Chung-Hsing Lin1,2, Li-Wei Lo1,3, Yenn-Jiang Lin1,3, Shih-Lin Chang1,3, Yu-Feng Hu1,3, Ta-Chuan Tuan1,3, Hung-Kai Huang1,4, Cheng-Hung Chiang1,5, Suresh Allamsetty1,6, Jo-Nan Liao1,3, Fa-Po Chung1,3, Yao-Ting Chang1,3, Chin-Yu Lin1,3, Abigail Louise D Te1, Shinya Yamada1,7, Rohit Walia1,8, Yuan Hung1,9, Shih-Ann Chen10,11. 1. Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan. 2. Division of Cardiology, Department of Medicine, Taipei Medical University, Shuang Ho Hospital, Taipei, Taiwan. 3. Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan. 4. Division of Cardiology, Department of Medicine, Changhua Christian Hospital, Changhua, Taiwan. 5. Division of Cardiology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan. 6. Apollo Hospital, Visakhapatnam, Andhra Pradesh, India. 7. Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan. 8. Bhagat Phool Singh Government Medical College, Sonipat, Haryana, India. 9. Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan. 10. Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan. epsachen@ms41.hinet.net. 11. Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan. epsachen@ms41.hinet.net.
Abstract
PURPOSE: There are few reports describing ventricular arrhythmias (VAs) from the crux and the corresponding endocardial site, i.e., the basal inferior segment of the interventricular septum (IVS). We aimed to investigate a distinct clinical group of VAs arising from the endocardium at this area in patients with structural heart diseases (SHD). METHODS: We included 17 patients with SHD and clinically documented VAs. Thirteen patients underwent endocardial mapping only. Three patients underwent both epicardial and endocardial approaches and one had only epicardial mapping. Eighteen VAs were identified, 14 focal and 4 reentrant VAs, confirmed by entrainment. RESULTS: There were 2 VAs from the crux, 5 VAs from the corresponding endocardial site in the right ventricle (RV), and 11 from the site in the left ventricle (LV). Compared with the VAs from RV endocardium, VAs from LV endocardium had a higher R wave in V3 than V2 (V2R/V3R ratio, 1.83 ± 0.84 vs. 0.86 ± 0.38, P = 0.008) and a higher V3 transition ratio percentage (2.16 ± 2.07 vs. 0.58 ± 0.62, P = 0.008). Combining all 16 patients with endocardial mapping, there were also lower bipolar voltages (1.21 ± 1.05 vs. 3.10 ± 2.65 mv, P < 0.0001), lower unipolar voltages (4.05 ± 1.92 vs. 5.75 ± 2.90 mv, P < 0.0001), and longer local electrocardiogram (EGM) lateness (157.6 ± 47.9 vs.140.3 ± 52.5 ms, P = 0.0001) in the dominant chambers. CONCLUSIONS: In VAs from the crux and the corresponding endocardial site, the complete ECG V2R/V3R ratio and V3 transition ratio percentage could differentiate the VAs from the RV or LV endocardium. The lower unipolar, bipolar voltage mapping, and longer EGM lateness are helpful to identify the abnormal substrate in the endocardium in these patients.
PURPOSE: There are few reports describing ventricular arrhythmias (VAs) from the crux and the corresponding endocardial site, i.e., the basal inferior segment of the interventricular septum (IVS). We aimed to investigate a distinct clinical group of VAs arising from the endocardium at this area in patients with structural heart diseases (SHD). METHODS: We included 17 patients with SHD and clinically documented VAs. Thirteen patients underwent endocardial mapping only. Three patients underwent both epicardial and endocardial approaches and one had only epicardial mapping. Eighteen VAs were identified, 14 focal and 4 reentrant VAs, confirmed by entrainment. RESULTS: There were 2 VAs from the crux, 5 VAs from the corresponding endocardial site in the right ventricle (RV), and 11 from the site in the left ventricle (LV). Compared with the VAs from RV endocardium, VAs from LV endocardium had a higher R wave in V3 than V2 (V2R/V3R ratio, 1.83 ± 0.84 vs. 0.86 ± 0.38, P = 0.008) and a higher V3 transition ratio percentage (2.16 ± 2.07 vs. 0.58 ± 0.62, P = 0.008). Combining all 16 patients with endocardial mapping, there were also lower bipolar voltages (1.21 ± 1.05 vs. 3.10 ± 2.65 mv, P < 0.0001), lower unipolar voltages (4.05 ± 1.92 vs. 5.75 ± 2.90 mv, P < 0.0001), and longer local electrocardiogram (EGM) lateness (157.6 ± 47.9 vs.140.3 ± 52.5 ms, P = 0.0001) in the dominant chambers. CONCLUSIONS: In VAs from the crux and the corresponding endocardial site, the complete ECG V2R/V3R ratio and V3 transition ratio percentage could differentiate the VAs from the RV or LV endocardium. The lower unipolar, bipolar voltage mapping, and longer EGM lateness are helpful to identify the abnormal substrate in the endocardium in these patients.
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