E l e c t ro c a rd i o g r a m

C h a r a c t e r i s t i c s of
O u t f l o w Tr a c t Ve n t r i c u l a r
Tac h yc ardia
Amit Mehrotra, MD, MBA, Sanjay Dixit, MD*

KEYWORDS
 Outflow tract  Electrocardiogram  Ventricular tachycardia  Idiopathic ventricular tachycardia
 Intracardiac electrogram

KEY POINTS
 The mechanism underlying outflow tract ventricular tachycardia (VT) is delayed after depolarization-
mediated triggered activity.
 Outflow tract VT arises from a focal site, and these patients generally lack structural heart disease.
Thus, pace mapping can be used to mimic the clinical VT.
 Outflow tract VTs most commonly arise from the superior right ventricular (RV) outflow tract, aortic
cusp region, basal left ventricle and the great cardiac/anterior interventricular vein.
 At the site of origin, local activation precedes QRS complexes by 15 to 30 milliseconds, and pace
mapping from this location matches the clinical arrhythmia.
 Electroanatomic mapping facilitates accurate catheter localization in the outflow tract region.

INTRODUCTION triggered activity caused by delayed after depolar-

Pathophysiology
Ventricular tachycardias (VTs) are usually
observed in the setting of structural heart disease.
However, in 10% of patients presenting with VT,
routine diagnostic modalities demonstrate no
myocardial damage. These arrhythmias have
been called idiopathic ventricular tachycardias
(IVTs).1
Outflow tract tachycardias comprise a subgroup
of IVTs that are predominantly localized in and
around the right and left ventricular outflow tracts
(RVOT and LVOT, respectively). Lerman and col-
leagues2 demonstrated that the mechanism un-
derlying this group of arrhythmias appears to be
izations that are determined by intracellular cal-
cium release (load). The release of calcium is
negatively affected by adenosine, which is why
these arrhythmias are considered adenosine
sensitive.3
Clinical Presentation
In general, outflow tract tachycardias can manifest
at any age and equally in both sexes.4 The typical
presentation of these arrhythmias consists of sal-
vos of paroxysmal ventricular ectopic beats and
nonsustained VT; sustained tachycardia is uncom-
mon. Most patients (48%–80%) experience palpi-
tations. Presyncope and lightheadedness may
cardiacEP.theclinics.com

Pertinent Disclosures: None.

Cardiovascular Division, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA
19104, USA
* Corresponding author. Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street,
Philadelphia, PA 19104.
E-mail address: Sanjay.Dixit@uphs.upenn.edu

Card Electrophysiol Clin 6 (2014) 553–565

http://dx.doi.org/10.1016/j.ccep.2014.05.005
1877-9182/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
554 Mehrotra & Dixit
also be observed (28%–50%). True syncope is
infrequently seen (overall incidence, <10%), and
these rhythm disorders are rarely life threat-
ening.5–7 Outflow tract tachycardias are typically
provoked by exercise in most patients.5,8 Other
triggers for inducing or enhancing the arrhythmia
include stress, anxiety, and stimulants such as
caffeine. In women, outflow tachycardias are
more often observed during premenstrual or peri-
menopausal periods and with gestation, suggest-
ing the role of hormonal influences.
Distribution
In the earlier experience at the authors’ center
(January 1999 and December 2003) of 122 pa-
tients undergoing ablation for IVT, the site of origin
(SOO) was localized to the RVOT region in 88 pa-
tients (72%). More recently (2004–2008), however,
the authors have noted a preponderance of the
SOO from the cusp region.1,9
This article describes the unique electrocardio-
gram (ECG) morphologies of outflow tract VT by
means of their SOO. It also briefly outlines strate-
gies that the authors have used for successfully
ablating these arrhythmias.
Fig. 1. Examples of variable 12-lead ECG characteristics encountered in outflow tract VT. They manifest inferior
axis with either RBBB or LBBB patterns, and either a right or left axis.
ECG CHARACTERISTICS OF OUTFLOW TRACT
VT
RVOT Versus LVOT
Outflow tract tachycardias typically manifest an
inferior axis (positive deflections in the inferior
leads) and a left or right bundle branch block
pattern (LBBB and RBBB, respectively), based
on QRS morphology in lead V1. These arrhythmias
can manifest diverse axes and different precordial
transition patterns (early, late, or none) (Fig. 1). A
predominantly or exclusively positive deflection
in lead V1 is considered RBBB morphology, which
suggests origin from the LVOT, whereas a pre-
dominantly negative deflection in lead V1 is
considered LBBB morphology; tachycardias man-
ifesting this morphology can arise from either the
RVOT or septal LVOT. The precordial transition is
helpful in predicting whether VT manifesting
LBBB is arising from the RVOT or septal LVOT or
the cusp region. Typically, if the precordial transi-
tion of the VT is later than that of the QRS com-
plexes in sinus rhythm, then the SOO is likely in
the RVOT. If the precordial transition is at V3 or
earlier and occurs before the transition in sinus
rhythm, the QRS complex in lead V2 should be
further analyzed to distinguish between an RVOT

versus LVOT SOO. A comparison of the R/R1S ra-
tio of the VT in lead V2 with that in sinus allows one
to distinguish between an RVOT or cusp site of
origin. A ratio above or below 0.6 has been estab-
lished to predict origin from cusp or RVOT, respec-
tively (Fig. 2).10
In order to define ECGs characteristic from spe-
cific anatomic locations in the outflow tract region,
the authors have developed algorithms using pace
mapping with electroanatomic guidance for accu-
rate catheter localization.
Localization of Outflow Tract Tachycardia
Arising from Superior RVOT
The RVOT region is defined superiorly by the pul-
monic valve and inferiorly by the superior margin
of the RV inflow tract (tricuspid valve). The inter-
ventricular septum and the RV free wall constitute
its medial and lateral aspects, respectively.
Because of the predilection for clinical arrhythmias
from the superior RVOT, the authors attempted to
further characterize the ECG features of pace
maps from this region. To accomplish this, the
superior-most sites in a posterior-to-anterior dis-
tribution were assigned numbers 1, 2, and 3 on
both the septal and free wall aspects of the
Fig. 2. Use of V2 transition ratio to differentiate RVOT from cusp SOO.
ECG Characteristics of Outflow Tract VT 555
superior RVOT (Fig. 3). The mapping catheter
was positioned serially at each of these sites,
and the location was paced at the diastolic
threshold for 10 to 20 beats, during which a 12-
lead ECG was acquired. The ECG was specifically
analyzed for (1) QRS amplitude and duration in all
limb leads; (2) presence of notching of R waves in
the inferior leads II and III, and/or aVF; (3) QRS
transition pattern in the precordial leads (from
QS/rS pattern to RS/Rs pattern) with a change at
or beyond lead V4 defined as being late transition;
and (4) QRS morphology in limb lead I.11 Fig. 4
shows clinical examples of VT/premature ventricu-
lar contractions (PVCs) arising from different
locations in the superior RVOT, and Table 1 sum-
marizes the findings that are unique to each loca-
tion in this region. In the authors’ series, pace
maps from superior RVOT septal sites manifested
monophasic R waves in the inferior leads, which
were taller and narrower when compared with
those seen in the counterpart free wall locations.
Likewise, the duration of the R wave in lead II at
septal sites was narrower than that of the R
wave at free wall sites. The contour of the R
wave in the inferior leads was also helpful in differ-
entiating septal and free wall locations in the supe-
rior RVOT. Typically, R waves from free wall sites
556 Mehrotra & Dixit
Fig. 3. Numbering system to demarcate various loca-
tions along the free wall and septum in the superior
RVOT region. Each location in this region manifests
a unique ECG morphology. PV, pulmonic valve; TV,
tricuspid valve.
demonstrated notching, which was uncommon in
R waves from septal locations. Another feature
that was helpful in distinguishing septal from free
wall site pace maps in superior RVOT was the
QRS transition pattern in the precordial leads
(late vs early). The authors also evaluated the
QRS morphology of pace maps in limb lead I. In
general, for both the free wall and septal posterior
locations (site 1), the QRS in lead I manifested pos-
itive polarity (r waves). In comparison, anterior
sites (site 3) along the septum and the free wall
demonstrated predominantly negative polarity (rs
or qs). Sites midway between the anterior and pos-
terior locations (site 2) along the septum and the
free wall demonstrated either a biphasic or a multi-
phasic QRS morphology (qr/rs pattern), or an iso-
electric segment preceding the q or r wave.11
Using these criteria, a blinded reviewer was accu-
rately able to predict the site of origin of clinical
tachycardias arising from the superior RVOT
region.11
Localization of Outflow Tract Tachycardia
Arising from the Basal Left Ventricle
The basal left ventricle constitutes ventricular
myocardium bordering the mitral valve and en-
compasses a wide area, including septum and
anterior, lateral, and inferior walls.4,12 The aortic
valve typically sits at the superior and medial
aspect of this region, distorting its otherwise circu-
lar shape. To develop ECG criteria for localizing
basal LV VT, the authors performed pace mapping
in a series of patients from 4 or more locations in
this region, including the parahisian region, the
aortomitral continuity and superior, superolateral,
and lateral locations along the mitral annulus
(Fig. 5, Table 2). In general, most medial basal
LV sites demonstrated the narrowest QRS com-
plexes, which were predominantly positive in
lead I, whereas superolateral mitral annulus loca-
tions demonstrated the widest complexes, which
were predominantly negative in lead I. With the
exception of parahisian sites, which consistently
demonstrate left bundle branch block morphology
and early precordial transition patterns, pace
maps from all other sites in this region manifested
right bundle branch block morphology. Addition-
ally, qR morphology in lead V1 was found to be
pathognomonic for pace maps from aortomitral
continuity location in the authors’ series.
Localization of Outflow Tract Tachycardia
Arising from Aortic Cusps and Surrounding
Epicardium
Outflow tract tachycardias frequently arise from
the region of the aortic cusps and the sinus of Val-
salva.13,14 It is important to understand the
anatomic relations between the aortic cusps and
their surrounding structures. The pulmonic valve
and superior RVOT region are located anteriorly,
slightly superior and rightward of the aortic valve.
The posterior septal aspect of the superior RVOT
typically lies adjacent to the right coronary cusp
(RCC), whereas the anterior septal aspect tends
to be situated at the junction of the right and left
cusp or anterior to the septal aspect of the latter
(Fig. 6).15 In some instances, a catheter in the
 ECG Characteristics of Outflow Tract VT 557

Fig. 4. 12-lead ECG morphology of clinical tachycardia that was successfully ablated from different locations in
the superior RVOT region. PV, pulmonic valve; TV, tricuspid valve.

anterior–superior septal RVOT can extend far left-
ward almost to the left coronary cusp (LCC) loca-
tion (Fig. 7).
To determine unique ECG characteristics of ar-
rhythmias arising from this region, the authors per-
formed pace mapping of the right, left, and
noncoronary cusps in 20 patients with structurally
normal hearts. They found lead V1 most useful in
distinguishing the pace maps from various sites
in the cusp region. LCC pace maps consistently
produced a multiphasic component, resembling
an M- or W-shaped QRS complex. RCC pacing
demonstrated a QS or QR type pattern with a pre-
dominantly negative vector in V1 (Fig. 8). Pacing
the noncoronary cusp resulted universally in cap-
ture of the atrium. Additional analysis of precordial
QRS transition demonstrated that, for pace maps
from the LCC, precordial transition occurred in
V2 or earlier, whereas for RCC pace maps, the
precordial transition was most commonly
after V2. Recently, in a series of patients at the au-
thors’ center who underwent successful ablation

Table 1
Superior RV outflow tract VT location

Septal Site 1 Septal Site 2 Septal Site 3 Free Wall Free Wall
Site 1 Site 3
Inferior Lead Morphology Monophasic Monophasic Monophasic Notched Notched
Inferior Lead Amplitude and Tall and Tall and Tall and Short and Short and
Duration narrow narrow narrow wide wide
Lead I Positive Biphasic Negative Positive Negative
Precordial Transition Early Early Early Late Late
558 Mehrotra & Dixit

Fig. 5. 12-lead ECG morphology of pace maps from various locations along the basal left ventricle. MA, mitral
annulus.

of PVC/VT from the aortic cusp region, the site of
origin of the tachycardia was localized to the
commissure between the LCC and RCC. Unique
features of tachycardias originating from this loca-
tion included QS morphology in lead V1 with
notching on the downward deflection. When map-
ping for these arrhythmias in the cusp region, a late
potential was observed during sinus rhythm at the
site of earliest activation that reversed during the
arrhythmia (Fig. 9).16
LOCALIZATION ALGORITHM
Several algorithms for the localization of outflow
tract VT by surface ECG have been published.17–19
Presented here is a simple algorithm that can be
used along with the figures and table in this article
to help localize idiopathic VT SOO (Fig. 10).
LIMITATIONS AND ADDITIONAL
CONSIDERATIONS
Although ECG manifestations of outflow tract
tachycardias are extremely helpful in predicting
their site of origin, there remain some limitations.
These include lead placement and VT originating
from the body of the right ventricle.
Lead Placement
Displacement of certain limb or precordial lead
electrodes can change the ECG morphology of

Table 2
Basal left ventricle VT localization

S-P AMC Superior MA Supero-Lateral MA Lateral MA

Lead I R or Rs Rs or rs rs or rS rS or QS rS or rs
Lead V1 QS or Qr qR R or Rs R or Rs R or Rs
Precordial Transition Early None None None None or late S wave
Ratio of QRS in Leads >1 1 1 1 >1
II and III
 ECG Characteristics of Outflow Tract VT 559

Fig. 6. Heart model transected in the axial plane demonstrates the proximity of common sites of origin of idio-
pathic VT: the superior RVOT, aortic cusp region, basal left ventricle and the mitral annulus. PV, pulmonic valve;
TV, tricuspid valve. (Courtesy of Samuel Asirvatham, MD, Rochester, MN.)

the clinical arrhythmia and/or pace maps, and can
adversely impact the accurate localization of the
SOO. The authors examined the impact of
changes in precordial leads V1 and V2 in a cohort
of 18 patients as well as the influence of changes
in upper limb electrode locations on QRS
morphology in lead I in a separate cohort of 16 pa-
tients with outflow tract tachycardias. They found
that superior displacement of leads V1 and V2
reduced the R-wave amplitude and led to a
decreased R/S ratio, while inferior displacement
of leads V1 and V2 resulted in increased R-wave
amplitude and led to an increased R/S ratio. These
changes adversely impacted the authors’ ability to
accurately differentiate RVOT from cusp location
of the clinical arrhythmias. Similarly, anterior
displacement of the arm leads from shoulders to
chest resulted in a reduction in the R-wave ampli-
tude in lead I, which limited the authors’ ability to
accurately differentiate between anterior and pos-
terior locations in the superior RVOT region
(Fig. 11).20
VT Originating from the Body of the Right
Ventricle
Although most IVT’s arise from the outflow tracts
or the basal left ventricle, a small number can
also arise from the body of the right ventricle.
Among 278 consecutive patients who underwent
radiofrequency ablation for idiopathic VT at the
authors’ institution between January 1999 and

Fig. 7. Catheters in anterior–superior portion of RVOT (septal site 3) and LCC, respectively, demonstrating the
proximity of these anatomic regions.
560

Fig. 8. 12-lead ECG morphology of right versus left coronary cusp site of origin (LCC SOO). NCC, non-coronary cusp.

Fig. 9. 12-lead ECG morphology of VT originating from RCC–LCC junction. Late potential present in sinus rhythm
that reverses with PVC. Arrow points to site of successful ablation. ICE, intracardiac echocardiography..

Fig. 10. Localization algorithm for IVT SOO. MA, mitral annulus.
December 2009, 29 patients were found to have
VT originating from the body of the right
ventricle.21 Of these 29 patients, for 14, the
SOO was within 2 cm of the tricuspid valve
annulus (TVA); for 8 patients the SOO was from
the basal RV, and for 7 patients, the SOO was
from the apical RV segments. Among VTs from
the TVA, the SOO for 8 patients was the free
wall, and for 6 patients, the SOO was the septum.
All but 1 RV basal or apical VT originated from the
free wall. All had a left bundle branch block
pattern. When the SOO was the free wall, the
QRS duration was longer, and the S wave in
lead V2 and V3 was deeper than in cases in which
the SOO was from the septum. When the SOO
was apical, the precordial R-wave transition
was V6, or there was no transition; additionally,
there was a smaller R wave in lead II and S
wave in lead aVR compared with VT from
basal RV.
MAPPING AND ABLATION
Localization of the SOO of the clinical tachycardia
is accomplished by intracardiac activation and
pace mapping. Careful analysis of the 12-lead
ECG during tachycardia is very useful and can
guide catheter localization to within 0.5 to 1 cm
of the site of successful ablation.11,12,22–24
ECG Characteristics of Outflow Tract VT 561
Although biplane fluoroscopy permits reasonable
catheter localization, use of electroanatomic map-
ping and intracardiac echocardiography allows
further refinement.
Activation and electroanatomic mapping can
be used together to localize VT SOO
(Fig. 12).23–26 Typically, at the site of successful
ablation, the local bipolar electrogram precedes
QRS onset by 20 to 30 milliseconds or more.26
Pace mapping is also performed to help confirm
VT SOO. The mapping catheter is advanced to
the area of interest (based on 12-lead ECG), and
pacing is performed at a rate similar to the tachy-
cardia cycle length. The goal is to achieve an
identical match (all 12 leads) between the clinical
arrhythmia and the pace map, paying particular
attention to subtle features such as notches in
the QRS complexes in various leads. Usually the
site of earliest activation is also the site of the
best pace map of the clinical arrhythmia.27 The
use of both localization techniques is helpful
(Fig. 13).
Radiofrequency ablation, if done carefully (with
attention to energy settings and the coronary anat-
omy), is a safe and highly effective (overall success
rate >90%) treatment option (Fig. 14). For this
reason, in the authors’ opinion, catheter ablation
may be considered first-line therapy for these
arrhythmias.
562 Mehrotra & Dixit

Fig. 11. (A) Impact of changes in limb lead placement on ECG morphology. (B) Impact of changes in V1 and V2
lead placement on ECG morphology.
 563

Fig. 12. Use of electroanatomic and activation mapping to facilitate localization of PVC site of origin. (Right)
Activation mapping using local bipolar electrogram at suspected site of ventricular tachycardia origin demon-
strates a signal 64 milliseconds earlier than the onset of the QRS on the 12-lead surface ECG. (Left) Use of 3-
dimensional electroanatomic mapping to demonstrate anatomy and site of earliest activation. Color coding
used to record activation timing of specific anatomic areas based on multiple points taken during tachycardia.
TV, tricuspid valve.

Fig. 13. Activation and pace mapping to localize ventricular tachycardia SOO in the LV summit. This area is closely
abutted by the superior RVOT, aortic cusp region, junction of the great cardiac/interventricular vein, and the
basal LV endocardium. Accurate localization of the SOO in this area is facilitated by electroanatomic and pace
mapping. Arrow points to site of successful ablation. AIV, anterior interventricular vein; NCC, non-coronary cusp.
564 Mehrotra & Dixit
Fig. 14. Elimination of PVCs almost immediately with initiation of radiofrequency energy delivery at site of
earliest activation and best pace map.
SUMMARY
Outflow tract tachycardias are thought to result
from triggered activity. The 12-lead ECG during
these arrhythmias manifests site-specific charac-
teristics that can facilitate accurate localization.
These arrhythmias, in general, are not life threat-
ening and therefore can initially be managed
conservatively. However, radiofrequency ablation
can be curative in more than 90% of cases with
a low risk (w1%) of serious complications.
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