QRS morphology in lead V1 for the rapid localization of idiopathic ventricular arrhythmias originating from the left ventricular papillary muscles: A novel electrocardiographic criterion

David F. Briceño, Pasquale Santangeli, David S. Frankel, Jackson J. Liang, Yasuhiro Shirai, Timothy Markman, Andres Enriquez, Katie Walsh, Michael P. Riley, Saman Nazarian, David Lin, Ramanan Kumareswaran, Jeffrey S. Arkles, Matthew C. Hyman, Rajat Deo, Gregory E. Supple, Fermin C. Garcia, Sanjay Dixit, Andrew E. Epstein, David J. CallansFrancis E. Marchlinski, Robert D. Schaller

Research output: Contribution to journalArticlepeer-review

Abstract

Background: Twelve-lead electrocardiogram (ECG) criteria have been developed to identify idiopathic ventricular arrhythmias (VAs) from the left ventricular (LV) papillary muscles (PAPs), but accurate localization remains a challenge. Objective: The purpose of this study was to develop ECG criteria for accurate localization of LV PAP VAs using lead V1 exclusively. Methods: Consecutive patients undergoing mapping and ablation of VAs from the LV PAPs guided by intracardiac echocardiography from 2007 to 2018 were reviewed (study group). The QRS morphology in lead V1 was compared to patients with VAs with a “right bundle branch block” morphology from other LV locations (reference group). Patients with structural heart disease were excluded. Results: One hundred eleven patients with LV PAP VAs (mean age 54 ± 16 years; 65% men) were identified, including 64 (55%) from the posteromedial PAP and 47 (42%) from the anterolateral PAP. The reference group included patients with VAs from the following LV locations: fascicles (n = 21), outflow tract (n = 36), ostium (n = 37), inferobasal segment (n = 12), and apex (5). PAP VAs showed 3 distinct QRS morphologies in lead V1 93% of the time: Rr (53%), R with a slurred downslope (29%), and RR (11%). Sensitivity, specificity, positive predictive value, and negative predictive value for the 3 morphologies combined are 93%, 98%, 98%, and 93%, respectively. The intrinsicoid deflection of PAP VAs in lead V1 was shorter than that of the reference group (63 ± 13 ms vs 79 ± 24 ms; P < .001). An intrinsicoid deflection time of <74 ms best differentiated the 2 groups (sensitivity 79%; specificity 87%). Conclusion: VAs originating from the LV PAPs manifest unique QRS morphologies in lead V1, which can aid in rapid and accurate localization.

Original languageEnglish (US)
Pages (from-to)1711-1718
Number of pages8
JournalHeart Rhythm
Volume17
Issue number10
DOIs
StatePublished - Oct 2020

Keywords

  • Ablation
  • Idiopathic ventricular tachycardia
  • Intracardiac echocardiography
  • Left ventricular papillary muscles
  • Mapping
  • Premature ventricular complex
  • Ventricular arrhythmias

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

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