Conduction patterns of idiopathic arrhythmias from the endocardium and epicardium of outflow tracts: New insights with noninvasive electroanatomic mapping

Stavros E Mountantonakis; Aditi S Vaishnav; Jeremy D Jacobson; Neil E Bernstein; Kabir Bhasin; Kristie M Coleman; Nicholas T Skipitaris

doi:10.1016/j.hrthm.2019.04.026

Conduction patterns of idiopathic arrhythmias from the endocardium and epicardium of outflow tracts: New insights with noninvasive electroanatomic mapping

Heart Rhythm. 2019 Oct;16(10):1562-1569. doi: 10.1016/j.hrthm.2019.04.026. Epub 2019 Apr 17.

Authors

Stavros E Mountantonakis¹, Aditi S Vaishnav², Jeremy D Jacobson², Neil E Bernstein², Kabir Bhasin², Kristie M Coleman², Nicholas T Skipitaris²

Affiliations

¹ Department of Cardiac Electrophysiology, Northwell Health-Lenox Hill Heart and Lung, New York, New York. Electronic address: [email protected].
² Department of Cardiac Electrophysiology, Northwell Health-Lenox Hill Heart and Lung, New York, New York.

PMID: 31004776
DOI: 10.1016/j.hrthm.2019.04.026

Abstract

Background: Idiopathic arrhythmias commonly arise from the septal right ventricular outflow tract (RVOT), sinuses of Valsalva (SoV), and great cardiac vein (GCV). Predicting the exact site of origin is important for preparation for catheter ablation.

Objective: The purpose of this study was to examine the diagnostic value of noninvasive electroanatomic mapping (NIEAM) to differentiate between septal RVOT, SoV, and GCV origin and compare it to that of 12-lead electrocardiography (ECG).

Methods: NIEAM maps (CardioInsight, Medtronic) were generated during spontaneous ventricular premature depolarizations (VPDs) and threshold pacing from septal RVOT, SoV, and GCV. Origin prediction using NIEAM was compared to algorithmic ECG criteria (maximal deflection index; V₂ transition ratio) and subjective ECG evaluation.

Results: Sixty NIEAMs (18 spontaneous VPDs and 42 pace-maps) from 31 patients (age 56 ± 16 years) were analyzed. NIEAM showed distinct conduction patterns, best visualized at the base of the heart: septal RVOT VPDs propagate toward the tricuspid annulus, depolarizing the septum from inferior to superior; SoV VPDs engage the superior septum early; and GCV VPDs move laterally along the mitral annulus, depolarizing the heart from left to right. Activation of the lateral mitral annulus >60.50 ms and the superior basal septum <22.5 ms from onset predicts RVOT and SoV origin, respectively, in 100% of cases. NIEAM was superior to maximum deflection index in predicting GCV origin (100% vs 42.2% accuracy) and superior to V₂ transition ratio in predicting SoV origin (100% vs 75.9% accuracy).

Conclusion: Arrhythmias arising from the outflow tracts follow distinct propagation patterns depending on the origin. A 2-step algorithm using activation timing by NIEAM yields 100% diagnostic accuracy in predicting origin.

Keywords: Body surface mapping; Catheter ablation; Idiopathic ventricular tachycardia; Noninvasive electroanatomic mapping; Premature ventricular contraction.

Publication types

Comparative Study

MeSH terms

Adult
Aged
Arrhythmias, Cardiac / diagnostic imaging
Arrhythmias, Cardiac / physiopathology
Arrhythmias, Cardiac / surgery*
Body Surface Potential Mapping / methods*
Catheter Ablation / methods*
Electrocardiography / methods
Electrophysiologic Techniques, Cardiac
Endocardium / physiopathology
Female
Follow-Up Studies
Heart Conduction System / physiopathology
Humans
Imaging, Three-Dimensional / methods*
Male
Middle Aged
Pericardium / physiopathology
Predictive Value of Tests
Prospective Studies
Treatment Outcome
Ventricular Premature Complexes / diagnostic imaging*
Ventricular Premature Complexes / physiopathology