9/14/2019 UPENN PVC / VT Ablations 1999-2018 (N = 4729) 1400 Surface ECG Recognition / 1200 Localization of Idiopathic Ventricular 1000 40% Arrhythmias 800 1216 1199 600 Sanjay Dixit, M.D. Professor, University of Pennsylvania School of Medicine 808 761 400 Director, Cardiac Electrophysiology, Philadelphia V.A.M.C. 200 233 238 144 85 45 0 ICM ARVC/D LVCM Idio RV Idio LV ILVT Pap VF trig Other Outflow Tract Tachycardias: Typical ECG Manifestations Outflow Tract and Basal Interventricular Septal Region: I I I Common sites of origin for idiopathic VAs II II II III III - Inferiorly III PV directed axis aVR aVR aVR Anteroseptal Sup. RVOT Superior Basal Epicardium aVL aVL Aortic Cusp Region aVL - Left or Right aVF AV aVF Bundle branch aVF Aorto-Mitral Continuity V 1 Block pattern V 1 V 1 Superior & lateral MA V 2 V 2 MV TV V 2 V 3 V 3 V 3 Infero-basal septum V 4 V 4 V 4 V 5 Infero-basal Crux V 5 V 5 V 6 V 6 - Heart model figure courtesy Samuel Asirvatham, MD V 6 1
9/14/2019 RVFW RV Septal RCC LV Septal LCC AMC I PV II III A V aVR MV aVL Influence of Cardiac Orientation on Unique ECG Manifestations of Outflow Tract Tachycardias: aVF Morphology in lead V 1 & Precordial Transition V1 AV NC RC LC MV RVOT V6 Position of ECG Leads V 1 & V 2 : Localization of Outflow Tract Tachycardia Anterior RVOT Left-Right Cusp Change in position: Influence of Cardiac Orientation on Unique ECG Leads V 1 and V 2 Manifestations of Outflow Tract Tachycardias: Morphology in limb lead I - Anter, Dixit et al, Heart Rhythm 2012;9:697 2
9/14/2019 3 2 1 3 2 1 Position of ECG Lead I: Superior RVOT I I Free Wall Localization of Outflow Tract Tachycardia II II III III aVR aVL aVR aVL aVF aVF 2 3 1 V1 V1 PV V2 V2 3 1 2 V3 V3 Septum V4 V4 V5 V5 V6 V6 Septum Free Wall - Dixit S et al, J Cardiovasc Electrophysiol. 2003;13(1):1-7 - Anter, Dixit et al, Heart Rhythm 2012;9:697 Aortic Cusp Region Right Coronary Cusp Left Coronary Cusp The V2 Transition Ratio: A New ECG Criterion for Distinguishing LV From RV Outflow Tachycardia Origin I I II Patient 1 Patient 2 II III III I V1 V1 I aVR aVR V2 V2 aVL II II aVL aVF 3 1 2 aVF V3 V3 III RVOT III V 1 V4 V4 V 1 R V 2 R V5 V5 V 2 V 3 L L V 3 V 4 V6 V6 V 4 F V 5 V 5 F V 6 Betensky … Gerstenfeld. JACC 2011;57:2255 -62 V 6 3
9/14/2019 Results – V2 Transition Ratio RVOT (n=18) LVOT (n=18) V1 V1 R R V2 1.16 0.29 V2 S S V3 V3 TRANSITION RATIO = RCC (R/R+S) VT V4 V4 (R/R+S) SR 0.6 V5 NCC V5 V6 V6 The V2 Transition Ratio: A New ECG Criterion for Summary – ECG Criteria OT PVCs Distinguishing LV From RV Outflow Tachycardia Origin RVOT Patient 2 LVOT Patient 1 I V1 V1 I LBB/inferior, precordial xition = V4 RVOT V2 V2 II LBB/inferior, precordial xition ≤ V2 II Ao cusp V3 V3 LBB/inferior, precordial xition = V3 V2 ratio III III V4 V4 LBB/inferior, precordial xition ≥V5 *Consider ARVC R R V5 V5 L L V6 V6 F F *Hoffmayer et al. JACC 2011;58:831-838. Betensky … Gerstenfeld. JACC 2011;57:2255 -62 4
9/14/2019 LBI PVCs with transition ≥ V 4 Distance between earliest RVOT & Cusp location: 1cm LBI PVC Mapping in the Right Cusp Pace Map Activation n in RVO VOT LV Summit: Anatomic Correlates AIV GCV R V O LCC T LVOT RCC NCC 5
9/14/2019 LV Summit VT: ECG Manifestations LV Summit VT: ECG Manifestations I I I I I II II II II II III III III III III aVR aVR aVR aVR aVR aVL aVL aVL aVL aVL aVF aVF aVF aVF aVF V 1 V 1 V 1 V 1 V 1 V 6 V 6 V 6 V 6 V 6 PERCUTANEOUS EPICARDIAL ABLATION OF VENTRICULAR ARRHYTHMIAS ARISING FROM THE LEFT VENTRICULAR SUMMIT: OUTCOMES AND ECG PREDICTORS OF SUCCESS ECG Features associated Localizing idiopathic ventricular arrhythmias with successful epicardial ablation of LV summit originating from the inferior basal septal region 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 6
9/14/2019 ECG features of VAs originating from the basal infero-septal LV 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 - Jackson L, Dixit S et al. J Am Coll Cardiol2019;5:833-42 ECG features of VAs originating from the slow pathway region Inferior lead discordance in idiopathic ventricular arrhythmias PV AV TV MV SPR Region Mod. Band AL Pap Muscle - Briceno D, Dixit S et al. Heart Rhythm Journal 2019;16:1421 - Enriquez A et al. JCE 2017;28:1179-1186 7
9/14/2019 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. Influence of Age on Cardiac Orientation in the Thoracic Cavity A. B. PV Other Challenges to ECG AV Localization of Outflow Tract MV AV TV Tachycardias MV TV - Maeda S, Lin D et al. 8
9/14/2019 VT Above The Right / Left Coronary Cusp Margin RVOT VT Originating Above Pulmonic Valve - Timmermans, et al., Circulation 2003 - Bala et al, Heart Rhythm 2010;7:312 VPD/VT from GCV/AIV – Accessible Area The Inaccessible Area Ablation from Adjacent Structures QS in lead I 1 LCC, LV Endo, RVOT I I III AIV aV LCC AIV R LCC aV NCC LCC L RCC aV NCC F RCC V1 RVOT Rs in V1 LV Endo CS CS Os Os V6 Santangeli, Marchlinski et al. Card EP Clinic. 2015 In Press W.A. McAlpine Collection-UCLA Cardiac Arrhythmia Center (with permission) 9
9/14/2019 Ablation from LCC or Adjacent Endocardium of VT Ablation from Adjacent Sites Source Near the AIV (Earliest site/best PM) -16pts Clue for Successful ablation – Better PM Match with Clue for Successful ablation – Anatomical Proximity High Output Pacing (Index of Anatomical Proximity) Anatomic Distance ECG clue - Q wave ratio aVL/aVR - <1.45 <13.5mm ≤20 mA >20 mA Unsuccessful Successful 7pts 9pts Other clues: • <5 ms difference in activation • Output better PM match Santangeli and Marchlinski. Heart Rhythm 2015. In Press Abularach et al Heart Rhythm. 2012;9:865-873 Targeting the inaccessible area of LV summit from Targeting the inaccessible area of LV summit from antero-septal RVOT antero-septal RVOT RAO LAO RVOT AIV LV LCC endo - Frankel et al, Circulation A&E, 2014;7:984 - Frankel et al, Circulation A&E, 2014;7:984 10
9/14/2019 Is the outflow tract region arrhythmogenic by design? 1 2 3 4 5 Lat MA Sup Lat MA Sup MA AMC Septal - Parahisian PA View I I II II III III 3 4 2 AV aVR aVR 5 M V 1 aVL aVL aVF • Developmentally the outflow tract (OFT) is derived from the second heart field aVF which is molecularly and phenotypically different from the first heart field that V 1 gives rise to the left ventricle. V 1 • The prenatal OFT remains undifferentiated and slowly conducting until it is V 2 incorporated into the RVOT; it is devoid of Tbx5 (which is required for expression of Cx40) and has no Cx43 expression. V 3 V 2 Superior • Remnants of the embryonic OFT phenotype and expression profile in the adult RVOT may determine its electrophysiologic characteristics and vulnerability to V 3 V 4 Lateral Septal arrhythmias. V 4 • V 5 There is heterogeneity over the apex to base axis of the heart and fate based V 5 Inferior mapping studies in the chicken heart show that cells located initially in the A V V 6 canal and OFT will become part of the base of ventricles. V 6 200 msec - Heart Rhythm, 2005 Proximity of Outflow Tract Structures Epicardial ablation of LV Summit VT: RVOT & Cusps Cusps & GCV Basal LV & GCV PENN experience • Over 10 year period, 86 patients LCC GCV with LV summit VT ablated. LCC • Basal In the majority (n=63; 73%) the VT GCV LV was successfully ablated from RVOT adjacent structures. • In remaining 23 patients, epicardial ablation was attempted in 14 and was successful in only 5. GCV • Presence of ≥2 of the previous ECG RVOT criteria predicted epicardial success LCC with 100% sensitivity and 72% specificity. LCC Basal GCV LV - Santangeli, Dixit et al, Circulation A&E, 2015;8:337 11
Recommend
More recommend
