Circulation, Vol 86, 1888-1901, Copyright © 1992 by American Heart Association
MA Hood, SM Pogwizd, J Peirick and ME Cain
BACKGROUND. Current methods of signal-averaged ECG analysis interrogate the
terminal 40 msec of the QRS complex and/or the ST segment and have a low
positive-predictive accuracy for detecting vulnerability to sustained
ventricular tachycardia (VT). The extent to which abnormalities detected
during these ECG intervals are generated by myocardial tissue responsible
for VT has not been well defined. The purpose of this study was to
determine when, during sinus rhythm, myocardium responsible for VT is
activated. METHODS AND RESULTS. Three- dimensional ventricular activation
maps were analyzed during sinus rhythm and during 10 VTs in eight patients
with healed myocardial infarctions undergoing arrhythmia surgery for
sustained monomorphic VT. The mechanism of VT was focal in five instances
and macroreentrant in five. During sinus beats, myocardium responsible for
all focal VTs activated 43 +/- 38 msec before the onset of the terminal
40-msec interval of the QRS complex. During sinus rhythm, activation of the
myocardium critical to macroreentrant VT began 72 +/- 13 msec before the
onset of the terminal QRS interval and in only three instances extended
2-25 msec into the terminal 40 msec of the QRS complex. Electrograms
recorded during the ST segment represented late activation of epicardial
sites overlying zones of infarction that were temporally and spatially
remote from tissue critical to VT. CONCLUSIONS. Current methods of
signal-averaged ECG analysis limiting interrogation to the terminal QRS/ST
segment exclude detection of > 95% of the signals generated by
myocardium responsible for sustained VT. These results establish a
pathophysiological basis for expanding signal-averaged ECG analysis to
include more of the cardiac cycle.
ARTICLES
Contribution of myocardium responsible for ventricular tachycardia to abnormalities detected by analysis of signal-averaged ECGs
Cardiology Division, Washington University School of Medicine, St. Louis, Mo. 63110.
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