Electrocardiographic algorithms to guide the management strategy of idiopathic outflow tract ventricular arrhythmias

INTRODUCTION The current guidelines of the European Society of Cardiology outlined electrocardiographic (ECG) differentiation of the site of origin (SoO) in patients with idiopathic ventricular arrhythmias (IVAs). OBJECTIVES The aim of this study was to compare 3 ECG algorithms for differentiating the SoO and to determine their diagnostic value for the management of outflow tract IVA. PATIENTS AND METHODS We analyzed 202 patients (mean age [SD]: 45 [16.7] years; 133 women [66%]) with IVAs with the inferior axis (130 premature ventricular contractions or ventricular tachycardias from the right ventricular outflow tract [RVOT]; 72, from the left ventricular outflow tract [LVOT]), who underwent successful radiofrequency catheter ablation (RFCA) using the 3‑dimensional electroanatomical system. The ECGs before ablation were analyzed using custom‑developed software. Automated measurements were performed for the 3 algorithms: 1) novel transitional zone (TZ) index, 2) V2S/V3R, and 3) V2 transition ratio. The results were compared with the SoO of acutely successful RFCA. RESULTS The V2S/V3R algorithm predicted the left‑sided SoO with a sensitivity and specificity close to 90%. The TZ index showed higher sensitivity (93%) with lower specificity (85%). In the subgroup with the transition zone in lead V3 (n = 44, 15 from the LVOT) the sensitivity and specificity of the V2-transition‑ratio algorithm were 100% and 45%, respectively. The combined TZ index+V2S/V3R algorithm (LVOT was considered only when both algorithms suggested the LVOT SoO) can increase the specificity of the LVOT SoO prediction to 98% with a sensitivity of 88%. CONCLUSIONS The combined TZ‑index and V2S/V3R algorithm allowed an accurate and simple identification of the SoO of IVA. A prospective study is needed to determine the strategy for skipping the RVOT mapping in patients with LVOT arrhythmias indicated by the 2 combined algorithms.