An electrocardiographic sign of idiopathic ventricular tachycardia ablatable from the distal great cardiac vein

Abstract

BACKGROUND Idiopathic ventricular arrhythmias (IVAs) can originate from the distal great cardiac vein (DGCV). However, inadequate distinction sometimes occurs when electrocardiographic (ECG) characteristics are used to distinguish ventricular arrhythmias (VAs) arising from the DGCV from those arising from the adjacent left ventricular endocardium (LV ENDO).OBJECTIVE The purpose of this study was to identify distinct ECG features in patients with idiopathic IVAs originating from the DGCV.METHODS A total of 32 patients with IVAs originating from the DGCV were identified from a consecutive group of 874 patients undergoing IVAs ablation. Patients with IVAs from the DGCV were compared with a consecutively chosen series of 40 patients with IVAs in whom the site of origin was the adjacent LV ENDO. RESULTSOf the 32 patients with IVAs arising from the DGCV, 13 had distinct ECG characteristics compared with the LV ENDO group.Notches in both the upstroke and downstroke of the R wave in lead III were found in all 13 patients. However, the characteristic ECG pattern in lead III was found in 1 of 40 patients in the LV ENDO group. The ECG characteristic of both early notch and late notches in lead III has sensitivity of 40.6%, specificity of 97.5%, negative predictive value of 67.2%, and positive predictive value of 92.9% to predict VAs arising from the DGCV.CONCLUSION The distinct ECG characteristics of VAs originating from the DGCV can help differentiate from adjacent LV ENDO sites of origin.

Electrocardiographic localization of ventricular arrhythmias successfully ablated from the distal great cardiac vein

“…Our approach using the simplified parameters may aid in diagnostic utility when planning for IVA ablation. If the preprocedural ECG does not reveal any of the ECG features highlighted in our study (Table 4) Another novel ECG feature used to predict VAs arising from the dGCV known as the "spike helmet" sign in lead III was recently reported by Yuan-Nan et al 4 In this study, 13 of 32 patients (40.6%) with successful IVA ablation in the dGCV showed early and late notches of the QRS complex in lead III while only 1 of 40 patients (2.5%) with IVAs originating from non-GCV sites showed this particular sign. However, there are limitations to utilizing the "spike helmet" sign.…”

“…As the authors noted, the notch on the upstroke of lead III was difficult to identify even at a speed of 100 mm/s with normal gain. 4 Their ECG interpretations were performed with 200 mm/s and twice the standard gain. In addition, while very specific (97.5%), the novel ECG feature had low sensitivity (40.6%).…”

“…In addition, while very specific (97.5%), the novel ECG feature had low sensitivity (40.6%). 4 In our cohort, we examined ECGs performed at a standard speed of 25 mm/s and normal gain. The "spike and helmet" sign was difficult to identify using the standard ECG setting and hence was not included in our ECG interpretations.…”

“…Some studies have also performed post-RFCA coronary angiography to confirm no damage to the coronary arteries. 4,9 According to the most recent expert consensus statement on catheter ablations of VAs, screening patients with coronary angiography before catheter ablation in the coronary venous system is a Class I indication. 19 Given that the ablations we included in our study were performed before 2019 when the Class I recommendation was made, our patients were not uniformly screened with coronary angiography during the RFCAs.…”

Mapping the Left Ventricular Summit for Ablation Success

“…6 Distal (DGCV) VTs/PVCs share the following ECG features: inferior axis, R pattern in all inferior leads, QS pattern in augmented vector left (aVL) and augmented vector right (aVR) leads, a dominant rs or rS pattern in lead I, a monophasic R or Rs pattern in all precordial leads, and a monophasic (positive concord ance), transition occurring earlier than V1. 7 The distinct ECG characteristics of VTs originating from the DGCV can help to differentiate VTs originating from adjacent LV endocardium sites of origin. 7 In the presence of even subtle structural abnormalities, however, a 12lead ECG may not be helpful for localizing the origin of VT/PVC as even subtle structural abnormalities may impact the typical ECG characteristics of VTs in normal hearts (e.g., RVOT or LVS).…”