Using the Initial Vector from Surface Electrocardiogram to Distinguish the Site of Outflow Tract Tachycardia

Background: The purpose of this study is to determine whether initial vector force might best distinguish tachycardias arising from the right ventricular (RV) outflow tract (OT) versus aortic sinus cusps (ASCs). Methods: Among 45 patients with OT tachycardia, we measured the time from the earliest QRS onset in any lead to local onset and to the first QRS peak/nadir in each surface leads during VT. We compared the earliest phase differences among patients with foci in RVOT (n = 32) and in ASCs (n = 13) (determined by ablation), using unpaired t‐tests. We determined the optimum cut‐points by analyzing the receiver–operator characteristics curves, and derived an algorithm to discriminate ASC from RVOT foci. Results: Compared with an RVOT focus, origin in the ASC was associated with lower likelihood that the earliest lead of QRS activation was V2 (4/13 [12%] vs 29/32 [88%], P = 0.0001), later initial peak/nadir in III (110 ± 19 vs 93 ± 16 ms, P = 0.0026) and V2 (75 ± 26 vs 42 ± 19 ms, P < 0.0001). After determining the optimum cut‐points for each, we found that the presence of any one of these findings discriminated well between RVOT and ASC foci (sensitivity 92%, specificity 88%, positive predictive value 75%, and negative predictive value 97%). The sensitivity and specificity using standard ECG criteria were inferior to the vector approach. Conclusions: The ECG phase differences during VT can distinguish the origin of OT‐VT. Earliest onset or first peak/nadir in V2 and early initial peak/nadir in the inferior leads suggest a RVOT focus.