1 CONTEMPORARY REVIEW 69

2 70
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How to use the 12-lead ECG to predict the site of origin 71
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of idiopathic ventricular arrhythmias 73
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7 75
8 Q21 Andres Enriquez, MD,* Adrian Baranchuk, MD,* David Briceno, MD,† Luis Saenz, MD,‡ 76
9 77
10 Q1 Fermin Garcia, MD† 78
11 79
12 From the *Division of Cardiology, Queen’s University, Kingston, Ontario, Canada, †Section of Cardiac 80
13 Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, and 81
14 ‡ 82
Fundación Cardioinfantil, Bogota, Colombia.
15 83
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17 85
18 Idiopathic ventricular arrhythmias may arise from anywhere in the tion is understanding the attitudinal orientation of the heart within 86
19 heart, and the majority of them can be effectively treated with cath- the chest and the relationship between the different cardiac struc- 87
20 eter ablation. The 12-lead electrocardiogram (ECG) is the initial map- tures. In this review, we provide a stepwise anatomical approach 88
21 ping tool to predict the most likely site of origin and is valuable to for the localization of idiopathic ventricular arrhythmias based on 89
22 choose the appropriate ablation strategy. Crucial to ECG interpreta- sequential analysis of the most relevant ECG features. 90
23 91
24 92
25 93
26 94
27 95
28 Introduction and has been the source of confusing and inappropriate 96
29 Idiopathic ventricular arrhythmias (VAs) occur in patients with nomenclature. More recently, efforts have been made toward 97
30 an anatomically correct or attitudinal description of the heart. 98
structurally normal hearts. The spectrum of clinical presenta-
31 99
tion includes isolated premature ventricular contractions A seminal contribution in this direction is the landmark
32 100
33 (PVCs), repetitive nonsustained or sustained ventricular tachy- anatomical atlas published by Wallace McAlpine in 1975.1 101
34 cardia (VT), and PVC-triggered ventricular fibrillation. The When the heart is viewed in an attitudinal perspective, the 102
35 majority originate from the outflow tract of the right ventricle right cardiac chambers are anterior relative to the left chambers. 103
36 The RV is positioned anteriorly and to the right of the LV. The 104
(RV) and left ventricle (LV), but they may arise from anywhere
37 105
in the heart. Idiopathic VAs can be effectively treated with LV lies obliquely in the chest, with the base located posteriorly
38 106
39 catheter ablation, and major advances have been made in the and the apex positioned to the left. The so-called anterior inter- 107
40 past decade in terms of mapping tools and energy delivery. ventricular sulcus in fact begins superiorly and travels to the left 108
41 Invasive electrophysiology has greatly benefited from a and slightly anteriorly, while the so-called posterior interven- 109
42 tricular sulcus is actually positioned inferiorly. 110
rediscovery of cardiac anatomy. The systematic study of
43 111
anatomical relationships using modern techniques has helped Regarding the outflow tract region, the anatomical rela-
44 112
45 us to understand the reasons why ablation may fail and to bet- tionships are complex and VAs from different structures in 113
46 ter approach challenging cases. The surface 12-lead electro- this region may have a similar ECG appearance. The RV 114
47 cardiogram (ECG) is useful to localize the site of origin of outflow tract (RVOT) wraps around and crosses the LV 115
48 outflow tract (LVOT) anteriorly, so that the pulmonary valve 116
VAs when catheter ablation is being considered. Several
49 117
studies have enriched our understanding of the correlation lies anterior and to the left of the aortic valve (AoV). This
50 118
51 between different VA sources and specific ECG patterns. relation is important, as the anterior aspect of the RVOT is 119
52 actually the most leftward and highest outflow tract structure. 120
53 The LVOT corresponds to the elliptical opening of the 121
54 LV, also termed the LV ostium by McAlpine.1,2 This is 122
55
Anatomical considerations 123
Classical anatomy textbooks described the human heart in the composed by the aortic root anteriorly and by the mitral
56 124
57 “Valentine position,” in which the heart stands on its apex annulus posteriorly and to the left. Both valves are 125
58 with some rightward rotation. This description is incorrect anatomically coupled through a band of fibrous tissue 126
59 known as the aortomitral continuity (AMC), which extends 127
60 between the anterior leaflet of the mitral valve (MV) and 128
61 Q2 KEYWORDS Electrocardiogram; Site of origin; Ventricular arrhythmias 129
(Heart Rhythm 2019;-:1–8) the left (LCC) and noncoronary cusp (NCC) of the AoV.
62 130
63 Address reprint requests and correspondence: Dr Andres Enriquez, Divi-
The AoV occupies a central position within the heart and is 131
64 sion of Cardiology, Queen’s University, 76 Stuart St, Kingston, Ontario, composed of 3 cusps, each one with relevant anatomical 132
65 Canada K7L 2V7. E-mail address: Andres.Enriquez@kingstonhsc.ca. relationships. In attitudinal orientation, the right coronary 133
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68 1547-5271/$-see front matter © 2019 Heart Rhythm Society. All rights reserved. https://doi.org/10.1016/j.hrthm.2019.04.002 136

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 2 Heart Rhythm, Vol -, No -, - 2019

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165 Figure 1 Anatomic approach for the regionalization of the VA site of origin based on frontal plane axis and bundle branch block pattern. AMC 5 aortomitral 233
166 continuity; APM 5 anterolateral papillary muscle; Inf. 5 inferior; LAF 5 left anterior fascicle; LBBB 5 left bundle branch block; LCC 5 left coronary cusp; LPF 234
167 5 left posterior fascicle; LV 5 left ventricular; MB 5 moderator band; MV 5 mitral valve; PPM 5 posteromedial papillary muscle; RBBB 5 right bundle branch 235
168 block; RCC 5 right coronary cusp; RVOT 5 right ventricular outflow tract; Sup. 5 superior; TV 5 tricuspid valve; VA 5 ventricular arrhythmia. 236
169 237
170 238
171 239
172 cusp (RCC) is the most anterior cusp relative to the sternum, The QRS axis has both a vertical (superior-inferior) and a 240
173 the NCC is posterior and rightward, and the LCC is posterior horizontal (right-left) dimension. The vertical dimension is 241
174 and leftward. The NCC is the most inferior and the LCC is the reflected by QRS polarity in bipolar leads II and III. For 242
175 243
176
most superior in position. The RCC is in close proximity to example, all outflow tract VAs share an inferiorly directed 244
177 the posteroseptal aspect of the RVOT, while the LCC is QRS axis, with positive forces in leads II and III. The hori- 245
178 adjacent to the anterior aspect of the LV ostium, in close zontal dimension is better reflected by lead I. Structures 246
179 proximity to the left anterior descending artery. closer to the left arm will produce a deeply negative complex 247
180 Conversely, the NCC is in relationship with both the left in lead I (rightward axis); conversely, structures closer to the 248
181 249
182
atrium and the right atrium separated by the interatrial right arm are strongly positive in lead I (leftward axis). Addi- 250
183 septum. Below the commissure between the RCC and the tional approximation to the horizontal dimension is given by 251
184 NCC lies the membranous ventricular septum, where the the relative amplitude between limb leads aVR and aVL: a 252
185 penetrating bundle of His is located. more positive polarity in lead aVR than in lead aVL suggests 253
186 A common site of origin of VAs is the LV summit. This a more leftward origin; a more positive polarity in lead aVL 254
187 255
188
corresponds to the highest portion of the LV epicardium, than in lead aVR points toward a more rightward origin. 256
189 above the upper end of the anterior interventricular sulcus The bundle branch block pattern is related to the sequence 257
190 and bounded by the bifurcation between the left anterior of RV and LV activation. VAs with a right bundle branch 258
191 descendant and the left circumflex coronary arteries.3 This block (RBBB) appearance typically arise in the LV, while 259
192 triangular region is transected by the great cardiac vein at VAs with a left bundle branch block (LBBB) appearance 260
193 261
194
its junction with the anterior interventricular vein, which pro- may arise anywhere in the RV, but also in the left side of 262
195 vides an access to map and sometimes ablate PVCs/VTs from the interventricular septum. 263
196 this region. The precordial transition in RBBB VAs (first lead with a 264
197 predominant S) occurs progressively earlier as the site of Q3 265
198 origin moves from the base toward the apex of the LV. In 266
199 267
200
ECG features LBBB VAs, the precordial transition (first lead with a pre- 268
201 Several ECG features are relevant for the localization of a dominant R) occurs progressively later as the site of origin Q4 269
202 particular VA. The most important are (1) QRS axis, (2) moves from the septum toward the RV free wall. Positive 270
203 bundle branch block pattern, (3) precordial transition, and concordance (all positive precordial leads) is seen in VAs 271
204 (4) QRS width. arising at the base of the heart, in which case ventricular 272

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 Enriquez et al Site of Origin 3

273 activation has to move anterior and apical. Conversely, nega- atrioventricular valves, while superior-axis VAs (negative 341
274 tive concordance (all negative precordial leads) is seen in II and III) have their origin at the inferior aspect of both ven- Q5 342
275 343
276
VAs originating near the apex, such that electrical activity tricles (Table 1). A few VAs may exhibit discordance be- 344
277 moves away from the chest wall. tween leads II and III (positive/negative or negative/ 345
278 Finally, septal VAs have narrower QRS durations than do positive). These will be discussed separately. 346
279 VAs originating on the free wall of both ventricles because of 347
280 synchronous rather than sequential ventricular activation. 348
281 Step 2 349
282
Having mentioned these general rules, it should be 350
Our next step is to separate VAs arising from the right or left
283 acknowledged that the 12-lead ECG has limitations4 and sig- 351
side of the chest midline, which does not necessarily means
284 nificant variation may result from several factors, such as 352
285
RV vs LV, especially in the outflow tracts, where there is a 353
body habitus, lead placement, and shifts in the relationship
286 significant overlap between the RVOT and the LVOT.5 354
of the heart to the chest wall.
287 355
288
1. For outflow tract VAs, the best single ECG discriminator 356
289 is the left/right axis reflected by lead I. Rightward struc- 357
290
Comprehensive anatomic approach for the tures, such as the posterior aspect of the RVOT, RCC, par- 358
291 prediction of the site of origin ahisian region, and superior aspect of the tricuspid valve Q6 359
292 We propose an algorithm based on 4 anatomical quadrants (TV), are positive in lead I, while leftward structures, 360
293 for rapid regionalization of a particular VT/PVC (Figures 1 361
294
such as the anterior aspect of the RVOT, LCC, AMC, an- 362
and 2). Once ascribed to any of these quadrants, analysis of terolateral MV annulus, and LV summit, will produce a
295 363
296
additional ECG features, such as precordial transition, QRS negative complex in lead I. The commissure between 364
297 duration, or specific morphology in certain leads, is helpful the RCC and the LCC, a common source of idiopathic 365
298 to postulate the most likely site of origin. VAs, is close to the midline, and, in our experience, ar- 366
299 367
300
rhythmias from this area may have either a positive, a 368
301 Step 1 negative, or a biphasic QRS complex in lead I.6 369
302 We start looking at the superior/inferior axis, represented by 2. For VAs arising from the inferior aspect of the ventricles, 370
303 polarity in leads II and III. Inferior-axis VAs (positive QRS the most helpful element is the bundle branch block 371
304 complex in leads II and III) arise from basal areas of the heart, appearance, as some VAs from the septal portion of the 372
305 373
306
including the outflow tracts and the superior aspect of the LV may exhibit a left axis. VAs with a superior axis 374
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336 Figure 2 Anatomical schema to understand the electrocardiographic patterns of outflow tract VAs, showing the value of precordial transition and frontal plane 404
337 axis. The free wall of the RVOT is the most anterior structure, and the precordial transition occurs progressively earlier as we move toward the anterolateral mitral 405
338 annulus. Lead I polarity allows one to discriminate structures located leftward from the midline from those located on the right side. Note that the anterior aspect of 406
339 the RVOT is actually a leftward structure while the right coronary cusp of the aortic valve is a rightward structure. Abbreviations as in Figure 1. Reproduced from 407
340 Dr K. Shivkumar with permission. Copyright UCLA Cardiac Arrhythmia Center, McAlpine Collection. 408

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 4 Heart Rhythm, Vol -, No -, - 2019

409 Table 1 Electrocardiographic features of idiopathic VAs Q16 477

410 478
411 A. Positive II and III: Suggests origin from the outflow tracts and top of atrioventricular valves 479
412 480
Positive lead I: Structures rightward from the midline
413 481
a. Posterior RVOT LBBB, transition at or after V3, QS in V1 Q17
414 482
b. RCC LBBB, V2-V3 transition (V2 transition ratio
0.6), QS in V1 Q18
415 483
c. Parahisian LBBB, typically V2-V3 transition, QS in V1, R in aVL (vs negative in the RVOT), III may
416 484
be negative, narrow QRS
417 485
d. Top of the TV LBBB, variable transition, QS or rS in V1, positive aVL (vs negative in the RVOT), III
418 486
may be negative
419 487
Negative lead I: Structures leftward from the midline
420 488
a. Anterior RVOT LBBB, transition at or after V3, QS in V1
421 489
b. LCC LBBB or RBBB, V1-V2 transition, rS, R, or multiphasic pattern in V1
422 490
c. AMC RBBB, positive concordance, qR in V1
423 491
d. Anterolateral MV RBBB, positive concordance, R in V1
424 492
e. LV summit RBBB or LBBB with V2 or V3 transition, larger R in III than in II, pseudo-delta wave Q19
425 493
and/or MDI . 0.55, V2 “pattern break”
426 494
Exceptions are 2 non-outflow tract structures:
427 495
a. Left anterior fascicle RBBB, rsR0 in V1, narrow QRS, right axis
428 496
b. Anterolateral PM RBBB, R, Rsr0 , or qR in V1, late R/S transition, II may be negative
429 497
430 B. Negative II and III: Suggests origin from the inferior aspect of both ventricles 498
431 499
432 LBBB pattern: RV structures or crux 500
433 a. Inferior TV LBBB, variable transition (V2 through V5), QS or rS in V1 501
434 b. Moderator band LBBB, late transition (V5 or V6), left superior axis 502
435 c. Cardiac crux LBBB, V2 transition, left superior axis, QS in inferior leads, pseudo-delta wave and/or 503
436 MDI . 0.55 504
437 RBBB pattern: LV structures 505
438 a. Inferior MV RBBB, positive concordance, R or Rsr0 in V1 506
439 b. Posteromedial PM RBBB, R , S in V5, R, Rsr0 , or qR in V1 507
440 c. Left posterior fascicle RBBB, R , S in V5, rsR0 in V1, narrow QRS 508
441 509
442 C. Inferior lead discordance: Suggests origin from the midcavitary structures or lateral aspect of the atrioventricular valves 510
443 511
444
- Positive II/negative III: Lateral TV, RV intracavitary structures (moderator band), interventricular septum (parahisian) 512
445
- Negative II/positive III: Lateral MV, anterolateral PM 513
446 AMC 5 aortomitral continuity; LBBB 5 left bundle branch block; LCC 5 left coronary cusp; LV 5 left ventricular; MDI 5 maximum deflection index; MV 5 514
447 mitral valve; PM 5 papillary muscle; RBBB 5 right bundle branch block; RCC 5 right coronary cusp; RV 5 right ventricular; RVOT 5 right ventricular outflow tract; 515
448 TV 5 tricuspid valve; VA 5 ventricular arrhythmia. 516
449 517
450 518
451 and LBBB appearance may arise from RV structures chest and, therefore, usually exhibit positive deflections in 519
452 lead aVL (any R or r waves).7,8 In addition, RVOT and 520
(inferior aspect of the TV or moderator band [MB]) or
453 521
454 the cardiac crux. Conversely, VAs with a superior axis RCC VAs show a strong inferior axis, with tall R waves in 522
455 and RBBB pattern arise from LV structures (inferior leads II and III. In VAs from the superior TV and 523
456 aspect of the MV, posteromedial papillary muscle parahisian region, positive forces are less pronounced, 524
457 [PPM], or left posterior fascicle). especially in lead III, which can be even isoelectric or 525
458 negative. Finally, a narrow QRS duration (usually ,130 526
459 527
460
ms) is typical of parahisian VAs given the early 528
461
Step 3 engagement of this His-Purkinje system. 529
462 Once we circumscribe the likely site of origin to 1 of these Differentiation between posterior RVOT and RCC VAs 530
463 4 quadrants, a more refined localization relies in other may be particularly challenging and has been the subject of 531
464 characteristics such as precordial transition, QRS width, several studies. A precordial R/S transition after lead V3 usu- 532
465 or QRS morphology in specific leads (Table 1 and 533
466
ally suggests RVOT origin, while the transition at lead V2 or 534
467
Figure 3). earlier is typical of LVOT origin. Differentiation is more 535
468 difficult when the transition is in lead V3, as this pattern 536
469 Right upper quadrant (Figures 4A–4E) can be seen in both VAs from the posteroseptal RVOT and 537
470 Outflow tract VAs, in general, can be differentiated from TV those from the RCC, and different algorithms have been pro- Q7 538
471 539
472
and parahisian VAs by looking at lead aVL polarity. Lead posed.9–13 One of them compares the precordial transition 540
473 aVL is a left sided but also a superior lead; thus, the majority during the PVC and sinus rhythm.9 When the PVC transition 541
474 of outflow tract VAs show negative deflections in lead aVL occurs later than the sinus rhythm transition, the origin is the 542
475 (QS waves) as well as in lead aVR. Conversely, TV and para- RVOT (100% specificity). If the PVC transition occurs at or 543
476 hisian VAs are located more inferiorly and rightward in the earlier than the sinus rhythm transition, then the so-called V2 544

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 Enriquez et al Site of Origin 5

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580 Figure 3 Stepwise electrocardiographic approach for the prediction of the VA site of origin. Abbreviations as in Figure 1. 648
581 649
582 650
583 651
584Q8 transition ratio is measured (percentage R wave during the have a multiphasic pattern in lead V1 (M or W); a qR pattern Q11 652
585 PVC divided by the percentage R wave during sinus rhythm). in lead V1 is often seen in VAs from the AMC; and VAs from 653
586 A ratio of
0.6 predicts an LVOT origin with a sensitivity of the anterolateral MA most often have an R pattern in lead V1 Q12 654
587 95% and a specificity of 100%. Another ECG criterion is the with positive precordial concordance. 655
588 656
V2S/V3R index, defined as the S-wave amplitude in lead V2 VAs arising from the LV summit may have either an
589 657
590 divided by the R-wave amplitude in lead V3. An index of LBBB pattern with lead V2 or V3 transition or an RBBB 658
591 1.5 predicts an LVOT origin with a sensitivity of 89% pattern.14,15 Attention should be paid to characteristics 659
592 and a specificity of 94%.10 suggesting an epicardial origin such prominent pseudo- 660
593 delta waves or maximum deflection index . 0.55. In addi- Q13 661
594 662
Left upper quadrant (Figures 4F–4L) tion, a V2 pattern break in LBBB VAs, defined as a loss of
595Q9 663
596 It includes the anterior aspect of the RVOT and most LVOT the R wave in lead V2 compared to leads V1 and V3 664
597 structures (excluding the RCC). The precordial transition is (Supplemental Figure 1), suggests an origin near the anterior 665
598 likely the most helpful characteristic to pay attention in this interventricular sulcus, often in close proximity to the 666
599 group (Figure 2). As we move progressively more posterior LAD.16 Q14
667
600 668
from the RVOT free wall to the lateral mitral annulus, the pre- Two non-outflow tract structures may also produce a right
601 669
602Q10 cordial transition occurs progressively earlier (lead V4-V5 for inferior-axis ECG pattern: 670
603 the RVOT free wall, lead V3-V4 for the RVOT septum, lead 671
604 V1-V2 for the LCC) and finally transforms from an LBBB to 1. Left anterior fascicle: Typically characterized by a narrow 672
605 an RBBB configuration at the AMC or the top of the MV. In QRS duration (,130 ms), an rsR0 pattern in lead V1 673
606 674
addition to the bundle branch block pattern, some specific mimicking typical RBBB, and right axis deviation.
607 675
608 characteristics of lead V1 may orientate to certain locations: 2. Anterolateral papillary muscle (APM): Usually exhibits 676
609 RVOT and RCC VAs typically exhibit a QS pattern in lead an RBBB pattern with a wider QRS duration, an R, 677
610 V1; a QS pattern with notching in downstroke is suggestive Rsr0 , or qR pattern in lead V1, and late R/S transition. 678
611 of VAs from the RCC/LCC commissure; LCC VAs often Lead II may be negative. 679
612 680

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 6 Heart Rhythm, Vol -, No -, - 2019

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711 Figure 4 Inferior-axis VAs with origin at the (A) posterior RVOT (septal wall), (B) RCC, (C) parahisian region, (D) superior TV, (E) RCC-LCC commissure, 779
712 (F) anterior RVOT, (G) LCC, (H) AMC, (I) anterolateral MV, (J) LV summit, (K) left anterior fascicle, and (L) anterolateral papillary muscle. Abbreviations as in 780
713 Figure 1. 781
714 782
715 783
716 Right lower quadrant (Figures 5A–5C) their more basal location. Conversely, VAs from the left 784
717 The most common sources of idiopathic VAs in this quadrant posterior fascicle and PPM usually have R , S by lead 785
718 are the inferior TV annulus, the MB, and the cardiac crux. V5. A QRS duration of ,130 ms is highly suggestive of Q15 786
719 787
The MB is a prominent muscular trabeculation that crosses fascicular VAs, reflecting the more rapid ventricular depo-
720 788
721 from the septum to the free wall of the RV and provides sup- larization via the Purkinje system. For the same reason, 789
722 port to the anterior papillary muscle of the TV. The crux of fascicular VAs typically have an rsR0 (r , R0 ) pattern in 790
723 the heart is an epicardial region near the junction of the mid- lead V1, mimicking typical RBBB. In comparison, PPM 791
724 dle cardiac vein and the coronary sinus. MB VAs typically and MV VAs usually have an Rsr0 (R . r0 ), R, or qR 792
725 793
have a left superior axis and late precordial transition (later pattern in lead V1.
726 794
727 than lead V4).17 Conversely, crux VAs also have a left supe- 795
728 rior axis, but with early transition (lead V2) and a QS pattern 796
729 in inferior leads.18 They may also present features suggesting Inferior lead discordance 797
730 an epicardial access, such a pseudo-delta wave or maximum Inferior lead discordance reflects an opposite depolarization 798
731 vector along bipolar limb leads II (from the left leg to the right 799
deflection index . 0.55. TV VAs have a variable precordial
732 arm) and III (from the left leg to the left arm).20 This is most 800
733 transition (leads V2 through V5) depending on their septal or 801
lateral origin (lead V2 or V3 for septal sites and lead V4 or V5 often observed in VAs originating from midcavitary struc-
734 802
735 for free wall sites). A QS pattern in lead V1 is recorded in the tures (interventricular septum, MB, and APM) and some- 803
736 majority of VAs arising from the septal portion of the TV times from the lateral aspect of the atrioventricular valves. 804
737 Positive/negative discordance (positive II/negative III) is 805
annulus, while most VAs from the free wall portion exhibit
738
an rS pattern in lead V1. equivalent to a frontal axis of 230 to 130 , and negative/ 806
739 positive discordance (negative II/positive III) is equivalent 807
740 808
741
to a frontal axis of 1150 to 1210 . In particular, the likely 809
Left lower quadrant (Figures 5D–5F)
742 sites of origin are as follows: 810
Idiopathic VAs with RBBB and superior axis may arise
743 811
744
from the inferior MV annulus, the left posterior fascicle, 1. Positive/negative discordance: RV structures, including 812
745 and the PPM. These can be differentiated on the basis of the lateral TV, MB, and interventricular septum (parahi- 813
746 3 main characteristics: precordial transition, QRS duration, sian region). All these have an LBBB configuration. 814
747 and V1 morphology.19 Positive precordial concordance (R 2. Negative/positive discordance: LV structures, including the 815
748 . S in lead V6) is relatively specific of MV VAs, reflecting lateral MV and APM. These have an RBBB configuration. 816

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 Enriquez et al Site of Origin 7

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848 Figure 5 Superior-axis VAs with origin at the (A) inferior TV, (B) moderator band, (C) cardiac crux, (D) inferior MV, (E) left posterior fascicle, and (F) poster- 916
849 omedial papillary muscle. Two examples of VAs with inferior lead discordance ablated from the (G) moderator band and (H) anterolateral papillary muscle. 917
850 Abbreviations as in Figure 1. 918
851 919
852 920
853 921
854 Conclusion 6. Bala R, Garcia FC, Hutchinson MD, et al. Electrocardiographic and electrophys- 922
855 iologic features of ventricular arrhythmias originating from the right/left coronary 923
Q20 The 12-lead ECG remains a valuable mapping tool for the cusp commissure. Heart Rhythm 2010;7:312–322.
856 924
857
determination of VA origin. Keeping in mind the attitudinal 7. Yamauchi Y, Aonuma K, Takahashi A, et al. Electrocardiographic characteristics
925
of repetitive monomorphic right ventricular tachycardia originating near the His-
858 orientation of the heart in the chest and looking at a number of 926
bundle. J Cardiovasc Electrophysiol 2005;16:1041–1048.
859 ECG features in an organized sequence makes it possible to 8. Tada H, Tadokoro K, Ito S, et al. Idiopathic ventricular arrhythmias originating 927
860 quickly regionalize a PVC/VT to 1 of 4 quadrants and postu- from the tricuspid annulus: prevalence, electrocardiographic characteristics, and 928
861 late the most likely differential diagnoses for the sites of results of radiofrequency catheter ablation. Heart Rhythm 2007;4:7–16. 929
862 9. Betensky BP, Park RE, Marchlinski FE, et al. The V2 transition ratio: a new elec- 930
863
origin. trocardiographic criterion for distinguishing left from right ventricular outflow 931
864 tract tachycardia origin. J Am Coll Cardiol 2011;57:2255–2262. 932
10. Yoshida N, Yamada T, McElderry HT, et al. A novel electrocardiographic
865 933
866
Appendix criterion for differentiating a left from right ventricular outflow tract tachy-
934
cardia origin: the V2S/V3R index. J Cardiovasc Electrophysiol 2014;
867 Supplementary data 25:747–753. 935
868 Supplementary data associated with this article can be found 11. Ouyang F, Fotuhi P, Ho SY, et al. Repetitive monomorphic ventricular tachy- 936
869 in the online version at https://doi.org/10.1016/j.hrthm.2019. cardia originating from the aortic sinus cusp: electrocardiographic characteriza- 937
870 04.002. tion for guiding catheter ablation. J Am Coll Cardiol 2002;39:500–508. 938
871 12. Cheng D, Ju W, Zhu L, et al. V3R/V7 index. Circ Arrhythm Electrophysiol 2018; 939
872 11:e006243. 940
873 13. Zhang F, Hamon D, Fang Z, et al. Value of a posterior electrocardiographic lead 941
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875 2. Yamada T, Litovsky SH, Kay GN. The left ventricular ostium: an anatomic 14. Yamada T, McElderry HT, Doppalapudi H, et al. Idiopathic ventricular arrhyth-
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876 concept relevant to idiopathic ventricular arrhythmias. Circ Arrhythm Electro- mias originating from the left ventricular summit: anatomic concepts relevant to 944
877 physiol 2008;1:396–404. ablation. Circ Arrhythm Electrophysiol 2010;3:616–623. 945
878 3. Enriquez A, Malavassi F, Saenz LC, et al. How to map and ablate left ventricular 15. Santangeli P, Marchlinski FE, Zado ES, et al. Percutaneous epicardial ablation of 946
879 summit arrhythmias. Heart Rhythm 2017;14:141–148. ventricular arrhythmias arising from the left ventricular summit: outcomes and 947
880 4. Jamil-Copley S, Bokan R, Kojodjojo P, et al. Noninvasive electrocardiographic electrocardiogram correlates of success. Circ Arrhythm Electrophysiol 2015; 948
881 mapping to guide ablation of outflow tract ventricular arrhythmias. Heart Rhythm 8:337–343. 949
882 2014;11:587–594. 16. Hayashi T, Santangeli P, Pathak RK, et al. Outcomes of catheter ablation 950
5. Hutchinson MD, Garcia FC. An organized approach to the localization, mapping, of idiopathic outflow tract ventricular arrhythmias with an R wave pattern
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956 18. Kawamura M, Gerstenfeld EP, Vedantham V, et al. Idiopathic ventricular 20. Enriquez A, Pathak RK, Santangeli P, et al. Inferior lead discordance in ventric- 1024
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