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

LVRV

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 ②① ③ ④

Electrocardiogram Characteristics of VT from RVOT

*ILs I R/L V1 R/S s /V5-6

① R ± =1 QS >V3 no

② R ± =1 QS >V3 no

③ R ± =1 rS >V3 no

④ R ＋ =1 QS >V2 no*ILs = inferior leads

Septal Wall: ① ②③Free 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

IIIIIIRLF V1V2V3V4V5V6Abl

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 ⑥⑤ ⑦ ⑧

Electrocardiogram Characteristics of VT from LVOT

*ILs I R/L V1 R/S s /V4-6

⑤ R - - <1 R <V1 yes

⑥ R - <1 Rs <V3 yes

⑦ R - <1 rS >V3 no

⑧ R - <1 rS <V3 yes*ILs = inferior leads

Infra-valvular: ⑤ Supra-valvular: ⑥⑦⑧

J Cardiovasc Electrophysiol 2002; 13: 1050-1053

Left Ventricular Outflow Tract Tachycardia Originating from the Right Coronary Cusp

J Cardiovasc Electrophysiol 2002; 13: 1050-1053

Left Ventricular Outflow Tract Tachycardia Originating from the Right Coronary Cusp

Left Ventricular Outflow Tract Tachycardia Originating from the Right Coronary Cusp

Left Ventricular Outflow Tract Tachycardia Originating from the Right Coronary Cusp

Left Ventricular Outflow Tract Tachycardia Originating from the Right Coronary Cusp

Left Ventricular Outflow Tract Tachycardia Originating from the Right Coronary Cusp

Noncoronary aortic cusp

J Cardiovasc Electrophysiol, 2012; 23, 98-101

Epicardial Radiofrequency Ablation of an Unusual and Unexpected Ventricular Tachycardia

J Cardiovasc Electrophysiol 2009; 20: 813-817

Ablation of Left Ventricular Epicardial OutflowTract 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: 878-885

Ventricular Arrhythmias Arising from theRight Ventricular Septum Close to the His Bundle

LSVLeft sinus VlsalvaLV endLV endocardiumLV epiLV epicardiumNear Hisnear His bundleRVright ventricle

J Cardiovasc Electrophysiology 2003; 14: 1280-86

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: 495-501

Variants of Idiopathic Left Ventricular Outflow Tract Ventricular Tachyarrhythmias

J Cardiovasc Electrophysiol 2008: 19: 495-501

Variants of Idiopathic Left Ventricular Outflow Tract Ventricular Tachyarrhythmias

J Cardiovasc Electrophysiol 2008: 19: 495-501

ECG Variants of Idiopathic Left Ventricular Outflow Tract Ventricular Tachyarrhythmias

ASC-VTs MA AMC

J Cardiovasc Electrophysiol 2005; 1378-1380

Epicardial Left Ventricular Outflow Tract Tachycardia from the Anterior Interventricular Coronary Vein

J Cardiovasc Electrophysiol 2005; 1378-1380

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; 22:886-891

Effect of Limb Lead Electrodes Location on ECG andLocalization of Idiopathic Outflow Tract Tachycardia

ECG: ARVC vs. 　 RVOT

J Am Coll Cardiol 2011;58:831–8Examples of Measurements Examples of Notching

ECG: ARVC vs. 　 RVOT

J Am Coll Cardiol 2011;58:831–8

Characteristic Features

ARVCDuration 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;57:2255–62Electrocardiographic Measurements

B/(B+C)VT ÷ E/(E+F)SRLVOT PVCs vs. RVOT PVCs 1.27 0.60 vs. 0.23 0.16; p 0.001

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%) withARVC 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

ARVOT septalBRVOT free wallC near His bundleDLV endocardiumELeft sinus VlsalvaFLV epicardium

J Cardiovasc Electrophysiology 2003; 14: 1280-86

ECG Algorityhm for Identifying the Optimal Ablation Site for Idiopathic Outflow Tract VT