Prevalence and ECG Features of Outflow Tract Arrhythmias With a Precordial Transitional Zone in Lead V4 Successfully Eliminated From the Coronary Cusp.

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Presentation transcript:

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