof morta!it# and arrh#thmi events in patients with redued !eft ventriu!ar funtion. Theusefu!ness of f56& for deteting m#oardia! sar and for identif#ing high*risk patients has eene9panded to various ardia diseases, suh as ardia saroidosis, arrh#thmogeni rightventriu!ar ardiom#opath#, aute oronar# s#ndrome, :rugada s#ndrome, and a;uired !ong5T s#ndrome. f56& an e app!ied to patients with wide 56& omp!e9es and is assoiatedwith m#oardia! sar and prognosis. M#oardia! sar deteted # f56& is assoiated withsuse;uent ventriu!ar d#sfuntion and heart fai!ure and is a sustrate for reentrant ventriu!artah#arrh#thmias.

e! w"rds:fragmented 56&, m#oardia! sar, ardia event

Intr"d#cti"n

/t has een show in some studies that a sut!e anorma!it# within the 56& omp!e9 anrepresent ondution disturane and m#oardia! sar. 0 noth in the 56& omp!e9 in patientswith !eft ventriu!ar h#pertroph# has een suggested to e a resu!t of an intraventriu!arondution defet pattern of the56& omp!e9


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f56& for the diagnosis and predition of prognosis has e9panded to patients with ishemi andnon*ishemi ardiom#opath# and patients with primar# e!etria! diseases.

Fig#re15C!assifiation of fragmented 56& 7various 6&6> patterns8. 4ragmented 56& was defined as an additiona!

spike of 56& omp!e9es without und!e ranh !ok. @arious 6&6> patterns are present in the mid preordia!!ead or inferior !ead.

Rec"rding and de6initi"n "6 6QRS

C% reording that is used to detet f56& is not a speifi setting and is the same as routine12*!ead C% reording high*pass fi!ter ).)*2) HA 7usua!!# ).1 HA8, !ow*pass fi!ter 1))*1)HA, 0C fi!ter ) or ?) HA, paper speed 2*) mmse 7usua!!# 2mmse8 and vo!tage1mmm@


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Das et a!. defined f56& as the 56& omp!e9es with the presene of an additiona! 6 wave 76>8or nothing in the nadir of the 6 wave or the & wave, or the presene of B1 6> 7fragmentation8in 2 ontiguous !eads, orresponding to a major oronar# territor#. T#pia! und!e ranh !ok7:::8 pattern 756& 12) ms8 and inomp!ete right ::: were e9!uded from the their origina!definition 7Fig#re 18.

f56& on a 12*!ead C% was origina!!# defined as narrow 56& omp!e9 duration 712) ms8. /s f56& ina wide 56& omp!e9 a !inia! indiator of m#oardia! sarE Das et a!. added f56& riteria in awide 56& omp!e9 7 12) ms8 the 56& omp!e9 with B2 6F waves or nothes in the 6 or &wave in a wide 56& omp!e9 of :::, or paed 56&, or premature ventriu!ar omp!e9es7'@C8 in 2 ontiguous !eads. /f the 56& omp!e9 of '@C on!# has 2 nothes in the 6 waves,the# onsidered the 56& omp!e9 to e f56&*positive when the nothes were B G) ms apartand present in 2 ontiguous !eads


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Tae et al0 Fragmented QRS 21.

Mechanism "6 6QRS

f56& an e aused # AigAag ondution around the sarred m#oardium, resu!ting in mu!tip!espikes within the 56& omp!e9


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Fig#re 5 4ragmented 56& in a patient with di!ated ardiom#opath#. C% and images from a (G*#ear*o!d patientwith !eft ventriu!ar d#sfuntion 7ejetion fration 32I8. The patient was diagnosed as having non*ishemidi!ated ardiom#opath#. 012*!ead C% showed right und!e ranh !ok, :8 f56& 7various 6&6F patterns8was present in !eft !atera! and inferior !eads, and C8 de!a#ed enhanement in %a*M6/ was present in theinfero!atera! resion 7white arrows8.

e studied the mehanism under!#ing f56& in an e9perimenta! mode! of :rugada s#ndrome


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8iagn"sis "6 m!"cardial scar in c"r"nar! arter! disease

6esu!ts of the first two studies on f56& in C0D were reported in 2))?


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Tae et al0 Fragmented QRS 21+

instai!ities and adverse ardiovasu!ar events in patients undergoing oronar# arter# #passgraft surger#


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Tae et al0 Fragmented QRS 22*

or seondar# proph#!a9is, ut it ou!d not predit death in that popu!ation


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%lectrical diseases

:rugada s#ndrome is harateriAed # ove*t#pe &T e!evation in right preordia! !eads andepisodes of ventriu!ar tah#arrh#thmia. 9perimenta! studies have shown that &T e!evationand arrh#thmia resu!t from right ventriu!ar repo!ariAation anorma!it#. &ome !inia! studieshave a!so shown the e9istene of depo!ariAation anorma!it# and it was a!so assoiated withhigh*risk patients


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Fig#re ,5 New ana!#sis of fragmented 56& using the first derivation of vo!tage # time 7d@dT8 of the 56&omp!e9. &pikes and nothes within the 56& omp!e9 were !ear!# represented as positive peaks in the d@dTana!#sis. C% and d@dT of the 56& omp!e9 were reorded # 4O*(2G of 4ukuda Denshi Co. Ltd and ana!#Aed# origina! software.

Re6erences

1. &urawiA :, Pni!ans T. Chou>s e!etroardiograph# in !inia! pratie. 'hi!ade!phia!sevierQ 2))+.

2. @arria!e ', Chr#ssos :. The 6&6> omp!e9 not re!ated to right und!e ranh !okdiagnosti va!ue as a sign of m#oardia! infartion sar. 0m Heart - 1JJ2Q1233?J*(?.

3. Das MP, Phan :, -ao &, Pumar 0, Mahenthiran -. &ignifiane of a fragmented 56&omp!e9 versus a 5 wave in patients with oronar# arter# disease. Ciru!ation 2))?Q1132GJ*)1.

G. Das MP, &uradi H, Maskoun , et a!. 4ragmented wide 56& on a 12*!ead C% a sign of

m#oardia! sar and poor prognosis. Cir 0rrh#thm !etroph#sio! 2))+Q12+*?+.

. Das MP, &aha C, ! Masr# H, et a!. 4ragmented 56& on a 12*!ead C% a preditor ofmorta!it# and ardia events in patients with oronar# arter# disease. Heart 6h#thm2))(QG13+*J2.

?. Morita H, Pusano P4, Miura D, et a!. 4ragmented 56& as a marker of ondutionanorma!it# and a preditor of prognosis of :rugada s#ndrome. Ciru!ation 2))+Q11+1?J(*()G.

(. Das MP, Maskoun , &hen C, et a!. 4ragmented 56& on twe!ve*!ead e!etroardiogram

predits arrh#thmi events in patients with ishemi and nonishemi ardiom#opath#. Heart6h#thm 2)1)Q((G*+).

Indian $acing and %lectr"&h!si"l"g! '"#rnal (ISS) *+,2-.2+2/0 12 (/: 213-22 (2*12/


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+. 6edd# C@, Cheriparami!! P, &au! :, et a!. 4ragmented !eft sided 56& in asene of und!eranh !ok sign of !eft ventriu!ar aneur#sm. 0nn Noninvasive !etroardio! 2))?Q11132*+.

J. Das MP, Ripes D'. 4ragmented 56& a preditor of morta!it# and sudden ardia death.Heart 6h#thm 2))JQ?&+*1G.

1). :asaran Y, Tigen P, Paraahmet T, et a!. 4ragmented 56& omp!e9es are assoiated withardia firosis and signifiant intraventriu!ar s#sto!i d#ss#nhron# in nonishemi di!atedardiom#opath# patients with a narrow 56& interva!. hoardiograph# 2)11Q2+?2*+.

11. Tigen P, Paraahmet T, %ure! , et a!. The uti!it# of fragmented 56& omp!e9es to preditsignifiant intraventriu!ar d#ss#nhron# in nonishemi di!ated ardiom#opath# patients witha narrow 56& interva!. Can - Cardio! 2))JQ21(*22.

12. Homsi M, 0!sa#ed L, &afadi :, Mahenthiran -, Das MP. 4ragmented 56& omp!e9es on12*!ead C% a marker of ardia saroidosis as deteted # gado!inium ardia magnetiresonane imaging. 0nn Noninvasive !etroardio! 2))JQ1G31J*2?.

13. 'ark &-, "n YP, Pim -&, et a!. 6e!ation of 4ragmented 56& Comp!e9 to 6ight @entriu!ar4irosis Deteted # Late %ado!inium nhanement Cardia Magneti 6esonane in 0du!tsith 6epaired Tetra!og# of 4a!!ot. 0m - Cardio! 2)12Q1)J11)*.

1G. :reithardt %, Cain M, e!*&herif N, et a!. &tandards for ana!#sis of ventriu!ar !atepotentia!s using high*reso!ution or signa!*averaged e!etroardiograph#. 0 statement # a Task4ore Committee of the uropean &oiet# of Cardio!og#, the 0merian Heart 0ssoiation, andthe 0merian Co!!ege of Cardio!og#. Ciru!ation 1JJ1Q+31G+1*+.

1. %omes -0, Cain M, :u9ton 0, -osephson M, Lee PL, Haf!e# %. 'redition of !ong*

term outomes # signa!*averaged e!etroardiograph# in patients with unsustained ventriu!artah#ardia, oronar# arter# disease, and !eft ventriu!ar d#sfuntion. Ciru!ation2))1Q1)GG3?*G1.

1?. PadS H, Ce#han P, Po 4, Ce!ik 0, "na!an ". 6e!ation etween fragmented 56& ando!!atera! iru!ation in patients with hroni tota! o!usion without prior m#oardia!infartion. 0nado!u Pardi#o! Derg 2)11Q113))*G.

1(. Mahenthiran -, Phan :6, &awada &%, Das MP. 4ragmented 56& omp!e9es not t#pia! ofa und!e ranh !ok a marker of greater m#oardia! perfusion tomograph# anorma!ities inoronar# arter# disease. - Nu! Cardio! 2))(Q1G3G(*3.

1+. Das MP, Mihae! M0, &uradi H, et a!. $sefu!ness of fragmented 56& on a 12*!eade!etroardiogram in aute oronar# s#ndrome for prediting morta!it#. 0m - Cardio!2))JQ1)G1?31*(.

1J. Patsuno T, Hirao P, Pimura &, et a!. Diagnosti signifiane of a sma!! 5 wave inpreordia! !eads @728 or @738. 0nn Noninvasive !etroardio! 2)1)Q111?*23.

2). Yan %H, ang M, Yiu PH, et a!. &u!inia! Left @entriu!ar D#sfuntion 6evea!ed #Cirumferentia! 2D &train /maging in 'atients with Coronar# 0rter# Disease and 4ragmented56& Comp!e9. Heart 6h#thm 2)12QJJ2+*J3.

21. ang DD, :uerke! DM, Corett -6, %urm H&. 4ragmented 56& omp!e9 has poorsensitivit# in deteting m#oardia! sar. 0nn Noninvasive !etroardio! 2)1)Q13)+*1G.



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22. Porhonen ', Husa T, Pontti!a T, et a!. 4ragmented 56& in predition of ardia deaths andheart fai!ure hospita!iAations after m#oardia! infartion. 0nn Noninvasive !etroardio!2)1)Q113)*(.

23. Torigoe P, Tamura 0, Pawano Y, &hinoAaki P, Potoku M, Padota -. The numer of !eadswith fragmented 56& is independent!# assoiated with ardia death or hospita!iAation for heartfai!ure in patients with prior m#oardia! infartion. - Cardio! 2)12QJ3?*G1.

2G. rdogan T, Cetin M, Poaman &0, et a!. 6e!ationship of fragmented 56& with prognostimarkers and in*hospita! M0C in patients undergoing C0:%. &and Cardiovas -2)12QG?1)(*13

2. ong CP, &tewart 60, %ao , 4renh -P, 6affe! C, hite HD. 'rognosti differenesetween different t#pes of und!e ranh !ok during the ear!# phase of aute m#oardia!infartion insights from the Hiru!og and ar!# 6eperfusion or "!usion 7H6"8*2 tria!. urHeart - 2))?Q2(21*+.

2?. 0ri H, Cetinka#a &, 0ri &, Poa @, :oAat T. The prognosti signifiane of a fragmented56& omp!e9 after primar# perutaneous oronar# intervention. Heart @esse!s 2)11Q2(2)*+

2(. 'ietrasik %, %o!denerg /, RdAienika -, Moss 0-, Rarea . 'rognosti signifiane offragmented 56& omp!e9 for prediting the risk of reurrent ardia events in patients with 5*wave m#oardia! infartion. 0m - Cardio! 2))(Q1))+3*?.

2+. Care# M%, Luisi 0-, -r., :a!dwa &, et a!. The &e!vester 56& &ore is more aurate than 5waves and fragmented 56& omp!e9es using the Mason*Likar onfiguration in estimatinginfart vo!ume in patients with ishemi ardiom#opath#. - !etroardio! 2)1)QG331+*2.

2J. Cheema 0, Pha!id 0, immer 0, et a!. 4ragmented 56& and morta!it# risk in patients with!eft ventriu!ar d#sfuntion. Cir 0rrh#thm !etroph#sio! 2)1)Q333J*GG.

3). &ha -, Rhang &, Tang M, Chen P, Rhao O, ang 4. 4ragmented 56& is assoiated with a!!*ause morta!it# and ventriu!ar arrh#thmias in patient with idiopathi di!ated ardiom#opath#.0nn Noninvasive !etroardio! 2)11Q1?2()*.

31. "kutuu &, "to 0. 6isk stratifiation in nonishemi di!ated ardiom#opath# Currentperspetives. Cardio! - 2)1)Q1(21J*2J.

32. &hu!!er -L, "!son MD, Ripse MM, et a!. !etroardiographi Charateristis in 'atients

ith 'u!monar# &aroidosis /ndiating Cardia /nvo!vement. - Cardiovas !etroph#sio!2)11Q2212G3*+.

33. Marus 4/, MPenna -, &herri!! D, et a!. Diagnosis of arrh#thmogeni right ventriu!arardiom#opath#d#sp!asia proposed modifiation of the Task 4ore Criteria. ur Heart -2)1)Q31+)?*1G.

3G. 'eters &, Trumme! M, Poeh!er :. 56& fragmentation in standard C% as a diagnostimarker of arrh#thmogeni right ventriu!ar d#sp!asia*ardiom#opath#. Heart 6h#thm2))+Q1G1(*21.

3. Takagi M, Yoko#ama Y, 0onuma P, 0ihara N, Hiraoka M. C!inia! harateristis and riskstratifiation in s#mptomati and as#mptomati patients with rugada s#ndrome mu!tienterstud# in -apan. - Cardiovas !etroph#sio! 2))(Q1+12GG*1.



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3?. 'riori &%, %asparini M, Napo!itano C, et a!. 6isk stratifiation in :rugada s#ndromeresu!ts of the '6L$D 7'6ogrammed Letria! stim$!ation preDitive va!u8 registr#. -0m Co!! Cardio! 2)12QJ3(*G.

3(. 0ntAe!evith C. 6o!e of transmura! dispersion of repo!ariAation in the genesis of drug*indued torsades de pointes. Heart 6h#thm 2))Q2&J*1.

3+. Haraoka P, Morita H, &aito Y, et a!. 4ragmented 56& is assoiated with torsades de pointesin patients with a;uired !ong 5T s#ndrome. Heart 6h#thm 2)1)Q(1+)+*1G.

3J. Yue M, Davutog!u @, "Aa!a :, et a!. 4ragmented 56& is preditive of m#oardia!d#sfuntion, pu!monar# h#pertension and severit# in mitra! stenosis. Tohoku - 9p Med2)1)Q22)2(J*+3.

G). Porhonen ', Husa T, Tiera!a /, et a!. /nreased intra*56& fragmentation inmagnetoardiograph# as a preditor of arrh#thmi events and morta!it# in patients with ardiad#sfuntion after m#oardia! infartion. - Cardiovas !etroph#sio! 2))?Q1(3J?*G)1.


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