Volume 13, Issue 1, Pages (January 2016)

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Volume 13, Issue 1, Pages 217-225 (January 2016) Vectorcardiographic QRS area identifies delayed left ventricular lateral wall activation determined by electroanatomic mapping in candidates for cardiac resynchronization therapy Masih Mafi Rad, MD, Gilbert W.M. Wijntjens, MD, Elien B. Engels, MSc, Yuri Blaauw, MD, PhD, Justin G.L.M. Luermans, MD, PhD, Laurent Pison, MD, PhD, Harry J. Crijns, MD, PhD, Frits W. Prinzen, PhD, Kevin Vernooy, MD, PhD Heart Rhythm Volume 13, Issue 1, Pages 217-225 (January 2016) DOI: 10.1016/j.hrthm.2015.07.033 Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 1 Vectorcardiogram consisting of 3 orthogonal leads X, Y and Z (left), which together form a 3D vector loop (right). The green/red loop represents the QRS vector loop and the blue/purple loop the T vector loop. Blue arrow represents the maximal QRS vector, and black arrow represents the maximal T vector. QRSAREA is calculated using the integral between the ventricular deflection curve and the baseline from QRS beginning to end in leads X, Y, and Z. Heart Rhythm 2016 13, 217-225DOI: (10.1016/j.hrthm.2015.07.033) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 2 Coronary venous electroanatomic map of a left bundle branch block patient demonstrating delayed activation of the left ventricular (LV) anterolateral wall (A), an intraventricular conduction delay (IVCD) patient demonstrating absence of delayed LV lateral wall activation (B), an intraventricular conduction delay (IVCD) patient demonstrating delayed activation of the LV inferolateral wall (C), a RBBB patient demonstrating absence of delayed LV lateral wall activation and a longer activation time of the right ventricle than the LV lateral wall (D), and a RBBB patient with a potential left anterior hemiblock, demonstrating delayed activation of the LV anterolateral wall (E). AIV = anterior interventricular vein; ALV = anterolateral vein; AP = anteroposterior; AT = electrical activation time; CS = coronary sinus; ILV = inferolateral vein; LAO = left anterior oblique; RA = right atrium; RAO = right anterior oblique; RBBB = right bundle branch block; RV = right ventricle. Heart Rhythm 2016 13, 217-225DOI: (10.1016/j.hrthm.2015.07.033) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 3 Receiver operating characteristic curves for QRS duration, QRSAMPL, and QRSAREA. The area under the curve (AUC) signifies the performance of each parameter for identifying delayed left ventricular lateral wall activation and is given for each parameter with the 95% confidence interval (CI). Heart Rhythm 2016 13, 217-225DOI: (10.1016/j.hrthm.2015.07.033) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 4 A: QRSAREA plotted as function of maximal left ventricular lateral wall activation time (maxLVLW-AT) expressed as percentage of QRS duration (QRSd) for the entire study cohort. Each dot represents a patient. B–F: Same plot as A, but with left bundle branch block (LBBB) diagnosed according to the definition provided by the REVERSE5 (B) and MADIT-CRT trial6(C), ESC Textbook of Cardiovascular Medicine4 (D), AHA3 (E), and Strauss et al13 (F). IVCD = intraventricular conduction delay; RBBB = right bundle branch block. Heart Rhythm 2016 13, 217-225DOI: (10.1016/j.hrthm.2015.07.033) Copyright © 2016 Heart Rhythm Society Terms and Conditions