New diagnostic criteria for identifying left-sided ventricular ectopy using non-contact mapping and virtual unipolar electrogram analysis

AIMS: To assess the efficacy of non-contact mapping for outflow tract premature ventricular contraction (PVC) and ventricular tachycardia (VT) ablation in patients without structural heart disease and a precordial transition at V3 or later and to determine the diagnostic accuracy of new virtual unipolar electrogram criteria for distinguishing left from right-sided foci using a multi-electrode array positioned within the right ventricular outflow tract. METHODS AND RESULTS: Virtual unipolar electrograms at early activation (EA) and break out (BO) sites in 100 patients (36 left-sided foci) who underwent acutely successful outflow tract ablation were analysed and voltage and timing-based criteria measured. The best performing parameters were then re-assessed in 41 patients (14 left-sided) prospectively. Of the candidate criteria for determining a left from right-sided focus, the voltage at 20 ms after EA (EA-V20) and the time from BO to QRS onset (BO-QRS) were the best discriminators with area under the curve (AUC) values based on receiver operator characteristics (ROCs) of 0.947 (0.905-0.989), P < 0.001, and 0.951 (0.907-0.995), P < 0.001, respectively. These two parameters were subsequently assessed prospectively in a further 41 patients (14 left-sided) using the pre-specified cut-off values of -2 mV for EA-V20 and 10 ms for BO-QRS which demonstrated excellent diagnostic accuracy and sufficient inter-beat and inter-observer reproducibility. CONCLUSIONS: This large single-centre experience demonstrates that a strategy for outflow tract PVC/VT ablation using non-contact mapping allows for excellent success rates. Furthermore, detailed analysis of virtual unipolar electrograms allows accurate and reproducible determination of left from right-sided foci that may be used to guide mapping and ablation.