Electrocardiographic landmarks of idiopathic ventricular arrhythmia origins

Heart ◽  
2019 ◽  
Vol 105 (14) ◽  
pp. 1109-1116 ◽  
Author(s):  
Stylianos Tzeis ◽  
Dimitrios Asvestas ◽  
Siew Yen Ho ◽  
Panos Vardas
Keyword(s):  
Heart Disease ◽  
Ventricular Arrhythmia ◽  
Ventricular Arrhythmias ◽  
Structural Heart Disease ◽  
Left Ventricular ◽  
Outflow Tract ◽  
Myocardial Scar ◽  
Mapping Tool ◽  
Surface Ecg

Idiopathic ventricular arrhythmias occur in the absence of underlying structural heart disease and less commonly in the presence of coexistent, but mechanistically unrelated, myocardial scar. These arrhythmias originate from several anatomical sites in both ventricles, with a predilection in outflow tract structures. The 12-lead surface ECG is the initial mapping tool, which is widely used to identify their origin. Specific features can predict the site of idiopathic ventricular arrhythmias, thus differentiating right from left ventricular, as well as endocardial from epicardial origins. In this review, we aim to analyse electrocardiographic landmarks for determination of idiopathic ventricular arrhythmia sources, with specific emphasis on pertinent caveats and anatomical relationships.

scholarly journals Idiopathic Outflow Tract Ventricular Arrhythmia Ablation: Pearls and Pitfalls

2019 ◽  
Vol 8 (2) ◽  
pp. 116-121 ◽  
Author(s):  
Jackson J Liang ◽  
Yasuhiro Shirai ◽  
Aung Lin ◽  
Sanjay Dixit
Keyword(s):  
Ventricular Arrhythmias ◽  
Left Ventricular Systolic Dysfunction ◽  
Systolic Dysfunction ◽  
Structural Heart Disease ◽  
Careful Analysis ◽  
Intracardiac Echocardiography ◽  
Left Ventricular ◽  
Outflow Tract ◽  
Successful Ablation ◽  
Pace Mapping

Idiopathic outflow tract ventricular arrhythmias (VAs) occur typically in patients without structural heart disease. They are often symptomatic and can sometimes lead to left ventricular systolic dysfunction. Both activation and pace mapping are utilised for successful ablation of these arrhythmias. Pace mapping is particularly helpful when the VA is infrequent and/or cannot be elucidated during the ablation procedure. VAs originating from different sites in the outflow tract region have distinct QRS patterns on the 12-lead ECG and careful analysis of the latter can help predict the site of origin of these arrhythmias. Successful ablation of these VAs requires understanding of the detailed anatomy of the OT region, which can be accomplished through electroanatomic mapping tools and intracardiac echocardiography.

scholarly journals Electrocardiographic Criteria for Differentiating Left from Right Idiopathic Outflow Tract Ventricular Arrhythmias

2021 ◽  
Vol 10 (1) ◽  
pp. 10-16
Author(s):  
Marco V Mariani ◽  
Agostino Piro ◽  
Domenico G Della Rocca ◽  
Giovanni B Forleo ◽  
Naga Venkata Pothineni ◽  
...  
Keyword(s):  
Ventricular Arrhythmias ◽  
Right Ventricular Outflow Tract ◽  
Structural Heart Disease ◽  
Ventricular Outflow Tract ◽  
Left Ventricular ◽  
Outflow Tract ◽  
Premature Ventricular Contractions ◽  
Left Ventricular Outflow ◽  
The Right ◽  
Ecg Criteria

Idiopathic ventricular arrhythmias are ventricular tachycardias or premature ventricular contractions presumably not related to myocardial scar or disorders of ion channels. Of the ventricular arrhythmias (VAs) without underlying structural heart disease, those arising from the ventricular outflow tracts (OTs) are the most common. The right ventricular outflow tract (RVOT) is the most common site of origin for OT-VAs, but these arrhythmias can, less frequently, originate from the left ventricular outflow tract (LVOT). OT-VAs are focal and have characteristic ECG features based on their anatomical origin. Radiofrequency catheter ablation (RFCA) is an effective and safe treatment strategy for OT-VAs. Prediction of the OT-VA origin according to ECG features is an essential part of the preprocedural planning for RFCA procedures. Several ECG criteria have been proposed for differentiating OT site of origin. Unfortunately, the ECG features of RVOT-VAs and LVOT-VAs are similar and could possibly lead to misdiagnosis. The authors review the ECG criteria used in clinical practice to differentiate RVOT-VAs from LVOT-VAs.

scholarly journals Recent advances in the management of ventricular tachyarrhythmias

F1000Research ◽  
2017 ◽  
Vol 6 ◽  
pp. 1027 ◽  
Author(s):  
Syeda Atiqa Batul ◽  
Brian Olshansky ◽  
John D. Fisher ◽  
Rakesh Gopinathannair
Keyword(s):  
Heart Disease ◽  
Implantable Cardioverter Defibrillator ◽  
Ventricular Arrhythmias ◽  
Symptom Relief ◽  
Structural Heart Disease ◽  
Left Ventricular ◽  
Cardioverter Defibrillator ◽  
Arrhythmic Death ◽  
Recent Advances ◽  
Cardiovascular Morbidity And Mortality

Ventricular arrhythmias are an important cause of cardiovascular morbidity and mortality, particularly in those with structural heart disease, inherited cardiomyopathies, and channelopathies. The goals of ventricular arrhythmia management include symptom relief, improving quality of life, reducing implantable cardioverter defibrillator shocks, preventing deterioration of left ventricular function, reducing risk of arrhythmic death, and potentially improving overall survival. Guideline-directed medical therapy and implantable cardioverter defibrillator implantation remain the mainstay of therapy to prevent sudden cardiac death in patients with ventricular arrhythmias in the setting of structural heart disease. Recent advances in imaging modalities and commercial availability of genetic testing panels have enhanced our mechanistic understanding of the disease processes and, along with significant progress in catheter-based ablative therapies, have enabled a tailored and more effective management of drug-refractory ventricular arrhythmias. Several gaps in our knowledge remain and require further research. In this article, we review the recent advances in the diagnosis and management of ventricular arrhythmias.

scholarly journals Monomorphic Ventricular Arrhythmias in Athletes

2019 ◽  
Vol 8 (2) ◽  
pp. 83-89 ◽  
Author(s):  
Jeffrey J Hsu ◽  
Ali Nsair ◽  
Jamil A Aboulhosn ◽  
Tamara B Horwich ◽  
Ravi H Dave ◽  
...  
Keyword(s):  
Heart Disease ◽  
Ventricular Arrhythmias ◽  
Comprehensive Evaluation ◽  
Arrhythmogenic Right Ventricular Cardiomyopathy ◽  
Sports Participation ◽  
Structural Heart Disease ◽  
Competitive Sports ◽  
Ventricular Cardiomyopathy ◽  
Electrical Heart Disease ◽  
Increase Risk

Ventricular arrhythmias are challenging to manage in athletes with concern for an elevated risk of sudden cardiac death (SCD) during sports competition. Monomorphic ventricular arrhythmias (MMVA), while often benign in athletes with a structurally normal heart, are also associated with a unique subset of idiopathic and malignant substrates that must be clearly defined. A comprehensive evaluation for structural and/or electrical heart disease is required in order to exclude cardiac conditions that increase risk of SCD with exercise, such as hypertrophic cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy. Unique issues for physicians who manage this population include navigating athletes through the decision of whether they can safely continue their chosen sport. In the absence of structural heart disease, therapies such as radiofrequency catheter ablation are very effective for certain arrhythmias and may allow for return to competitive sports participation. In this comprehensive review, we summarise the recommendations for evaluating and managing athletes with MMVA.

scholarly journals Minimising radiation exposure in catheter ablation of ventricular arrhythmias

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Matevž Jan ◽  
David Žižek ◽  
Tine Prolič Kalinšek ◽  
Dimitrij Kuhelj ◽  
Primož Trunk ◽  
...  
Keyword(s):  
Catheter Ablation ◽  
Radiation Exposure ◽  
Ventricular Arrhythmias ◽  
Major Complication ◽  
Structural Heart Disease ◽  
Left Ventricular ◽  
Complex Nature ◽  
Group 2 ◽  
Procedural Outcomes ◽  
Group 1

Abstract Background Conventional fluoroscopy guided catheter ablation (CA) is an established treatment option for ventricular arrhythmias (VAs). However, with the complex nature of most procedures, patients and staff bare an increased radiation exposure. Near-zero or zero-fluoroscopy CA is an alternative method which could substantially reduce or even eliminate the radiation dose. Our aim was to analyse procedural outcomes with fluoroscopy minimising approach for treatment of VAs in patients with structurally normal hearts (SNH) and structural heart disease (SHD). Methods Fifty-two (age 53.4 ± 17.8 years, 38 male, 14 female) consecutive patients who underwent CA of VAs in our institution between May 2018 and December 2019 were included. Procedures were performed primarily with the aid of the three-dimensional electro-anatomical mapping system and intra-cardiac echocardiography. Fluoroscopy was considered only in left ventricular (LV) summit mapping for coronary angiography and when epicardial approach was planned. Acute and long-term procedural outcomes were analysed. Results Sixty CA procedures were performed. Twenty-five patients had SHD-related VAs (Group 1) and 27 patients had SNH (Group 2). While Group 1 had significantly higher total procedural time (256.9 ± 71.7 vs 123.6 ± 42.2 min; p < 0.001) compared to Group 2, overall procedural success rate [77.4% (24/31) vs 89.7% (26/29); p = 0.20)] and recurrence rate after the first procedure [8/25, (32%) vs 8/27, (29.6%); p = 0.85] were similar in both groups. Fluoroscopy was used in 3 procedures in Group 1 where epicardial approach was needed and in 4 procedures in Group 2 where LV summit VAs were ablated. Overall procedure-related major complication rate was 5%. Conclusions Fluoroscopy minimising approach for CA of VAs is feasible and safe in patients with SHD and SNH. Fluoroscopy could not be completely abolished in VAs with epicardial and LV summit substrate location.

Advanced interatrial block precedes atrial fibrillation and stroke. The prospective interatrial Block And Yearly EventS (BAYES) registry

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
M Martinez-Selles ◽  
R Elosua ◽  
M Ibarrola ◽  
M De Andres ◽  
P Diez-Villanueva ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Heart Disease ◽  
Sinus Rhythm ◽  
Structural Heart Disease ◽  
P Wave ◽  
Wave Duration ◽  
P Wave Duration ◽  
Previous Diagnosis ◽  
Surface Ecg ◽  
Interatrial Block

Abstract Background Advanced interatrial block (IAB), prolonged and bimodal P waves in surface ECG inferior leads, is an unrecognized surrogate of atrial dysfunction and a trigger of atrial dysrhythmias, mainly atrial fibrillation (AF). Our aim was to prospectively assess whether advanced IAB in sinus rhythm precedes AF and stroke in elderly outpatients with structural heart disease, a group not previously studied. Methods Prospective observational registry that included outpatients aged ≥70 years with structural heart disease and no previous diagnosis of AF. Patients were divided into three groups according to P-wave characteristics. Results Among 556 individuals, 223 had normal P-wave (40.1%), 196 partial IAB (35.3%), and 137 advanced IAB (24.6%). After a median follow-up of 694 days; 93 patients (16.7%) developed AF, 30 stroke (5.4%), and 34 died (6.1%). Advanced IAB was independently associated with AF (hazard ratio [HR] 2.9, 95% confidence interval [CI] 1.7–5.1, p&lt;0.001), stroke (HR 3.8, 95% CI 1.4–10.7, p=0.010), and AF/stroke (HR 2.6, 95% CI 1.5–4.4, p=0.001). P-wave duration (ms) was independently associated with AF (HR 1.05, 95% CI 1.03–1.07, p&lt;0.001), AF/stroke (HR 1.04, 95% CI 1.02–1.06, p&lt;0.001), and mortality (HR 1.04, 95% CI 1.00–1.08, p=0.021). Conclusions The presence of advanced IAB in sinus rhythm is a risk factor for AF and stroke in an elderly population with structural heart disease and no previous diagnosis of AF. P-wave duration was also associated with all-cause mortality. Figure. Age- and sex-adjusted linear and non-linear association between P-wave duration (msec) and atrial fibrillation (A), stroke (B), and atrial fibrillation or stroke (C) risk. Results of a generalized additive model with spline smoothing functions and 4 degrees of freedom. Figure 1. Kaplan-Meyer curves of survival free of atrial fibrillation (A), stroke (B) and atrial fibrillation or stroke (C) in patients with normal P-wave, partial interatrial block (IAB) and advanced IAB. Funding Acknowledgement Type of funding source: None

scholarly journals Diagnostic and prognostic impact of cardiac magnetic resonance, including scar quantification and strain imaging in patients with malignant ventricular arrhythmias and nonobstructed coronary arteries

2021 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
L Szabo ◽  
V Bodi ◽  
CS Czimbalmos ◽  
ZS Dohy ◽  
V Horvath ◽  
...  
Keyword(s):  
Cardiac Magnetic Resonance ◽  
Magnetic Resonance ◽  
Coronary Arteries ◽  
Ventricular Arrhythmias ◽  
Left Ventricular ◽  
Myocardial Scar ◽  
Scar Formation ◽  
Structural Abnormality ◽  
Icd Therapy ◽  
All Cause Mortality

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Development and Innovation Fund of Hungary, National Research, Development and Innovation Office Background In case of malignant ventricular arrhythmias (VA) and nonobstructed coronary arteries, the differential diagnosis of the  underlying diseases is still challenging, due to the board spectrum of possible causes. Cardiac magnetic resonance (CMR) provides functional, morphological and tissue specific information, including necrotic and scar-tissue.  Aims   We aimed to assess the diagnostic and prognostic implications of CMR parameters including global strain values and myocardial scar in patients after ventricular fibrillation (VF) or sustained ventricular tachycardia (SVT) and nonobstructed coronary arteries. Methods Between 2011 and 2019, 99 patients (42 ±17 years, 54 male) presenting with VF or SVT and nonobstructed coronary arteries, who underwent CMR examination before secondary prevention implantable cardioverter defibrillator (ICD) implantation were included in our study. Post-processing included feature-tracking strain analysis and left ventricular (LV) scar quantification. Patients were followed for the combined endpoint of all-cause-mortality and appropriate ICD therapy. Results CMR examination proved structural myocardial disease in 72%: dilated (n = 21), arrhythmogenic (n = 11), hypertrophic cardiomyopathy (n = 7) and other cardiomyopathies (n = 3). We found LGE patterns showing chronic myocardial infarction (n = 4), suggesting chronic myocarditis (n = 4) and aspecific nonischemic scar formation (n = 14). In 7 cases aspecific structural alterations without scar formation were detected. Overall, myocardial scar was found in 52%, with an average extent of 12 ± 8% of the LV myocardium. The CMR examination changed the clinical diagnosis in 55% of the patients.  During a median follow-up at 2 years, 6 patients died and 42 experienced appropriate ICD therapy. We found an association between cardiac events and the presence of structural abnormality and myocardial scar (logrank: 4,553, p &lt; 0.05 and 8.375, p &lt;0.01).  On Cox proportional-hazards modell LV ejection fraction, LV stroke volume index, the presence of structural abnormality, the presence and extent of  myocardial scar, global LV strain parameters including longitudinal and circumferential strain, and a global left ventricular dssynchrony parameter (mechanical dispersion) were univariate predictors of the combined endpoint of all-cause-mortality and appropriate ICD therapy(p &lt; 0.05).  Conclusion CMR performed in patients after malignant VA and nonobstructed coronary arteries not only establishes the diagnosis in a high proportion of patients, but may also provide additional prognostic factors. This may indicate that CMR could play a complementary role in the risk stratification in this patient population. Abstract Figure.

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