董建增 首都医科大学北京安贞医院 ECG Outflow Tract VT

内容 Ventricular outflow tract VT  right ventricular outflow tract septal （ anterior ， mid ， posterial ） free wall  left ventricular outflow tract supra valvular (above aortic valve) left cusp ， right cusp ， non-coronary infra valvular (below aortic valve)  others para-His ， epicardially…. LV RV

心室流出道有关解剖 Suleiman M, Heart Rhythm 2008;5:1485

VT from Septal RVOT I: ±, R/S transition late

I II III R L F V1 V2 V3 V4 V5 V6 ②①③④ Electrocardiogram Characteristics of VT from RVOT *ILs I R/L V 1 R/S s /V 5-6 ① R ± =1 QS >V 3 no ② R ± =1 QS >V 3 no ③ R ± =1 rS >V 3 no ④ R ＋ =1 QS >V 2 no *ILs = inferior leads Septal Wall: ① ②③ Free Wall : ④

J Cardiovasc Electrophysiol 2003; 14: 1-7 Electrocardiographic Patterns of Superior RVOTs: Distinguishing Septal and Free-Wall Sites of Origin

J Cardiovasc Electrophysiol 2003; 14: 1-7 Electrocardiographic Patterns of Superior RVOTs: Distinguishing Septal and Free-Wall Sites of Origin Septal free wall

J Cardiovasc Electrophysiol 2003; 14: 1-7 Electrocardiographic Patterns of Superior RVOTs: Distinguishing Septal and Free-Wall Sites of Origin

J Cardiovasc Electrophysiol 2003; 14: 1-7 Electrocardiographic Patterns of Superior RVOTs: Distinguishing Septal and Free-Wall Sites of Origin

VT from Supravalvular LVOT 30ms ↗ aVR<aVL ↗ rS/ S too shallow ↗ rS/ r too big ↗ V5 terminated by tiny s

VT from Supravalvular LVOT I II III R L F V1 V2 V3 V4 V5 V6 Abl pace map activation map 40ms

VT from infravalvular LVOT I: more negative, R/S transition V1

I II III R L F V1 V2 V3 V4 V5 V6 ⑥⑤⑦⑧ Electrocardiogram Characteristics of VT from LVOT *ILs I R/L V 1 R/S s /V 4-6 ⑤ R - - <1 R <V 1 yes ⑥ R - <1 Rs <V 3 yes ⑦ R - V 3 no ⑧ R - <1 rS <V 3 yes *ILs = inferior leads Infra-valvular: ⑤ Supra-valvular: ⑥⑦⑧

J Cardiovasc Electrophysiol 2002; 13: Left Ventricular Outflow Tract Tachycardia Originating from the Right Coronary Cusp

J Cardiovasc Electrophysiol 2002; 13: Left Ventricular Outflow Tract Tachycardia Originating from the Right Coronary Cusp

Noncoronary aortic cusp J Cardiovasc Electrophysiol, 2012; 23,

Epicardial Radiofrequency Ablation of an Unusual and Unexpected Ventricular Tachycardia J Cardiovasc Electrophysiol 2009; 20:

Ablation of Left Ventricular Epicardial Outflow Tract Tachycardia From the Distal Great Cardiac Vein J Am Coll Cardiol 2006; 48: 1813–17

J Am Coll Cardiol 2005;45:418 –23 Outflow Tract Tachycardia With R/S Transition in Lead V3

J Cardiovasc Electrophysiol 2011; 22: Ventricular Arrhythmias Arising from the Right Ventricular Septum Close to the His Bundle

LSV Left sinus Vlsalva LV end LV endocardium LV epi LV epicardium Near His near His bundle RV right ventricle J Cardiovasc Electrophysiology 2003; 14: ECG Algorityhm for Identifying the Optimal Ablation Site for Idiopathic Outflow Tract VT

脑子中装 3 份体表心电图 典型右室流出道间隔部 典型左室流出道左冠瓣上 典型左室流出道主动脉瓣下

胸导联位置位置关系 Holter 的差异 左中右 上下前后

J Cardiovasc Electrophysiol 2008: 19: Variants of Idiopathic Left Ventricular Outflow Tract Ventricular Tachyarrhythmias

J Cardiovasc Electrophysiol 2008: 19: Variants of Idiopathic Left Ventricular Outflow Tract Ventricular Tachyarrhythmias

J Cardiovasc Electrophysiol 2008: 19: ECG Variants of Idiopathic Left Ventricular Outflow Tract Ventricular Tachyarrhythmias ASC-VTs MA AMC

J Cardiovasc Electrophysiol 2005; Epicardial Left Ventricular Outflow Tract Tachycardia from the Anterior Interventricular Coronary Vein

J Cardiovasc Electrophysiol 2005; Epicardial Left Ventricular Outflow Tract Tachycardia from the Anterior Interventricular Coronary Vein

J Am Coll Cardiol 2005;45:418 –23 Outflow Tract Tachycardia With R/S Transition in Lead V3

J Cardiovasc Electrophysiol 2011; 22: Effect of Limb Lead Electrodes Location on ECG and Localization of Idiopathic Outflow Tract Tachycardia

ECG: ARVC vs. RVOT J Am Coll Cardiol 2011;58:831–8 Examples of Measurements Examples of Notching

ECG: ARVC vs. RVOT J Am Coll Cardiol 2011;58:831–8 Characteristic Features ARVC Duration of QRS in lead I of 120 ms Notching on QRS complex Notching on upstroke of QRS Multiple notching of the QRS across several leads Earliest onset of QRS on lead V1 Transition at V5 or later†

The V2 Transition Ratio The V2 transition ratio is a novel electrocardiographic measure that reliably distinguishes LVOT from RVOT origin in patients with lead V3 precordial transition J Am Coll Cardiol 2011;57:2255–62 Electrocardiographic Measurements B/(B+C) VT ÷ E/(E+F) SR LVOT PVCs vs. RVOT PVCs vs ; p V2 transition ratio 0.60 predicted an LVOT origin with 91% accuracy A PVC precordial transition occurring later than the sinus rhythm transition excluded an LVOT origin with 100% accuracy

Am J Cardiol 2010; 105: 1821–1824 Precordial TWI to Distinguish Arrhythmogenic Right Ventricular Cardiomyopathy from Idiopathic Ventricular Tachycardia Arising from the Right Ventricular Outflow Tract During sinus rhythm, 37 patients (47%) with ARVC and 5 patients (4%) with RVOT tachycardia had TWI in leads V1 to V3. For the diagnosis of ARVC, TWI in leads V1 to V3 had sensitivity of 47% and specificity of 96%. In conclusion, in patients with VT of right ventricular origin, the presence of TWI in electrocardiographic leads V1 to V3 supports the diagnosis of ARVC

A RVOT septal B RVOT free wall C near His bundle D LV endocardium E Left sinus Vlsalva F LV epicardium J Cardiovasc Electrophysiology 2003; 14: ECG Algorityhm for Identifying the Optimal Ablation Site for Idiopathic Outflow Tract VT