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Review
. 2019 Apr;16(4):362-377.
doi: 10.11909/j.issn.1671-5411.2019.04.008.

Discrimination of ventricular tachycardia and localization of its exit site using surface electrocardiography

Heber Ivan Condori Leandro  1 , Dmitry S Lebedev  2   3 , Evgeny N Mikhaylov  1   2   3
Affiliations
Review

Discrimination of ventricular tachycardia and localization of its exit site using surface electrocardiography

Heber Ivan Condori Leandro et al. J Geriatr Cardiol. 2019 Apr.

Abstract

Differential diagnosis of supraventricular tachycardia (SVT) and ventricular tachycardia (VT) is of paramount importance for appropriate patient management. Several diagnostic algorithms for discrimination of VT and SVT based on surface electrocardiogram (ECG) analysis have been proposed. Following established diagnosis of VT, a specific origination tachycardia site can be supposed according to QRS complex characteristics. This review aims to cover comprehensive and comparative description of the main VT diagnostic algorithms and to present ECG characteristics which permit to suggest the most common VT origination sites.

Keywords: Arrhythmias; Electrocardiogram; Supraventricular; Tachycardia; Ventricular.

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Figures

Figure 1.
Figure 1.. Brugada algorithm for the differential diagnosis of WCTs.
With modifications from Brugada, et al. AV: atrioventricular; LBBB: left bundle branch block; RBBB: right bundle branch block; SVT: supraventricular tachycardia; VT: ventricular tachycardia; WCTs: wide complex tachycardias.
Figure 2.
Figure 2.. Morphological criteria for diagnosis of ventricular tachycardias used by Brugada, et al.
With modifications from Eckardt L, et al. LBBB: left bundle branch block; RBBB: right bundle branch block; SVT: supraventricular tachycardia; VT: ventricular tachycardia.
Figure 3.
Figure 3.. Vereckei algorithm for the differential diagnosis of WCT.
With modifications from Vereckei, et al. AV: atrioventricular; BBB: bundle branch block; SVT: supraventricular tachycardia; VT: ventricular tachycardia; WCT: wide complex tachycardia.
Figure 4.
Figure 4.. Schematic electrocardiogram representations.
In lead V4 there are vertical lines denoting the onset of QRS complex, the initial and terminal 40 ms of the QRS complex is marked by small red points. During the initial 40 ms of the QRS, the impulse advanced vertically 0.8 mV, then the Vi = 0.8 and during the terminal 40 ms of the QRS, the impulse advanced vertically 0.2 mV, consequently the Vt = 0.2, and thus the Vi/Vt > 1 suggesting the diagnosis of SVT. In lead V3; Vi = 0.3 and Vt = 0.65 in this example, and therefore the Vi/Vt < 1 suggesting the diagnosis of VT. SVT: supraventricular tachycardia; VT: ventricular tachycardia.
Figure 5.
Figure 5.. Vereckei algorithm for the differential diagnosis of wide QRS tachycardia based on the aVR lead.
With modifications from Vereckei, et al. SVT: supraventricular tachycardia; VT: ventricular tachycardia.
Figure 6.
Figure 6.. Schematic electrocardiogram representations.
Vi/Vt ratio criterion in the fourth step of the aVR algorithm. In the inferior part, most common lead aVR electrocardiogram patterns in SVT and VT. SVT: supraventricular tachycardia; VT: ventricular tachycardia.
Figure 7.
Figure 7.. Measurement of the RWPT in lead II.
RWPT measured from the “isoelectric” line to the point of first change in polarity, was >50 ms (80 ms), with modifications from Pava LF, et al. RWPT: R-wave peak time; SVT: supraventricular tachycardia; VT: ventricular tachycardia.
Figure 8.
Figure 8.. Common characteristics found in outflow tract ventricular tachycardia (inferior axis deviation, positive QRS complexes in II, III and aVF).
(A): RVOT tachycardia; (B): LVOT tachycardia. LVOT: left ventricular outflow tract; RVOT: right ventricular outflow tracts.
Figure 9.
Figure 9.. Criteria for differentiating LVOT from RVOT.
With modifications from Cheng D, et al. LVOT: left ventricular outflow tract; RVOT: right ventricular outflow tract.
Figure 10.
Figure 10.. Typical electrocardiograms for VT originating from the aortic root.
With permission from Yamada T, et al. L: left coronary cusp; LA: left atrium; N: non-coronary cusp; R: right coronary cusp; RA: right atrium; RV: right ventricle; VT: ventricular tachycardia.
Figure 11.
Figure 11.. Schematic electrocardiogram representations.
Differentiating the QRS morphology of LPFVT from RBBB and LAHB aberrancy, when 3 or 4 criteria are positive the diagnosis of left posterior fascicular VT is likely. LAHB: left anterior hemiblock; LPFVT: left posterior fascicular ventricular tachycardia; RBBB: right bundle branch block; VT: ventricular tachycardia.
Figure 12.
Figure 12.. VT from the inferoseptal papillary muscle (A) and VT from the anteroseptal papillary muscle (B: schematic ECG representation).
VT: ventricular tachycardia.
Figure 13.
Figure 13.. Representative 12-lead electrocardiograms of premature ventricular contractions originating from the anterolateral (A), posterior (B), and posteroseptal (C) portions of the mitral annulus.
Arrows indicate “notching” of the late phase of the QRS complex in the inferior leads, with permission from Tada H, et al.
Figure 14.
Figure 14.. Representative 12-lead electrocardiograms of papillary muscle, fascicular, and mitral annular ventricular arrhythmias with corresponding locations on schematic diagram.
With permission from Al'Aref SJ, et al. AL: anterolateral; LAF: left anterior fascicle; LPF: left posterior fascicular; Pap: papillary muscle; PM: posteromedial.
Figure 15.
Figure 15.. Algorithm for differentiation of focal left VA.
(A): Flow chart shows algorithm for differentiation of inferior axis VA into papillary, fascicular, or mitral annular arrhythmia based on QRS duration and positive precordial concordance; (B): Flow chart shows algorithm for differentiation of superior axis VA into papillary, fascicular, or mitral annular arrhythmia based on QRS morphology in leads V1 and V5. VA: ventricular arrhythmia.
Figure 16.
Figure 16.. Representative 12-lead electrocardiograms of premature ventricular contractions originating from the posterolateral, anterior, and anteroseptal portions of the tricuspid annulus.
Arrows indicate the second peak of the “notched” QRS complex in the limb leads, with permission from Tada H, et al.
Figure 17.
Figure 17.. VT with epicardial origin.
A pseudo delta wave ≥ 34 ms (measured from the earliest ventricular activation to the earliest fast deflection in any precordial lead), intrinsicoid deflection V2 ≥ 85 ms (defined as the interval measured from the earliest ventricular activation to the peak of QRS in V2), shortest RS complex ≥ 121 ms (defined as the interval measured from the earliest ventricular activation to the nadir of the first S wave in any precordial lead). VT: ventricular tachycardia.
Figure 18.
Figure 18.. Schematic representation of anatomical areas in right anterior oblique (RAO) and left anterior oblique (LAO) views.
LAO: left anterior oblique; RAO: right anterior oblique.
Figure 19.
Figure 19.. Algorithm proposed by Kuchar and collaborators for the identification of exit sites of VT.
A: anterior; C: central; I: inferior; L: lateral; M: middle; S: septal; VT: ventricular tachycardia; o: isoelectric; (+): positive; (–): negative.
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