Distinguishing ventricular arrhythmia originating from the right coronary cusp, peripulmonic valve area, and the right ventricular outflow tract: Utility of lead i

Elisa Ebrille, Vishnu M. Chandra, Faisal Syed, Freddy Del Carpio Munoz, Sudip Nanda, Jo Jo Hai, Yong-Mei Cha, Paul Andrew Friedman, Stephen C. Hammill, Thomas M. Munger, K. L. Venkatachalam, Douglas L Packer, Samuel J Asirvatham

Research output: Contribution to journalArticle

10 Citations (Scopus)

Abstract

ECG Lead I and Outflow Tract Arrhythmia Introduction Outflow tract ventricular arrhythmia (OTVA) can be complicated to target for ablation when originating from either the periaortic or pulmonary valve (PV) region. Both sites may present with a small R wave in lead V1. However, the utility of lead I in distinguishing these arrhythmia locations is unknown. Methods and Results Thirty-six consecutive patients (mean age 41 ± 14 years, 13 male) underwent catheter ablation for OTVA. OTVA origin was determined from intracardiac electrogram tracings and electroanatomic maps. Observers blinded to results measured QRS waveform amplitude and duration from standard 12-lead ECG tracings. Measurements with highest diagnostic performance were modeled into an algorithm. Sites of successful ablation were anterior right ventricular outflow tract (RVOT; n = 6), posterior RVOT (n = 4), PV (n = 18), and right coronary cusp (RCC; n = 8). Highest performing surface ECG discriminators were from lead I to V1 vectors: RCC, lead I R wave ≥ 1.5 mV, and V1 R wave ≥2.0 mV (sensitivity 87%, specificity 93%); PV, V1 R wave > 0 mV, and lead I R/(R+S) ≤ 0.75 (sensitivity 78%, specificity 72%); anterior RVOT, V1 R wave = 0 mV, and lead I R/(R+S) <0.4 (sensitivity 67%, specificity 97%); posterior RVOT, V1 R wave > 0 mV, and lead I R/(R+S) > 0.75 (sensitivity 75%, specificity 84%). Sequential algorithmic application of these criteria resulted in an overall accuracy of 72% in predicting site of OTVA origin. Conclusions A relatively large R wave in lead I is seen with RCC origin but not PV origin. A sequential algorithm has limited but potentially significant value beyond assessment of lead I in approaching OTVA.

Original languageEnglish (US)
Pages (from-to)404-410
Number of pages7
JournalJournal of Cardiovascular Electrophysiology
Volume25
Issue number4
DOIs
StatePublished - 2014

Fingerprint

Cardiac Arrhythmias
Pulmonary Valve
Electrocardiography
Sensitivity and Specificity
Cardiac Electrophysiologic Techniques
Catheter Ablation
Lead

Keywords

  • catheter ablation
  • outflow tract
  • premature ventricular contractions
  • right coronary cusp
  • sinus of Valsalva
  • ventricular tachycardia

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

Distinguishing ventricular arrhythmia originating from the right coronary cusp, peripulmonic valve area, and the right ventricular outflow tract : Utility of lead i. / Ebrille, Elisa; Chandra, Vishnu M.; Syed, Faisal; Del Carpio Munoz, Freddy; Nanda, Sudip; Hai, Jo Jo; Cha, Yong-Mei; Friedman, Paul Andrew; Hammill, Stephen C.; Munger, Thomas M.; Venkatachalam, K. L.; Packer, Douglas L; Asirvatham, Samuel J.

In: Journal of Cardiovascular Electrophysiology, Vol. 25, No. 4, 2014, p. 404-410.

Research output: Contribution to journalArticle

Ebrille, Elisa ; Chandra, Vishnu M. ; Syed, Faisal ; Del Carpio Munoz, Freddy ; Nanda, Sudip ; Hai, Jo Jo ; Cha, Yong-Mei ; Friedman, Paul Andrew ; Hammill, Stephen C. ; Munger, Thomas M. ; Venkatachalam, K. L. ; Packer, Douglas L ; Asirvatham, Samuel J. / Distinguishing ventricular arrhythmia originating from the right coronary cusp, peripulmonic valve area, and the right ventricular outflow tract : Utility of lead i. In: Journal of Cardiovascular Electrophysiology. 2014 ; Vol. 25, No. 4. pp. 404-410.
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title = "Distinguishing ventricular arrhythmia originating from the right coronary cusp, peripulmonic valve area, and the right ventricular outflow tract: Utility of lead i",
abstract = "ECG Lead I and Outflow Tract Arrhythmia Introduction Outflow tract ventricular arrhythmia (OTVA) can be complicated to target for ablation when originating from either the periaortic or pulmonary valve (PV) region. Both sites may present with a small R wave in lead V1. However, the utility of lead I in distinguishing these arrhythmia locations is unknown. Methods and Results Thirty-six consecutive patients (mean age 41 ± 14 years, 13 male) underwent catheter ablation for OTVA. OTVA origin was determined from intracardiac electrogram tracings and electroanatomic maps. Observers blinded to results measured QRS waveform amplitude and duration from standard 12-lead ECG tracings. Measurements with highest diagnostic performance were modeled into an algorithm. Sites of successful ablation were anterior right ventricular outflow tract (RVOT; n = 6), posterior RVOT (n = 4), PV (n = 18), and right coronary cusp (RCC; n = 8). Highest performing surface ECG discriminators were from lead I to V1 vectors: RCC, lead I R wave ≥ 1.5 mV, and V1 R wave ≥2.0 mV (sensitivity 87{\%}, specificity 93{\%}); PV, V1 R wave > 0 mV, and lead I R/(R+S) ≤ 0.75 (sensitivity 78{\%}, specificity 72{\%}); anterior RVOT, V1 R wave = 0 mV, and lead I R/(R+S) <0.4 (sensitivity 67{\%}, specificity 97{\%}); posterior RVOT, V1 R wave > 0 mV, and lead I R/(R+S) > 0.75 (sensitivity 75{\%}, specificity 84{\%}). Sequential algorithmic application of these criteria resulted in an overall accuracy of 72{\%} in predicting site of OTVA origin. Conclusions A relatively large R wave in lead I is seen with RCC origin but not PV origin. A sequential algorithm has limited but potentially significant value beyond assessment of lead I in approaching OTVA.",
keywords = "catheter ablation, outflow tract, premature ventricular contractions, right coronary cusp, sinus of Valsalva, ventricular tachycardia",
author = "Elisa Ebrille and Chandra, {Vishnu M.} and Faisal Syed and {Del Carpio Munoz}, Freddy and Sudip Nanda and Hai, {Jo Jo} and Yong-Mei Cha and Friedman, {Paul Andrew} and Hammill, {Stephen C.} and Munger, {Thomas M.} and Venkatachalam, {K. L.} and Packer, {Douglas L} and Asirvatham, {Samuel J}",
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TY - JOUR

T1 - Distinguishing ventricular arrhythmia originating from the right coronary cusp, peripulmonic valve area, and the right ventricular outflow tract

T2 - Utility of lead i

AU - Ebrille, Elisa

AU - Chandra, Vishnu M.

AU - Syed, Faisal

AU - Del Carpio Munoz, Freddy

AU - Nanda, Sudip

AU - Hai, Jo Jo

AU - Cha, Yong-Mei

AU - Friedman, Paul Andrew

AU - Hammill, Stephen C.

AU - Munger, Thomas M.

AU - Venkatachalam, K. L.

AU - Packer, Douglas L

AU - Asirvatham, Samuel J

PY - 2014

Y1 - 2014

N2 - ECG Lead I and Outflow Tract Arrhythmia Introduction Outflow tract ventricular arrhythmia (OTVA) can be complicated to target for ablation when originating from either the periaortic or pulmonary valve (PV) region. Both sites may present with a small R wave in lead V1. However, the utility of lead I in distinguishing these arrhythmia locations is unknown. Methods and Results Thirty-six consecutive patients (mean age 41 ± 14 years, 13 male) underwent catheter ablation for OTVA. OTVA origin was determined from intracardiac electrogram tracings and electroanatomic maps. Observers blinded to results measured QRS waveform amplitude and duration from standard 12-lead ECG tracings. Measurements with highest diagnostic performance were modeled into an algorithm. Sites of successful ablation were anterior right ventricular outflow tract (RVOT; n = 6), posterior RVOT (n = 4), PV (n = 18), and right coronary cusp (RCC; n = 8). Highest performing surface ECG discriminators were from lead I to V1 vectors: RCC, lead I R wave ≥ 1.5 mV, and V1 R wave ≥2.0 mV (sensitivity 87%, specificity 93%); PV, V1 R wave > 0 mV, and lead I R/(R+S) ≤ 0.75 (sensitivity 78%, specificity 72%); anterior RVOT, V1 R wave = 0 mV, and lead I R/(R+S) <0.4 (sensitivity 67%, specificity 97%); posterior RVOT, V1 R wave > 0 mV, and lead I R/(R+S) > 0.75 (sensitivity 75%, specificity 84%). Sequential algorithmic application of these criteria resulted in an overall accuracy of 72% in predicting site of OTVA origin. Conclusions A relatively large R wave in lead I is seen with RCC origin but not PV origin. A sequential algorithm has limited but potentially significant value beyond assessment of lead I in approaching OTVA.

AB - ECG Lead I and Outflow Tract Arrhythmia Introduction Outflow tract ventricular arrhythmia (OTVA) can be complicated to target for ablation when originating from either the periaortic or pulmonary valve (PV) region. Both sites may present with a small R wave in lead V1. However, the utility of lead I in distinguishing these arrhythmia locations is unknown. Methods and Results Thirty-six consecutive patients (mean age 41 ± 14 years, 13 male) underwent catheter ablation for OTVA. OTVA origin was determined from intracardiac electrogram tracings and electroanatomic maps. Observers blinded to results measured QRS waveform amplitude and duration from standard 12-lead ECG tracings. Measurements with highest diagnostic performance were modeled into an algorithm. Sites of successful ablation were anterior right ventricular outflow tract (RVOT; n = 6), posterior RVOT (n = 4), PV (n = 18), and right coronary cusp (RCC; n = 8). Highest performing surface ECG discriminators were from lead I to V1 vectors: RCC, lead I R wave ≥ 1.5 mV, and V1 R wave ≥2.0 mV (sensitivity 87%, specificity 93%); PV, V1 R wave > 0 mV, and lead I R/(R+S) ≤ 0.75 (sensitivity 78%, specificity 72%); anterior RVOT, V1 R wave = 0 mV, and lead I R/(R+S) <0.4 (sensitivity 67%, specificity 97%); posterior RVOT, V1 R wave > 0 mV, and lead I R/(R+S) > 0.75 (sensitivity 75%, specificity 84%). Sequential algorithmic application of these criteria resulted in an overall accuracy of 72% in predicting site of OTVA origin. Conclusions A relatively large R wave in lead I is seen with RCC origin but not PV origin. A sequential algorithm has limited but potentially significant value beyond assessment of lead I in approaching OTVA.

KW - catheter ablation

KW - outflow tract

KW - premature ventricular contractions

KW - right coronary cusp

KW - sinus of Valsalva

KW - ventricular tachycardia

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