CONTEMPORARY REVIEW

How to use the 12-lead ECG to predict the site of origin

of idiopathic ventricular arrhythmias
Andres Enriquez, MD,* Adrian Baranchuk, MD,* David Briceno, MD,† Luis Saenz, MD,‡
Fermin Garcia, MD†
From the *Division of Cardiology, Queen’s University, Kingston, Ontario, Canada, †Section of Cardiac
Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, and
‡
Fundación Cardioinfantil, Bogota, Colombia.

Idiopathic ventricular arrhythmias may arise from anywhere in the for the localization of idiopathic ventricular arrhythmias based on
heart, and the majority of them can be effectively treated with cath- sequential analysis of the most relevant ECG features.
eter ablation. The 12-lead electrocardiogram (ECG) is the initial map-
ping tool to predict the most likely site of origin and is valuable to KEYWORDS Catheter ablation; Electrocardiogram; Site of origin;
choose the appropriate ablation strategy. Crucial to ECG interpreta- Ventricular arrhythmias; Ventricular tachycardia
tion is understanding the attitudinal orientation of the heart within
the chest and the relationship between the different cardiac struc- (Heart Rhythm 2019;16:1538–1544) © 2019 Heart Rhythm Society.
tures. In this review, we provide a stepwise anatomical approach All rights reserved.

Introduction nomenclature. More recently, efforts have been made toward

Idiopathic ventricular arrhythmias (VAs) occur in patients with an anatomically correct or attitudinal description of the heart.
structurally normal hearts. The spectrum of clinical presenta- A seminal contribution in this direction is the landmark
tion includes isolated premature ventricular contractions anatomical atlas published by Wallace McAlpine in 1975.1
(PVCs), repetitive nonsustained or sustained ventricular tachy- When the heart is viewed in an attitudinal perspective, the
cardia (VT), and PVC-triggered ventricular fibrillation. The right cardiac chambers are anterior relative to the left chambers.
majority originate from the outflow tract of the right ventricle The RV is positioned anteriorly and to the right of the LV. The
(RV) and left ventricle (LV), but they may arise from anywhere LV lies obliquely in the chest, with the base located posteriorly
in the heart. Idiopathic VAs can be effectively treated with and the apex positioned to the left. The so-called anterior inter-
catheter ablation, and major advances have been made in the ventricular sulcus in fact begins superiorly and travels to the left
past decade in terms of mapping tools and energy delivery. and slightly anteriorly, while the so-called posterior interven-
Invasive electrophysiology has greatly benefited from a tricular sulcus is actually positioned inferiorly.
rediscovery of cardiac anatomy. The systematic study of Regarding the outflow tract region, the anatomical rela-
anatomical relationships using modern techniques has helped tionships are complex and VAs from different structures in
us to understand the reasons why ablation may fail and to bet- this region may have a similar ECG appearance. The RV
ter approach challenging cases. The surface 12-lead electro- outflow tract (RVOT) wraps around and crosses the LV
cardiogram (ECG) is useful to localize the site of origin of outflow tract (LVOT) anteriorly, so that the pulmonary valve
VAs when catheter ablation is being considered. Several lies anterior and to the left of the aortic valve (AoV). This
studies have enriched our understanding of the correlation relation is important, as the anterior aspect of the RVOT is
between different VA sources and specific ECG patterns. actually the most leftward and highest outflow tract structure.
The LVOT corresponds to the elliptical opening of the
Anatomical considerations LV, also termed the LV ostium by McAlpine.1,2 This is
Classical anatomy textbooks described the human heart in the composed by the aortic root anteriorly and by the mitral
“Valentine position,” in which the heart stands on its apex annulus posteriorly and to the left. Both valves are
with some rightward rotation. This description is incorrect anatomically coupled through a band of fibrous tissue
and has been the source of confusing and inappropriate known as the aortomitral continuity (AMC), which extends
between the anterior leaflet of the mitral valve (MV) and
Address reprint requests and correspondence: Dr Andres Enriquez, Divi-
the left (LCC) and noncoronary cusp (NCC) of the AoV.
sion of Cardiology, Queen’s University, 76 Stuart St, Kingston, Ontario, The AoV occupies a central position within the heart and is
Canada K7L 2V7. E-mail address: [email protected]. composed of 3 cusps, each one with relevant anatomical

1547-5271/$-see front matter © 2019 Heart Rhythm Society. All rights reserved. https://doi.org/10.1016/j.hrthm.2019.04.002
Enriquez et al Site of Origin 1539

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
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
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
block; RCC 5 right coronary cusp; RVOT 5 right ventricular outflow tract; Sup. 5 superior; TV 5 tricuspid valve; VA 5 ventricular arrhythmia.

relationships. In attitudinal orientation, the right coronary reflected by QRS polarity in bipolar leads II and III. For
cusp (RCC) is the most anterior cusp relative to the example, all outflow tract VAs share an inferiorly directed
sternum, the NCC is posterior and rightward, and the LCC QRS axis, with positive forces in leads II and III. The hor-
is posterior and leftward. The NCC is the most inferior and izontal dimension is better reflected by lead I. Structures
the LCC is the most superior in position. The RCC is in closer to the left arm will produce a deeply negative com-
close proximity to the posteroseptal aspect of the RVOT, plex in lead I (rightward axis); conversely, structures closer
while the LCC is adjacent to the anterior aspect of the LV to the right arm are strongly positive in lead I (leftward
ostium, in close proximity to the left anterior descending axis). Additional approximation to the horizontal dimension
coronary artery. Conversely, the NCC is in relationship is given by the relative amplitude between limb leads aVR
with both the left atrium and the right atrium separated by and aVL: a more positive polarity in lead aVR than in
the interatrial septum. Below the commissure between the lead aVL suggests a more leftward origin; a more positive
RCC and the NCC lies the membranous ventricular polarity in lead aVL than in lead aVR points toward a
septum, where the penetrating bundle of His is located. more rightward origin.
A common site of origin of VAs is the LV summit. This cor- The bundle branch block pattern is related to the sequence
responds to the highest portion of the LV epicardium, above of RV and LV activation. VAs with a right bundle branch
the upper end of the anterior interventricular sulcus and block (RBBB) appearance typically arise in the LV, while
bounded by the bifurcation between the left anterior descend- VAs with a left bundle branch block (LBBB) appearance
ing and the left circumflex coronary arteries.3 This triangular may arise anywhere in the RV, but also in the left side of
region is transected by the great cardiac vein at its junction the interventricular septum.
with the anterior interventricular vein, which provides an ac- The precordial transition in RBBB VAs (first lead with a
cess to map and sometimes ablate PVCs/VTs from this region. predominant S wave) occurs progressively earlier as the
site of origin moves from the base toward the apex of the
ECG features LV. In LBBB VAs, the precordial transition (first lead with
Several ECG features are relevant for the localization of a a predominant R wave) occurs progressively later as the
particular VA. The most important are (1) QRS axis, (2) site of origin moves from the septum toward the RV free
bundle branch block pattern, (3) precordial transition, and wall. Positive concordance (all positive precordial leads) is
(4) QRS width. seen in VAs arising at the base of the heart, in which case
The QRS axis has both a vertical (superior-inferior) and a ventricular activation has to move anterior and apical.
horizontal (right-left) dimension. The vertical dimension is Conversely, negative concordance (all negative precordial
1540 Heart Rhythm, Vol 16, No 10, October 2019

leads) is seen in VAs originating near the apex, such that elec- exhibit discordance between leads II and III (positive/nega-
trical activity moves away from the chest wall. tive or negative/positive). These will be discussed separately.
Finally, septal VAs have narrower QRS durations than do
VAs originating on the free wall of both ventricles because of Step 2
synchronous rather than sequential ventricular activation. Our next step is to separate VAs arising from the right or left
Having mentioned these general rules, it should be side of the chest midline, which does not necessarily means
acknowledged that the 12-lead ECG has limitations4 and sig- RV vs LV, especially in the outflow tracts, where there is a
nificant variation may result from several factors, such as significant overlap between the RVOT and the LVOT.5
body habitus, lead placement, and shifts in the relationship
of the heart to the chest wall. 1. For outflow tract VAs, the best single ECG discriminator is
the left/right axis reflected by lead I. Rightward structures,
such as the posterior aspect of the RVOT, RCC, para-
Comprehensive anatomic approach for the Hisian region, and superior aspect of the tricuspid valve
prediction of the site of origin (TV), are positive in lead I, while leftward structures,
We propose an algorithm based on 4 anatomical quadrants such as the anterior aspect of the RVOT, LCC, AMC, ante-
for rapid regionalization of a particular VT/PVC (Figures 1 rolateral MV annulus, and LV summit, will produce a
and 2). Once ascribed to any of these quadrants, analysis of negative complex in lead I. The commissure between the
additional ECG features, such as precordial transition, QRS RCC and the LCC, a common source of idiopathic VAs,
duration, or specific morphology in certain leads, is helpful is close to the midline, and, in our experience, arrhythmias
to postulate the most likely site of origin. from this area may have either a positive, a negative, or a
biphasic QRS complex in lead I.6
Step 1 2. For VAs arising from the inferior aspect of the ventricles,
We start looking at the superior/inferior axis, represented by the most helpful element is the bundle branch block
polarity in leads II and III. Inferior-axis VAs (positive QRS appearance, as some VAs from the septal portion of the
complex in leads II and III) arise from basal areas of the heart, LV may exhibit a left axis. VAs with a superior axis
including the outflow tracts and the superior aspect of the and LBBB appearance may arise from RV structures
atrioventricular valves, while superior-axis VAs (negative (inferior aspect of the TV or moderator band [MB]) or
QRS complex in leads II and III) have their origin at the infe- the cardiac crux. Conversely, VAs with a superior axis
rior aspect of both ventricles (Table 1). A few VAs may and RBBB pattern arise from LV structures (inferior

Figure 2 Anatomical schema to understand the electrocardiographic patterns of outflow tract VAs, showing the value of precordial transition and frontal plane
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
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
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
Dr K. Shivkumar with permission. Copyright UCLA Cardiac Arrhythmia Center, McAlpine Collection.
Enriquez et al Site of Origin 1541

Table 1 Electrocardiographic features of idiopathic VAs

A. Positive II and III: Suggests origin from the outflow tracts and top of atrioventricular valves
Positive lead I: Structures rightward from the midline
a. Posterior RVOT LBBB, transition at or after V3, QS in V1
b. RCC LBBB, V2 or V3 transition (V2 transition ratio
0.6), QS in V1
c. Para-Hisian LBBB, typically V2 or V3 transition, QS in V1, R in aVL (vs negative in the RVOT), III
may be negative, narrow QRS
d. Top of the TV LBBB, variable transition, QS or rS in V1, positive aVL (vs negative in the RVOT), III
may be negative
Negative lead I: Structures leftward from the midline
a. Anterior RVOT LBBB, transition at or after V3, QS in V1
b. LCC LBBB or RBBB, V1 or V2 transition, rS, R, or multiphasic pattern in V1
c. AMC RBBB, positive concordance, qR in V1
d. Anterolateral MV RBBB, positive concordance, R or Rsr0 in V1
e. LV summit RBBB or LBBB with V2 or V3 transition, taller R wave in III than in II, pseudo-delta
wave and/or MDI . 0.55, V2 “pattern break”
Exceptions are 2 non-outflow tract structures:
a. Left anterior fascicle RBBB, rsR0 in V1, narrow QRS, right axis
b. Anterolateral PM RBBB, R, Rsr0 , or qR in V1, late R/S transition, II may be negative

B. Negative II and III: Suggests origin from the inferior aspect of both ventricles
LBBB pattern: RV structures or crux
a. Inferior TV LBBB, variable transition (V2 through V5), QS or rS in V1
b. Moderator band LBBB, late transition (V5 or V6), left superior axis
c. Cardiac crux LBBB, V2 transition, left superior axis, QS in inferior leads, pseudo-delta wave and/or
MDI . 0.55
RBBB pattern: LV structures
a. Inferior MV RBBB, positive concordance, R or Rsr0 in V1
b. Posteromedial PM RBBB, R , S in V5, R, Rsr0 , or qR in V1
c. Left posterior fascicle RBBB, R , S in V5, rsR0 in V1, narrow QRS

C. Inferior lead discordance: Suggests origin from the midcavitary structures or lateral aspect of the atrioventricular valves
- Positive II/negative III: Lateral TV, RV intracavitary structures (moderator band), interventricular septum (parahisian)
- Negative II/positive III: Lateral MV, anterolateral PM
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
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;
TV 5 tricuspid valve; VA 5 ventricular arrhythmia.

aspect of the MV, posteromedial papillary muscle [PPM], III. In VAs from the superior TV and para-Hisian region,
or left posterior fascicle). positive forces are less pronounced, especially in lead III,
which can be even isoelectric or negative. Finally, a narrow
QRS duration (usually ,130 ms) is typical of para-Hisian
Step 3 VAs given the early engagement of this His-Purkinje system.
Once we circumscribe the likely site of origin to 1 of these 4 Differentiation between posterior RVOT and RCC VAs
quadrants, a more refined localization relies in other charac- may be particularly challenging and has been the subject of
teristics such as precordial transition, QRS width, or QRS several studies. A precordial R/S transition after lead V3 usu-
morphology in specific leads (Table 1 and Figure 3). ally suggests RVOT origin, while the transition at lead V2 or
earlier is typical of LVOT origin. Differentiation is more
Right upper quadrant difficult when the transition is in lead V3, as this pattern
In includes the posterior aspect of the RVOT, RCC, superior can be seen in both VAs from the posteroseptal RVOT and
TV and para-Hisian region (Figures 4A–4E). Outflow tract those from the RCC, and different algorithms have been pro-
VAs, in general, can be differentiated from TV and para- posed.9–13 One of them compares the precordial transition
Hisian VAs by looking at lead aVL polarity. Lead aVL is a during the PVC and sinus rhythm.9 When the PVC transition
left sided but also a superior lead; thus, the majority of outflow occurs later than the sinus rhythm transition, the origin is the
tract VAs show negative deflections in lead aVL (QS waves) RVOT (100% specificity). If the PVC transition occurs at or
as well as in lead aVR. Conversely, TV and para-Hisian VAs earlier than the sinus rhythm transition, then the so-called V2
are located more inferiorly and rightward in the chest and, transition ratio is measured (percentage R wave during the
therefore, usually exhibit positive deflections in lead aVL PVC divided by the percentage R wave during sinus rhythm).
(any R or r waves).7,8 In addition, RVOT and RCC VAs A ratio of
0.6 predicts an LVOT origin with a sensitivity of
show a strong inferior axis, with tall R waves in leads II and 95% and a specificity of 100%. Another ECG criterion is the
1542 Heart Rhythm, Vol 16, No 10, October 2019

Figure 3 Stepwise electrocardiographic approach for the prediction of the VA site of origin. Abbreviations as in Figure 1.

V2S/V3R index, defined as the S-wave amplitude in lead V2 VAs arising from the LV summit may have either an
divided by the R-wave amplitude in lead V3. An index of LBBB pattern with lead V2 or V3 transition (septal aspect,
1.5 predicts an LVOT origin with a sensitivity of 89% also known as inaccessible area) or an RBBB pattern (lateral
and a specificity of 94%.10 aspect or accessible area).14,15 Attention should be paid to
characteristics suggesting an epicardial origin such
Left upper quadrant prominent pseudo-delta waves or maximum deflection index
It includes the anterior aspect of the RVOT and most LVOT . 0.55. In addition, a V2 pattern break in LBBB VAs,
structures (excluding the RCC) (Figures 4F–4L). The precor- defined as a loss of the R wave in lead V2 compared to leads
dial transition is likely the most helpful characteristic to pay V1 and V3 (Supplemental Figure 1), suggests an origin near
attention in this group (Figure 2). As we move progressively the anterior interventricular sulcus, often in close proximity
more posterior from the RVOT free wall to the lateral mitral to the left anterior descending coronary artery.16
annulus, the precordial transition occurs progressively earlier Two non-outflow tract structures may also produce a right
(lead V4 or V5 for the RVOT free wall, lead V3 or V4 for the inferior-axis ECG pattern:
RVOT septum, lead V1 or V2 for the LCC) and finally trans-
1. Left anterior fascicle: Typically characterized by a narrow
forms from an LBBB to an RBBB configuration at the AMC
QRS duration (,130 ms), an rsR0 pattern in lead V1
or the top of the MV. In addition to the bundle branch block
mimicking typical RBBB, and right axis deviation.
pattern, some specific characteristics of lead V1 may orientate
2. Anterolateral papillary muscle (APM): Usually exhibits
to certain locations: RVOT and RCC VAs typically exhibit a
an RBBB pattern with a wider QRS duration, an R,
QS pattern in lead V1; a QS pattern with notching in down-
Rsr0 , or qR pattern in lead V1, and late R/S transition
stroke is suggestive of VAs from the RCC/LCC commissure;
(V3 to V5). Lead II may be negative.
LCC VAs often have a multiphasic pattern in lead V1 (M or
W pattern); a qR pattern in lead V1 is often seen in VAs from
the AMC; and VAs from the anterolateral MV annulus most Right lower quadrant
often have an R pattern in lead V1 with positive precordial The most common sources of idiopathic VAs in this quadrant
concordance. are the inferior TV annulus, the MB, and the cardiac crux
Enriquez et al Site of Origin 1543

Figure 4 Inferior-axis VAs with origin at the (A) posterior RVOT (septal wall), (B) RCC, (C) para-Hisian region, (D) superior TV, (E) RCC-LCC commissure, (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 Figure 1.

(Figures 5A–5C). The MB is a prominent muscular trabecu- rapid ventricular depolarization via the Purkinje system.
lation that crosses from the septum to the free wall of the RV For the same reason, fascicular VAs typically have an
and provides support to the anterior papillary muscle of the rsR0 (r , R0 ) pattern in lead V1, mimicking typical
TV. The crux of the heart is an epicardial region near the RBBB. In comparison, PPM and MV VAs usually have
junction of the middle cardiac vein and the coronary sinus. an Rsr0 (R . r0 ), R, or qR pattern in lead V1.
MB VAs typically have a left superior axis and late precordial
transition (later than lead V4).17 Conversely, crux VAs also
Inferior lead discordance
have a left superior axis, but with early transition (lead V2)
Inferior lead discordance reflects an opposite depolarization vec-
and a QS pattern in inferior leads.18 They may also present
tor along bipolar limb leads II (from the left leg to the right arm)
features suggesting an epicardial access, such a pseudo-
and III (from the left leg to the left arm).20 This is most often
delta wave or maximum deflection index . 0.55. TV VAs
observed in VAs originating from midcavitary structures (inter-
have a variable precordial transition (leads V2 through V5)
ventricular septum, MB, and APM) and sometimes from the
depending on their septal or lateral origin (lead V2 or V3
lateral aspect of the atrioventricular valves. Positive/negative
for septal sites and lead V4 or V5 for free wall sites). A QS
discordance (positive II/negative III) is equivalent to a frontal
pattern in lead V1 is recorded in the majority of VAs arising
axis of 230 to 130 , and negative/positive discordance (nega-
from the septal portion of the TV annulus, while most VAs
tive II/positive III) is equivalent to a frontal axis of 1150 to
from the free wall portion exhibit an rS pattern in lead V1.
1210 . In particular, the likely sites of origin are as follows:
Left lower quadrant 1. Positive/negative discordance: RV structures, including
Idiopathic VAs with RBBB and superior axis may arise the lateral TV, MB, and interventricular septum (para-
from the inferior MV annulus, the left posterior fascicle, Hisian region). All these have an LBBB configuration.
and the PPM (Figures 5D–5F). These can be differentiated 2. Negative/positive discordance: LV structures, including the
on the basis of 3 main characteristics: precordial transition, lateral MV and APM. These have an RBBB configuration.
QRS duration, and V1 morphology.19 Positive precordial
concordance (R . S in lead V6) is relatively specific of
MV VAs, reflecting their more basal location. Conversely, Conclusion
VAs from the left posterior fascicle and PPM usually The 12-lead ECG remains a valuable mapping tool for the
have R , S by lead V5. A QRS duration of ,130 ms is determination of VA origin. Keeping in mind the attitudinal
highly suggestive of fascicular VAs, reflecting the more orientation of the heart in the chest and looking at a number
1544 Heart Rhythm, Vol 16, No 10, October 2019

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-
omedial papillary muscle. Two examples of VAs with inferior lead discordance ablated from the (G) moderator band and (H) anterolateral papillary muscle.
Abbreviations as in Figure 1.

of ECG features in an organized sequence makes it possible to 9. Betensky BP, Park RE, Marchlinski FE, et al. The V2 transition ratio: a new elec-
trocardiographic criterion for distinguishing left from right ventricular outflow
quickly regionalize a PVC/VT to 1 of 4 quadrants and postulate tract tachycardia origin. J Am Coll Cardiol 2011;57:2255–2262.
the most likely differential diagnoses for the sites of origin. 10. Yoshida N, Yamada T, McElderry HT, et al. A novel electrocardiographic crite-
rion for differentiating a left from right ventricular outflow tract tachycardia
origin: the V2S/V3R index. J Cardiovasc Electrophysiol 2014;25:747–753.
Appendix 11. Ouyang F, Fotuhi P, Ho SY, et al. Repetitive monomorphic ventricular tachy-
Supplementary data cardia originating from the aortic sinus cusp: electrocardiographic characteriza-
Supplementary data associated with this article can be found tion for guiding catheter ablation. J Am Coll Cardiol 2002;39:500–508.
12. Cheng D, Ju W, Zhu L, et al. V3R/V7 index. Circ Arrhythm Electrophysiol 2018;
in the online version at https://doi.org/10.1016/j.hrthm.2019. 11:e006243.
04.002. 13. Zhang F, Hamon D, Fang Z, et al. Value of a posterior electrocardiographic lead
for localization of ventricular outflow tract arrhythmias: the V4/V8 ratio. JACC
Clin Electrophysiol 2017;3:678–686.
References 14. Yamada T, McElderry HT, Doppalapudi H, et al. Idiopathic ventricular arrhyth-
1. McAlpine WA. Heart and Coronary Arteries. New York: Springer-Verlag; 1975. mias originating from the left ventricular summit: anatomic concepts relevant to
2. Yamada T, Litovsky SH, Kay GN. The left ventricular ostium: an anatomic ablation. Circ Arrhythm Electrophysiol 2010;3:616–623.
concept relevant to idiopathic ventricular arrhythmias. Circ Arrhythm Electro- 15. Santangeli P, Marchlinski FE, Zado ES, et al. Percutaneous epicardial ablation of
physiol 2008;1:396–404. ventricular arrhythmias arising from the left ventricular summit: outcomes and
3. Enriquez A, Malavassi F, Saenz LC, et al. How to map and ablate left ventricular electrocardiogram correlates of success. Circ Arrhythm Electrophysiol 2015;
summit arrhythmias. Heart Rhythm 2017;14:141–148. 8:337–343.
4. Jamil-Copley S, Bokan R, Kojodjojo P, et al. Noninvasive electrocardiographic 16. Hayashi T, Santangeli P, Pathak RK, et al. Outcomes of catheter ablation of idio-
mapping to guide ablation of outflow tract ventricular arrhythmias. Heart Rhythm pathic outflow tract ventricular arrhythmias with an R wave pattern break in lead
2014;11:587–594. V2: a distinct clinical entity. J Cardiovasc Electrophysiol 2017;28:504–514.
5. Hutchinson MD, Garcia FC. An organized approach to the localization, mapping, 17. Sadek MM, Benhayon D, Sureddi R, et al. Idiopathic ventricular arrhythmias
and ablation of outflow tract ventricular arrhythmias. J Cardiovasc Electrophysiol originating from the moderator band: electrocardiographic characteristics and
2013;24:1189–1197. treatment by catheter ablation. Heart Rhythm 2015;12:67–75.
6. Bala R, Garcia FC, Hutchinson MD, et al. Electrocardiographic and electrophys- 18. Kawamura M, Gerstenfeld EP, Vedantham V, et al. Idiopathic ventricular
iologic features of ventricular arrhythmias originating from the right/left coronary arrhythmia originating from the cardiac crux or inferior septum: epicardial idio-
cusp commissure. Heart Rhythm 2010;7:312–322. pathic ventricular arrhythmia. Circ Arrhythm Electrophysiol 2014;7:1152–1158.
7. Yamauchi Y, Aonuma K, Takahashi A, et al. Electrocardiographic characteristics 19. Al’Aref SJ, Ip JE, Markowitz SM, et al. Differentiation of papillary muscle from
of repetitive monomorphic right ventricular tachycardia originating near the His- fascicular and mitral annular ventricular arrhythmias in patients with and without
bundle. J Cardiovasc Electrophysiol 2005;16:1041–1048. structural heart disease. Circ Arrhythm Electrophysiol 2015;8:616–624.
8. Tada H, Tadokoro K, Ito S, et al. Idiopathic ventricular arrhythmias originating 20. Enriquez A, Pathak RK, Santangeli P, et al. Inferior lead discordance in ventric-
from the tricuspid annulus: prevalence, electrocardiographic characteristics, and ular arrhythmias: a specific marker for certain arrhythmia locations. J Cardiovasc
results of radiofrequency catheter ablation. Heart Rhythm 2007;4:7–16. Electrophysiol 2017;28:1179–1186.