日大医誌　74 (3): 95–102 (2015) 95

Original Article

ECG Criteria for Distinguishing Left from Right Ventricular

Outflow Tract Tachycardia
Kimie Ohkubo, Ichiro Watanabe, Yasuo Okumura, Masayoshi Kofune, Koichi Nagashima,
Kazumasa Sonoda, Naoko Sasaki, Rikitake Kogawa, Keiko Takahashi, Kazuki Iso,
Toshiko Nakai, Satoshi Kunimoto and Atsushi Hirayama
Division of Cardiology, Department of Medicine, Nihon University School of Medicine

Background: Several ECG criteria have been proposed to differentiate left from right ventricular outflow tract
(OT) premature ventricular contractions (PVC)/ventricular tachycardia (VT); however, differentiating PVC/VT in left
bundle branch block (LBBB) remains challenging. Individual patient differences in cardiac rotation, lead positions,
and chest wall size may limit the accuracy of the ECG algorithm. We hypothesized that correcting for sinus rhythm
(SR) precordial transition would aid in OTVT localization.
Methods: We analyzed the surface ECG patterns of 16 patients (8 men, 8 women; age, 55.7 ± 22.2 years) with right
ventricular (RV) OTVT and 8 patients (7 men, 8 women; age, 50.1 ± 16.6 years) with left ventricular (LV) OTVT
who underwent catheter ablation. SR and VT morphologies were measured with the same 12-lead ECG system.
V2 transition ratios were determined by calculating the percentage R wave during VT (R/R+S) VT divided by the
percentage R wave in SR (R/R+S) SR. We also determined the V1 and V2 R/S ratios, the time from V2 R-wave onset
to its peak (V2Rp), V1- and V2 R-wave durations, S wave in V5 and V6, the precordial transitional zone, and the lead
I ECG QRS pattern during PVCs/VT.
Results: The V2 transition ratio was significantly greater for LVOT vs. RVOT (1.50 ± 0.69 vs. 0.18 ± 0.11; P =
0.0004). A V2 transition ratio >1.1 predicted an LVOT origin with a sensitivity of 83% and specificity of 88%. Time to
V2Rp was significantly greater for LVOT vs. RVOT (82.50 ± 6.12 vs. 41.2 ± 9.90 ms; P = 0.0003). A V2Rp time >70
ms predicted an LVOT origin with a sensitivity of 100% and specificity of 100%.
Conclusions: Electrocardiographic measures, the V2 transition ratio, and V2Rp time can reliably distinguish
between an RVOT and LVOT origin in patients with LBBB. These measures may be useful in planning the ablation
strategy.
Key words: ventricular tachycardia, ventricular premature beat, outflow tract origin, 12-lead ECG
(J. Nihon Univ. Med. Ass., 2015; 74 (3): 95–102)

with precordial R/S transition at or after V3. 5) In

Introduction
contrast, LVOT PVCs/VT usually manifests either
Outflow tract (OT) ventricular arrhythmia rep­ as a right bundle branch block (RBBB)/inferior axis
re­s ents the most common subgroup of idiopathic or LBBB/inferior axis with a precordial R/S-wave
premature ventricular premature contractions (PVCs)/ transition at or before lead V3.6) Criteria to distinguish
ventricular tachycardia (VT). It typically occurs an RVOT from an LVOT origin for patients with
in healthy young to middle-aged patients without precordial transition occurring at lead V3 are lacking.
structural heart disease and can be provoked by Existing ECG algorithms do not account for cardiac
emotional stress, exercise, or dietary stimulants. 1) rotation, respiratory variation, or position of the
Prognosis is generally excellent; OTVT can be ECG leads on the chest, which might vary depending
effectively treated by drugs or radiofrequency (RF) on body habitus, breast size, and the technician’s
catheter ablation. 2) Detailed intracardiac electrical expertise in placing the leads.7,8) We hypothesized that
mapping has shown that the vast majority of OTPVCs/ comparison of the PVC/VT morphology with sinus
OTVTs originate from the right ventricular (RV) OT.3) rhythm (SR) QRS morphology would be an effective
However, in approximately 10% to 15% of cases, the means of distinguishing LVOT from RVOT PVC/VT.
arrhythmia originates from the left ventricular (LV)
Methods
OT and can be mapped to the region of the aortic
cusps.4) Typically, OTPVCs/VT originating in the RV Study design
manifests as an inferior axis in the frontal ECG plane We conducted a retrospective review of OT
and a left bundle branch block (LBBB) configuration PVC/VT ablation cases so that we might develop a

Received: December 14, 2014 Accepted: January 15, 2015

 Figure 1

96 Kimie OHKUBO et al. 日大医誌

Intracardiac ECG
diagnostic ECG algorithm. V2 LVOT origin RVOT origin
Patient characteristics
Time
200 ms to R wave
200 mspeak (ms)
We reviewed the records of 24 patients who 200 ms
underwent mapping and ablation of idiopathic OT I

PVC/VT at Nihon University Itabashi Hospital R

II wave (mV)
between January 2010 and December 2012. The
majority of patients had echocardiographically normal III R-wave duration
LV function, although patients with a presumed (ms)
V1
cardiomyopathy due to frequent ventricular ectopy
S wave (mV)
were not excluded. Patients with ECG evidence of V6
prior myocardial infarction, with RBBB during SR, or
ABL1-2
with a clinical arrhythmia that could not be abolished -28msec
by catheter ablation were excluded from the analysis.
Earliest activation site
ABLuni
Mapping and ablation protocol Fig. 1 Electrocardiographic measurements.
A decapolar catheter was positioned in the RV to LVOT: left ventricular outflow tract, RVOT: right ventricular
create an RV shell with a noncontact mapping system outflow tract.
(EnSite 3000 Ver. 8; Endocardial Solutions, Inc./
St. Jude Medical, St. Paul, MN, USA). An octapolar both SR and PVCs/VT (Fig. 1): 1) QRS morphology
catheter was positioned at the His bundle electrogram in lead I, 2) precordial transition zone of the PVCs/
recording site. A decapolar catheter with a central VT, 3) R- and S-wave amplitudes in leads V1 and V2
lumen was placed at the coronary sinus via the right of the PVCs/VT and R/S ratios (R/S V1 and R/S V2),
internal jugular vein. Details of the procedure used 3) R/R+S in lead V2 (R/R+SV2) during SR and during
to locate the site of origin of the OT PVCs/VT with PVCs, 4) V2 transition ratio (R/R+S in V2) during
the noncontact mapping system were described PVCs/VT / (R/R+S in V2) during SR, 5) S wave (if
previously.9) Pace-mapping at a threshold just above present) in leads V5 and V6 (S-V5, 6), 6) R-wave
local capture was performed in all patients with duration (ms) in leads V1 and V2 (RDV1, RDV2), and
careful comparison of the paced QRS morphology 7) time (ms) to the R wave peak in lead V2 (V2Rp).
against that of the clinical PVCs. The decision to Statistical Analysis
extend mapping to an LVOT site was made if no Continuous variables are presented as mean ± SD
adequate RVOT sites were identified or ablation in and categorical variables as proportions. Continuous
the RVOT did not abolish the arrhythmia. The LVOT variables were analyzed by Mann-Whitney U test, and
sites were mapped via a retrograde aortic approach. categorical variables were analyzed by Fisher’s exact
All mapping was performed after a heparin bolus was probability test. P < 0.05 was considered significant.
administered to maintain an activated clotting time All statistical analyses were performed with StatView
of >300 s. In most patients, a nonirrigated 4-mm tip 5.0 software (SAS Institute, Cary, NC, USA).
catheter was used for power delivery of up to 50 W
Results
and temperature up to 55°C for RVOT ablation and up
to 35 W and up to 50°C for LVOT ablation. Beginning The PVCs/VT origin was located at the RVOT
in 2011, irrigated 3.5-mm tip catheters were used (Figs. 2–4) in 16 patients (8 men, 8 women; age, 50.1
almost exclusively in the LVOT and occasionally by ± 16.1 [range, 21–76] years) and at the LVOT (Figs.
some operators in the RVOT. The typical maximal 5–7) in 8 patients (7 men, 1 woman; age, 59.3 ± 21.2
power setting was 30–35 W for the RVOT region and [range, 21–80] years). Absolute measurements of
30 W for the LVOT/aortic cusp region. Acute ablation PVC/VT and SR QRS indices in each patient are listed
success was defined as absence of the clinical PVCs/ in Tables 1 and 2, and mean values and statistical
VT at 30 min after the last RF energy delivery and data are shown in Table 3. Patients with a PVCs/VT
was confirmed by continuous full disclosure cardiac morphology of a QS pattern in leads V1 and/or V2
telemetry during the subsequent 24 h of inpatient care. were excluded from the statistical analysis. Patient
ECG measurement protocol ages in the RVOT and LVOT groups were similar.
SR and PVC/VT ECG morphologies were measured The RVOT group comprised 12 patients in whom the
on the same 12-lead ECG system with electronic site of origin was anteroseptal and 4 patients in whom
calipers (BARD LABSYSTEMTM PRO EP Recording it was posteroseptal. The LVOT group comprised 7
System; Bard Electrophysiology, Lowell, MA, USA). patients in whom the tachycardia was of left coronary
Standard 12-lead ECG electrode placement was used. cusp (LCC) origin and 1 in whom the origin was in the
Lead gain was uniform with a paper speed of 100 mm/ LVOT just below the aortic cusp. The R/S ratio of the
s. The following measurements were obtained during PVCs/VT was greater for LVOT PVCs/VT than for
74 (3) 2015 LVOT vs. RVOT Tachycardia Origin: ECG 97

Table 1 Patient and 12-lead ECG characteristics of PVCs/VT of LVOT origin

(R/R+S) (R/R+S)
Age Transition SV5,6 PVCs/VT
Patient Sex Type Lead I R/S V1 R/S V2 V2 V2 RDV1 RDV2 V2Rp
(yr) zone PVCs origin
SR PVCs/SR
1 48 F NSVT RS V3 QS QS QS QS QS QS QS - LCC
2 16 M VT rS V2 1.2 2.6 0.77 1.2 120 120 80 - LCC
3 63 M VT rS V5 QS 0.13 0.15 0.73 QS 120 100 - LCC
4 41 M VT rS V2 14 3.0 0.93 0.81 120 120 80 - LCC
5 71 M VT RS V1 1.0 2.8 0.41 1.66 100 120 80 - LCC
6 80 M VT RS V3 0.15 0.24 0.13 1.00 120 130 90 - LVOT
7 63 M PVCs RS V3 0.2 0.36 0.35 1.63 40 80 80 - LCC
8 71 M PVCs Rs V3 6.5 7.5 0.32 2.72 100 140 95 + NCC
LCC: left coronary cusp, LVOT: left ventricular outflow tract just below the aortic cusp, NCC: non-coronary cusp, NSVT: non-
sustained ventricular tachycardia, PVCs: premature ventricular contractions, RD: R-wave duration from the onset to the peak
of the R wave, Rp: time from the onset to the peak of the R wave, (R/R+S) V2 PVC: R-wave / R wave + S-wave amplitude in
V2 of the PVCs/VT, (R/R+S) V2 PVC or VT/SR: [R-wave /R-wave + S-wave amplitude in V2 of the PVCs or VT] / [R-wave
/ R-wave + S-wave amplitude in V2 during SR], R/SV1: R-wave amplitude / S-wave amplitude in V1 lead, R/SV2: R-wave
amplitude / S-wave amplitude in lead V2, SV5,6: presence of the S wave in leads V5 and/or V6, SR: sinus rhythm, VT:
ventricular tachycardia.

Table 2 Patient and 12-lead ECG characteristics of PVCs/VT of RVOT origin

(R/R+S) (R/R+S)
Age Transition SV5,6 PVCs/VT
Patient Sex Type Lead I R/S V1 R/S V2 V2 V2 RDV1 RDV2 V2Rp
(yr) zone PVCs origin
SR PVCs/SR
1 68 F VT QS V2 0.19 0.58 0.37 2.31 100 110 40 + RVOT
2 59 M VT QS V3 0.33 0.42 0.25 0.5 100 80 50 - RVOT
3 37 M VT QS V4 0.05 0.08 0.07 0.37 120 120 40 + RVOT
4 49 M VT QS V4 0.09 0.16 0.14 0.35 200 200 40 - RVOT
5 58 M VT RS V4 0.17 0.27 0.12 0.63 120 120 45 - RVOT
6 76 M VT RS V4 0.11 0.21 0.18 0.78 120 130 50 - RVOT
7 56 M VT QS V4 0.20 0.25 0.20 1.33 120 120 30 - RVOT
8 42 M VT RS V3 QS 0.08 0.07 0.19 90 110 30 - RVOT
9 37 F VT RS V3 0.06 0.11 0.1 0.26 100 100 25 - RVOT
10 74 F VT rS V3 0.14 0.24 0.1 0.71 100 100 40 - RVOT
11 33 F VT QS V3 0.15 0.26 0.14 0.32 90 90 40 + RVOT
12 46 F VT QR V4 0.11 0.15 0.14 0.24 130 140 40 - RVOT
13 66 F VT rS V3 0.13 0.36 0.26 1.04 120 120 60 + RVOT
14 21 M VT QS V4 0.05 0.13 0.05 0.15 120 120 30 - RVOT
15 26 F VT RS V4 0.16 0.18 0.14 0.42 110 120 35 + RVOT
16 53 F VT QS V2 QS 0.88 0.47 0.22 120 120 60 - RVOT
PVCs: premature ventricular contractions, RD: R-wave duration from the onset to the peak of the R wave, Rp: time from the
onset to the peak of the R wave, (R/R+S) V2 PVC: R-wave / R-wave + S-wave amplitude in V2 of the PVCs/VT, (R/R+S) V2
PVCs or VT/SR: [R-wave / R-wave + S-wave amplitude in V2 of the PVC or VT] / [R-wave / R wave + S-wave amplitude in V2
during SR], R/SV1: R-wave amplitude / S-wave amplitude in V1 lead, R/SV2: R-wave amplitude / S-wave amplitude in lead V2,
RVOT: right ventricular outflow tract, SR: sinus rhythm, SV5,6: presence of the S wave in leads V5 and/or V6, VT: ventricular
tachycardia.

RVOT PVCs/VT in leads V1 (P = 0.0065) and V2 (P = greater for LVOT PVCs/VT than for RVOT PVCs/VT
0.0045). The R-wave duration of the PVCs/VT did not (P = 0.0004). The transitional zone in leads V1–V3
differ significantly between LVOT and RVOT PVCs/ did not differ significantly between LVOT PVCs/VT
VT. However, the time to V2Rp was significantly and RVOT PVCs/VT (P = 0.08749). The lead I QRS
longer for LVOT than for RVOT PVCs/VT (P = morphologies also did not differ significantly between
0.00003). The R/R+S ratio in lead V2 during SR did LVOT PVCs/VT and RVOT PVCs/VT. Proposed
not differ significantly between LVOT PVCs/VT algorithm combining 2 qualitative measures is shown
and RVOT PVCs/VT; however, the (R/R+S) during in Fig. 8.
PVCs/VT / (R/R+S ratio) during SR was significantly
98 Kimie OHKUBO et al. 日大医誌

Table 3 ECG characteristics in LVOT and RVOT PVCs/VT

LVOT RVOT
P value
n=8 n = 16
Patient age (yr) 55.7 ± 22.2 50.1 ± 16.6 0.159
V2 R/R+S: SR 0.49 ± 0.30 0.61 ± 0.56 0.8249
V2 R/R+S: PVC/SR 1.50 ± 0.69 0.18 ± 0.11 0.0004
V1 R/S 1.74 ± 2.39 0.14 ± 0.07 0.0065
V2 R/S 2.75 ± 2.63 0.27 ± 0.21 0.0045
V2 R peak time 82.50 ± 6.12 41.2 ± 9.90 0.0003
V1 R duration 100.00 ± 30.98 116.3 ± 25.53 0.5057
V2 R duration 118.33 ± 20.41 118.80 ± 26.3 0.4853
S wave in V5, 6 1/8 5/16 0.3191
PVC/VT transitional zone
V1 1 0
V2 3 2
V1-V3 vs. V4, V5
V3 4 6
0.08749
V4 0 8
V5 1 0
Lead I ECG QRS pattern
QS 1 7
RS 5 6
rS 2 2
qR 0 1
LVOT, left ventricular outflow tract, PVCs: premature ventricular contractions, RD: R-wave duration from the onset to the peak
of the R wave, Rp: time from the onset to the peak of the R wave, (R/R+S) V2 PVCs: R-wave / R-wave + S-wave amplitude in
V2 of the PVCs/VT, (R/R+S) V2 PVCs or VT/SR: [R-wave / R-wave + S-wave amplitude in V2 of the PVCs or VT] / [R-wave
/ R-wave + S-wave amplitude in V2 during SR], R/SV1: R-wave amplitude / S-wave amplitude in V1 lead, R/SV2: R-wave
amplitude / S-wave amplitude in V2 lead, RVOT: right ventricular outflow tract, SR: sinus rhythm, VT: ventricular tachycardia.

Figure 5 Figure 6
Patient 13 (RVOT origin) Intracardiac ECG
I
II I
II
III
V1
aVR
V6
Earliest activation site
aVL ABL-d -96 msec
aVF ABL-p 366 ms
V1 HRA3-4
HRA1-2
V2
HIS1-8
V3 HIS7-8
V4 HIS5-6
V5 HIS3-4
V6
HIS1-2
CS9-10
Fig. 2 Twelve-lead ECG in a patient (Patient 13) with CS7-8
premature ventricular contractions of right ventricular CS5-6
outflow tract (RVOT) origin. CS3-4
CS1-2
Uni

Fig. 3 Intracardiac electrograms of the successful ablation site.

ABL-d: bipolar electrograms from the distal electrode pair
of the ablation catheter, ABL-p: bipolar electrograms from
proximal electrode pair of the ablation catheter, CS: coronary
sinus, 9-10: proximal pair, 1-2: distal pair, HIS: His bundle
electrogram recording site, HRA: bipolar electrograms from
the high right atrium, 1-2: distal pair, 7-8: proximal pair,
Uni: unipolar electrograms from the distal electrode of the
ablation catheter.
 74 (3) 2015 LVOT vs. RVOT Tachycardia Origin: ECG 99
Figure 7
Ablation site

AP
ABL

CS
HIS

ABL

CS ABL
HIS
HRA HIS
CS
RAO 35°

LAO 45°
Fig. 4 Tip of the ablation catheter (ABL) at the right ventricular outflow tract as seen fluoroscopically.
AP: antero-posterior projection, CS: coronary sinus, HIS: His bundle, LAO: left anterior projection,
RAO: right anterior oblique projection.

Figure 2 Figure 3
Patient 3 (LVOT LCC origin) Intracardiac ECG
I
II 200 ms 200 ms
200 ms
III I

aVR
II
aVL
III
aVF
V1 V1
V2
V6
V3
V4 ABL1-2
-28 msec
Earliest activation site
V5 ABLuni
V6

Fig. 5 Twelve-lead ECG in a patient (Patient 3) with left Fig. 6 Intracardiac electrograms of the successful ablation site.
ventricular outflow tract (LVOT) premature ventricular ABL1-2: bipolar electrograms from the distal electrode pair
contractions of left coronary cusp (LCC) origin. of the ablation catheter, ABLuni: unipolar electrograms from
the distal electrode of the ablation catheter.
 100 Kimie OHKUBO et al. 日大医誌
Figure 4
Ablation site
AP
LMT

HRA
ABL
HIS

RAO LAO
LMT
LMT

HRA ABL ABL

HIS
HRA
HIS

Fig. 7 Tip of the ablation catheter (ABL) at the left coronary cusp as seen fluoroscopically.
AP: antero-posterior projection, HIS: His bundle, HRA: high right atrium, LAO: left anterior
projection, LMT: left main coronary artery, RAO: right anterior oblique projection.

Figure 7

Lead V3 R/S ratio 0.6≤ Discussion

no yes We present several surface ECG measurements

1/16 RVOT origin 15/16 for distinguishing an LVOT origin from an RVOT
5/8 LVOT origin 3/8 origin in patients with an LBBB pattern in idiopathic
PVC/VT. The present study showed that the R/S ratio
V2 R/R+S: PVC/SR 0.7≤ of the PVCs/VT, time from the onset to the peak of
the R wave in lead V2, the PVCs/VT / R/R+S ratio
no yes during SR, and the transitional zone in leads V1–V3
3/16 RVOT origin 13/16 differed significantly between LVOT PVCs/VT and
7/8 LVOT origin 1/8
RVOT PVCs/VT. Of these variables, the R/R+S ratio
of PVCs/VT / R/R+S ratio during SR and the onset
Lead V3 R/S ratio 0.6≤ or V2 R/R+S: PVC/SR 0.7≤
to peak time of the R wave in lead V2 (V2Rp) were
no yes the most reliable for discriminating between LVOT
0/16 RVOT origin 16/16 and RVOT foci. A V2Rp ≥70 ms predicted an LVOT
7/8 LVOT origin 1/8 origin with sensitivity of 100% and specificity of
Fig. 8 Diagnostic algorithm for outflow tract ventricular 100%, and a value of [(R/R+S) PVC/VT] / [(R/R+S)
tachycardia. during SR] ≥1.1 predicted an LVOT origin with a
Lead V3 R/S ratio 0.6≤ or V2 R/R+S: PVC/SR 0.7≤ sensitivity of 83% and specificity of 88%. As show in
discriminates right ventricular outflow tachycardia and left Fig. 8, Lead V3 R/S ratio 0.6≤ or V2 R/R+S: PVC/SR
ventricular tachycardia except 1 patient with left ventricular 0.7≤ discriminated RVOT and LVOT PVC/VT except
outflow tract tachycardia in whom V1 and V2 leads 1 LVOT VT patient in whom V1 and Vs leads showed
demonstrated QS pattern.
QS pattern.
For patients referred for catheter ablation of OT
PVCs/VT, these simple ECG measurements might
be performed in the office to help plan the ablation
74 (3) 2015 LVOT vs. RVOT Tachycardia Origin: ECG 101

strategy and to enhance patient counseling when PVC/VT origin as shown by Yoshida et al.14) with the
it comes to explaining procedure time, potential onset to the peak time of the R wave in lead V2 (V2Rp)
outcomes, and risks associated with arterial access, remains relevant.
mapping, and ablation.
Conclusions
Prior work
Many prior studies have evaluated surface ECG We present electrocardiographic measures including
characteristics for localization of OT PVCs/VT. the onset to peak time of the R wave in lead V2
Ouyang et al. found that a greater R-wave duration (V2Rp) and the value of (R/R+S in V2) PVC/VT /
and R/S-wave amplitude ratio in leads V1 or V2 (R/R+S in V2) SR (V2 transition ratio) as algorithms
reliably predict an aortic sinus cusp versus RVOT that can reliably distinguish left from right OT PVC/
origin.4) Lin et al. described site-specific ECG features VT. A V2Rp ≥70 ms predicted an LVOT origin with
of PVCs originating from the aortic cusps; the features a sensitivity of 100% and specificity of 100%, and
were based on electroanatomic and intracardiac echo- [(R/R+S) PVC/VT] / [(R/R+S) SR] ≥1.1 predicted an
guided pacemapping.10) They concluded that an LCC LVOT origin with a sensitivity of 83% and specificity
origin typically produces a precordial transition of 88%. These algorithms might lead to improved
by V2, whereas the right coronary cusp shows a patient counseling and planning of medical therapy or
precordial transition by lead V3. Furthermore, Yamada ablation procedures in patients referred for ablation of
et al.11) and Bala et al.12) characterized the left-right OTVT.
coronary cusp junction as often possessing a QRS
References
pattern in leads V1 to V3 or a QS pattern in lead
V1. One reported study of patients undergoing RF 1) Callans DJ, Menz V, Schwartzman D, Gottlieb CD,
catheter ablation for idiopathic VT or symptomatic Marchlinski FE. Repetitive monomorphic tachycardia
from the left ventricular outflow tract: electrocardio-
PVCs pointed to the R-wave amplitude proportion
graphic patterns with a left ventricular site of origin. J
as a means of discriminating between RVOT and Am Coll Cardiol 1997; 29: 1023–1027.
extra-RVOT foci; however, the study was limited 2) Stevenson WG, Soejima K. Catheter ablation for ven-
by its small size, lack of prospective evaluation, and tricular tachycardia. Circulation 2007; 115: 2750–2760.
nonassessment of the frontal plane. 13) As reported 3) Moskowitz C, Schwartzman D, Callans DJ, et al.
previously, lead V3 R/S transition is highly variable, Idiopathic right ventricular outflow tract tachycardia:
yielding only 55% sensitivity and 38% specificity for narrowing the anatomic location for successful ablation.
Am Heart J 1996; 131: 930–936.
predicting an RVOT origin.8) Yoshida et al. proposed
4) Ouyang F, Fotuhi P, Ho SY, et al. Repetitive mono-
a novel transitional zone index, which was defined morphic ventricular tachycardia originating from the
according to the site of the R-wave transition of aortic sinus cusp: electrocardiographic characterization
sinus beats and OT PVCs/VT. They reported that the for guiding catheter ablation. J Am Coll Cardiol 2002;
transitional zone index was significantly lower for an 29: 500–508.
aortic sinus cusp origin than for an RVOT origin (-1.2 5) Dixit S, Gerstenfeld EP, Callans DJ, Marchlinski
± 0.9 vs. 0.3 ± 0.7, P < 0.0001), and a transition index FE. Electrocardiographic patterns of superior right
ventricular outflow tract tachycardias: distinguishing
cutoff value of <0 predicted an aortic sinus cusp origin
septal and free-wall sites of origin. J Cardiovasc
with 88% sensitivity and 82% specificity.14) Electrophysiol 2003; 14: 1–7.
Study Limitations 6) Hachiya H, Aonuma K, Yamauchi Y, et al. Electro-
Our patient group was small, making validation cardiographic characteristics of left ventricular outflow
in larger patient groups necessary. To validate our tract tachycardia. Pacing Clin Electrophysiol 2000; 23 (11
findings, 20 RVOT and 20 LVOT VTs might be Pt 2): 1930–1934.
necessary. We used the location of the ablation 7) Ito S, Tada H, Naito S, et al. Development and valida-
tion of an ECG algorithm for identifying the optimal
catheter in the RVOT or LVOT during ablation of the
ablation site for idiopathic ventricular outflow tract
clinical arrhythmia as the site of PVC/VT origin. It is tachycardia. J Cardiovasc Electrophysiol 2003; 14 :
possible that ablation lesions from the RVOT or LVOT 1280–1286.
extended into adjacent structures and that PVCs/VT 8) Tanner H, Hindricks G, Schirdewahn P, et al. Outflow
of an epicardial or LVOT origin was abolished from flow tachycardia with R/S transition in lead V3: six
the RVOT. This might explain the few cases that did different anatomic approaches for successful ablation. J
Am Coll Cardiol 2005; 45: 418–423.
not match [(R/R+S) PVC/VT] / [(R/R+S) SR] criteria.
9) Okumura Y, Watanabe I, Nakai T, et al. A quantitative
Detailed measurements with digital calipers were used
and qualitative analysis of the virtual unipolar
to develop the algorithm. Such measurements may electrograms from non-contact mapping of right or left-
prove difficult in routine clinical practice, although the sided outflow tract premature ventricular contractions/
theory of incorporating the SR precordial transition ventricu lar tachycardia origins. J Inte r v Card
into the decision algorithm for predicting the site of Electrophysiol 2011; 30: 17–25.
102 Kimie OHKUBO et al. 日大医誌

10) Lin D, Ilkhanoff L, Gerstenfeld E, et al. Twelve- cardiographic and electrophysiologic features of
lead electrocardiographic characteristics of the aortic ventricular arrhythmias originating from the right/
cusp region guided by intracardiac echocardiography left coronary cusp commissure. Heart Rhythm 2010; 7:
and electroanatomic mapping. Heart Rhythm 2008; 5: 312–322.
663–669. 13) Tanner H, Wolber T, Schwick N, Fuhrer J, Delacretas E.
11) Ya m a d a T, Yo s h i d a N , M u r a k a m i Y, e t a l . Electrocardiographic pattern as a guide for management
Electrocardiographic characteristics of ventricular and radiofrequency ablation of idiopathic ventricular
arrhythmias originating from the junction of the left tachycardia. Cardiology 2005; 103: 30–36.
and right coronary sinuses of Valsalva in the aorta: 14) Yoshida N, Inden Y, Uchikawa T, et al. Novel
the activation pattern as a rationale for the electro- transitional index allows more accurate differentiation
cardiographic characteristics. Heart Rhythm 2008; 5: between idiopathic right ventricular outflow tract and
184–192. aortic sinus cusp ventricular arrhythmias. Heart Rhythm
12) Bala R, Garcia FC, Hutchingson MD, et al. Electro- 2011; 8: 349–356.