Correlation between signal-averaged ecg and the histologic evaluation of the myocardial substrate in right ventricular outflow tract arrhythmias

Pasquale Santangeli, Maurizio Pieroni, Antonio Dello Russo, Michela Casella, Gemma Pelargonio, Luigi Di Biase, Andrea Macchione, J. David Burkhardt, Fulvio Bellocci, Pietro Santarelli, Claudio Tondo, Andrea Natale

Research output: Contribution to journalArticle

15 Citations (Scopus)

Abstract

Background-The differential diagnosis between idiopathic and cardiomyopathy-related right ventricular outflow tract (RVOT) ventricular arrhythmias (VAs) is crucial. Signal-averaged ECG (SAECG) abnormalities are frequent in cardiomyopathy-related RVOT-VAs, although their pathophysiologic basis and diagnostic value in this setting are undefined. We tested the association between SAECG and the myocardial substrate underlying RVOT-VAs. Methods and Results-Twenty-four consecutive patients (median age, 50 years [42-59]; 12 men) with RVOT-VAs (10 with frequent [>1000/24 hours] premature ventricular contractions, 14 with ventricular tachycardias) underwent SAECG with 40-Hz filtering and electroanatomic mapping (EAM) with EAM-guided biopsy for characterization of the RVOT-VAs substrate. A filtered averaged QRS (fQRS) was obtained and analyzed for fQRS duration, low amplitude signal duration <40 mV (LAS40), and root-mean-square voltage in the last 40 ms of the QRS (RMS40). Standard definition of EAM scar was used. EAM-guided biopsy diagnosed ARVC in 11 (46%), myocarditis in 8 (33%), and idiopathic RVOT-VAs in 5 (21%) patients. Patients with cardiomyopathy-related RVOT-VAs had ≥1 EAM scar (median, 2 [1-2]; all with RVOT scar). EAM of patients with idiopathic RVOT-VAs was normal. Patients with cardiomyopathy-related RVOT-VAs had significantly longer fQRS (106 ms [92-132] versus 83 ms [82-84], P=0.01) and LAS40 (39 ms [36-51] versus 19 ms [18-21], P=0.02), and lower RMS40 (18 μV [9-26] versus 33 μV [32-33], P=0.04). A significant linear correlation was found between the extension (cm2) of the RVOT scar and all 3 SAECG parameters (r s=0.76, P<0.001 for the fQRSd; rs=0.73, P<0.001 for the LAS40; and rs=-0.72, P<0.001 for the RMS40). Using the established 2 of 3 criteria (ie, late potentials), SAECG diagnosed cardiomyopathy-related RVOT-VAs with high positive (100%) but low negative (38%) predictive values and missed 7 of 9 (78%) patients with RVOT scar <8 cm2. Conclusions-In patients with RVOT-VAs, abnormal SAECG parameters reflect the presence of extensive cardiomyopathic involvement of the RVOT. However, a negative SAECG does not reliably rule out cardiomyopathy-related RVOT-VAs in the presence of a small RVOT scar. (Circ Arrhythm Electrophysiol. 2012;5:475-483.)

Original languageEnglish (US)
Pages (from-to)475-483
Number of pages9
JournalCirculation: Arrhythmia and Electrophysiology
Volume5
Issue number3
DOIs
StatePublished - Jun 2012
Externally publishedYes

Fingerprint

Cardiac Arrhythmias
Cardiomyopathies
Electrocardiography
Cicatrix
Patient Rights
Biopsy
Ventricular Premature Complexes
Myocarditis
Ventricular Tachycardia
Differential Diagnosis

Keywords

  • Right ventricular outflow tract tachycardia
  • Signal-averaged ECG
  • Three-dimensional electroanatomic mapping

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

Correlation between signal-averaged ecg and the histologic evaluation of the myocardial substrate in right ventricular outflow tract arrhythmias. / Santangeli, Pasquale; Pieroni, Maurizio; Russo, Antonio Dello; Casella, Michela; Pelargonio, Gemma; Di Biase, Luigi; Macchione, Andrea; Burkhardt, J. David; Bellocci, Fulvio; Santarelli, Pietro; Tondo, Claudio; Natale, Andrea.

In: Circulation: Arrhythmia and Electrophysiology, Vol. 5, No. 3, 06.2012, p. 475-483.

Research output: Contribution to journalArticle

Santangeli, P, Pieroni, M, Russo, AD, Casella, M, Pelargonio, G, Di Biase, L, Macchione, A, Burkhardt, JD, Bellocci, F, Santarelli, P, Tondo, C & Natale, A 2012, 'Correlation between signal-averaged ecg and the histologic evaluation of the myocardial substrate in right ventricular outflow tract arrhythmias', Circulation: Arrhythmia and Electrophysiology, vol. 5, no. 3, pp. 475-483. https://doi.org/10.1161/CIRCEP.111.967893
Santangeli, Pasquale ; Pieroni, Maurizio ; Russo, Antonio Dello ; Casella, Michela ; Pelargonio, Gemma ; Di Biase, Luigi ; Macchione, Andrea ; Burkhardt, J. David ; Bellocci, Fulvio ; Santarelli, Pietro ; Tondo, Claudio ; Natale, Andrea. / Correlation between signal-averaged ecg and the histologic evaluation of the myocardial substrate in right ventricular outflow tract arrhythmias. In: Circulation: Arrhythmia and Electrophysiology. 2012 ; Vol. 5, No. 3. pp. 475-483.
@article{d8a10d16d5fd42f3b0bf69189664ee67,
title = "Correlation between signal-averaged ecg and the histologic evaluation of the myocardial substrate in right ventricular outflow tract arrhythmias",
abstract = "Background-The differential diagnosis between idiopathic and cardiomyopathy-related right ventricular outflow tract (RVOT) ventricular arrhythmias (VAs) is crucial. Signal-averaged ECG (SAECG) abnormalities are frequent in cardiomyopathy-related RVOT-VAs, although their pathophysiologic basis and diagnostic value in this setting are undefined. We tested the association between SAECG and the myocardial substrate underlying RVOT-VAs. Methods and Results-Twenty-four consecutive patients (median age, 50 years [42-59]; 12 men) with RVOT-VAs (10 with frequent [>1000/24 hours] premature ventricular contractions, 14 with ventricular tachycardias) underwent SAECG with 40-Hz filtering and electroanatomic mapping (EAM) with EAM-guided biopsy for characterization of the RVOT-VAs substrate. A filtered averaged QRS (fQRS) was obtained and analyzed for fQRS duration, low amplitude signal duration <40 mV (LAS40), and root-mean-square voltage in the last 40 ms of the QRS (RMS40). Standard definition of EAM scar was used. EAM-guided biopsy diagnosed ARVC in 11 (46{\%}), myocarditis in 8 (33{\%}), and idiopathic RVOT-VAs in 5 (21{\%}) patients. Patients with cardiomyopathy-related RVOT-VAs had ≥1 EAM scar (median, 2 [1-2]; all with RVOT scar). EAM of patients with idiopathic RVOT-VAs was normal. Patients with cardiomyopathy-related RVOT-VAs had significantly longer fQRS (106 ms [92-132] versus 83 ms [82-84], P=0.01) and LAS40 (39 ms [36-51] versus 19 ms [18-21], P=0.02), and lower RMS40 (18 μV [9-26] versus 33 μV [32-33], P=0.04). A significant linear correlation was found between the extension (cm2) of the RVOT scar and all 3 SAECG parameters (r s=0.76, P<0.001 for the fQRSd; rs=0.73, P<0.001 for the LAS40; and rs=-0.72, P<0.001 for the RMS40). Using the established 2 of 3 criteria (ie, late potentials), SAECG diagnosed cardiomyopathy-related RVOT-VAs with high positive (100{\%}) but low negative (38{\%}) predictive values and missed 7 of 9 (78{\%}) patients with RVOT scar <8 cm2. Conclusions-In patients with RVOT-VAs, abnormal SAECG parameters reflect the presence of extensive cardiomyopathic involvement of the RVOT. However, a negative SAECG does not reliably rule out cardiomyopathy-related RVOT-VAs in the presence of a small RVOT scar. (Circ Arrhythm Electrophysiol. 2012;5:475-483.)",
keywords = "Right ventricular outflow tract tachycardia, Signal-averaged ECG, Three-dimensional electroanatomic mapping",
author = "Pasquale Santangeli and Maurizio Pieroni and Russo, {Antonio Dello} and Michela Casella and Gemma Pelargonio and {Di Biase}, Luigi and Andrea Macchione and Burkhardt, {J. David} and Fulvio Bellocci and Pietro Santarelli and Claudio Tondo and Andrea Natale",
year = "2012",
month = "6",
doi = "10.1161/CIRCEP.111.967893",
language = "English (US)",
volume = "5",
pages = "475--483",
journal = "Circulation: Arrhythmia and Electrophysiology",
issn = "1941-3149",
publisher = "Lippincott Williams and Wilkins",
number = "3",

}

TY - JOUR

T1 - Correlation between signal-averaged ecg and the histologic evaluation of the myocardial substrate in right ventricular outflow tract arrhythmias

AU - Santangeli, Pasquale

AU - Pieroni, Maurizio

AU - Russo, Antonio Dello

AU - Casella, Michela

AU - Pelargonio, Gemma

AU - Di Biase, Luigi

AU - Macchione, Andrea

AU - Burkhardt, J. David

AU - Bellocci, Fulvio

AU - Santarelli, Pietro

AU - Tondo, Claudio

AU - Natale, Andrea

PY - 2012/6

Y1 - 2012/6

N2 - Background-The differential diagnosis between idiopathic and cardiomyopathy-related right ventricular outflow tract (RVOT) ventricular arrhythmias (VAs) is crucial. Signal-averaged ECG (SAECG) abnormalities are frequent in cardiomyopathy-related RVOT-VAs, although their pathophysiologic basis and diagnostic value in this setting are undefined. We tested the association between SAECG and the myocardial substrate underlying RVOT-VAs. Methods and Results-Twenty-four consecutive patients (median age, 50 years [42-59]; 12 men) with RVOT-VAs (10 with frequent [>1000/24 hours] premature ventricular contractions, 14 with ventricular tachycardias) underwent SAECG with 40-Hz filtering and electroanatomic mapping (EAM) with EAM-guided biopsy for characterization of the RVOT-VAs substrate. A filtered averaged QRS (fQRS) was obtained and analyzed for fQRS duration, low amplitude signal duration <40 mV (LAS40), and root-mean-square voltage in the last 40 ms of the QRS (RMS40). Standard definition of EAM scar was used. EAM-guided biopsy diagnosed ARVC in 11 (46%), myocarditis in 8 (33%), and idiopathic RVOT-VAs in 5 (21%) patients. Patients with cardiomyopathy-related RVOT-VAs had ≥1 EAM scar (median, 2 [1-2]; all with RVOT scar). EAM of patients with idiopathic RVOT-VAs was normal. Patients with cardiomyopathy-related RVOT-VAs had significantly longer fQRS (106 ms [92-132] versus 83 ms [82-84], P=0.01) and LAS40 (39 ms [36-51] versus 19 ms [18-21], P=0.02), and lower RMS40 (18 μV [9-26] versus 33 μV [32-33], P=0.04). A significant linear correlation was found between the extension (cm2) of the RVOT scar and all 3 SAECG parameters (r s=0.76, P<0.001 for the fQRSd; rs=0.73, P<0.001 for the LAS40; and rs=-0.72, P<0.001 for the RMS40). Using the established 2 of 3 criteria (ie, late potentials), SAECG diagnosed cardiomyopathy-related RVOT-VAs with high positive (100%) but low negative (38%) predictive values and missed 7 of 9 (78%) patients with RVOT scar <8 cm2. Conclusions-In patients with RVOT-VAs, abnormal SAECG parameters reflect the presence of extensive cardiomyopathic involvement of the RVOT. However, a negative SAECG does not reliably rule out cardiomyopathy-related RVOT-VAs in the presence of a small RVOT scar. (Circ Arrhythm Electrophysiol. 2012;5:475-483.)

AB - Background-The differential diagnosis between idiopathic and cardiomyopathy-related right ventricular outflow tract (RVOT) ventricular arrhythmias (VAs) is crucial. Signal-averaged ECG (SAECG) abnormalities are frequent in cardiomyopathy-related RVOT-VAs, although their pathophysiologic basis and diagnostic value in this setting are undefined. We tested the association between SAECG and the myocardial substrate underlying RVOT-VAs. Methods and Results-Twenty-four consecutive patients (median age, 50 years [42-59]; 12 men) with RVOT-VAs (10 with frequent [>1000/24 hours] premature ventricular contractions, 14 with ventricular tachycardias) underwent SAECG with 40-Hz filtering and electroanatomic mapping (EAM) with EAM-guided biopsy for characterization of the RVOT-VAs substrate. A filtered averaged QRS (fQRS) was obtained and analyzed for fQRS duration, low amplitude signal duration <40 mV (LAS40), and root-mean-square voltage in the last 40 ms of the QRS (RMS40). Standard definition of EAM scar was used. EAM-guided biopsy diagnosed ARVC in 11 (46%), myocarditis in 8 (33%), and idiopathic RVOT-VAs in 5 (21%) patients. Patients with cardiomyopathy-related RVOT-VAs had ≥1 EAM scar (median, 2 [1-2]; all with RVOT scar). EAM of patients with idiopathic RVOT-VAs was normal. Patients with cardiomyopathy-related RVOT-VAs had significantly longer fQRS (106 ms [92-132] versus 83 ms [82-84], P=0.01) and LAS40 (39 ms [36-51] versus 19 ms [18-21], P=0.02), and lower RMS40 (18 μV [9-26] versus 33 μV [32-33], P=0.04). A significant linear correlation was found between the extension (cm2) of the RVOT scar and all 3 SAECG parameters (r s=0.76, P<0.001 for the fQRSd; rs=0.73, P<0.001 for the LAS40; and rs=-0.72, P<0.001 for the RMS40). Using the established 2 of 3 criteria (ie, late potentials), SAECG diagnosed cardiomyopathy-related RVOT-VAs with high positive (100%) but low negative (38%) predictive values and missed 7 of 9 (78%) patients with RVOT scar <8 cm2. Conclusions-In patients with RVOT-VAs, abnormal SAECG parameters reflect the presence of extensive cardiomyopathic involvement of the RVOT. However, a negative SAECG does not reliably rule out cardiomyopathy-related RVOT-VAs in the presence of a small RVOT scar. (Circ Arrhythm Electrophysiol. 2012;5:475-483.)

KW - Right ventricular outflow tract tachycardia

KW - Signal-averaged ECG

KW - Three-dimensional electroanatomic mapping

UR - http://www.scopus.com/inward/record.url?scp=84863687840&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84863687840&partnerID=8YFLogxK

U2 - 10.1161/CIRCEP.111.967893

DO - 10.1161/CIRCEP.111.967893

M3 - Article

VL - 5

SP - 475

EP - 483

JO - Circulation: Arrhythmia and Electrophysiology

JF - Circulation: Arrhythmia and Electrophysiology

SN - 1941-3149

IS - 3

ER -