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ECG Criteria to Identify Epicardial Ventricular Tachycardia in Nonischemic CardiomyopathyCLINICAL PERSPECTIVE by Ermengol Vallès, Victor Bazan, and Francis E. Marchlinski Circ Arrhythm Electrophysiol Volume 3(1):63-71 February 1, 2010 Copyright © American Heart Association, Inc. All rights reserved. Figure 1. A, Left posterior oblique view of a bipolar ENDO voltage map in sinus rhythm shows the typical distribution of low voltage (<1.5 mV) abnormalities around the mitral annulus. Ermengol Vallès et al. Circ Arrhythm Electrophysiol. 2010;3:63-71 Copyright © American Heart Association, Inc. All rights reserved. Figure 2. QRS from ENDO VT showing discrepancy between interval and morphology criteria. Ermengol Vallès et al. Circ Arrhythm Electrophysiol. 2010;3:63-71 Copyright © American Heart Association, Inc. All rights reserved. Figure 3. Schematic representation showing suggested basis for morphological differences in QRS in lead I and aVF based on initial regional (small arrow) followed by global LV activation (large arrows) from endocardial versus epicardial VT origin from superior-lateral LV. A, VT origin from the endocardium shows small q waves in inferior leads and small r wave in lead I representing the small segment of myocardium that depolarizes with an ENDO to EPI activation before the main activation wave front proceeds from a superior to inferior and left to right direction. Ermengol Vallès et al. Circ Arrhythm Electrophysiol. 2010;3:63-71 Copyright © American Heart Association, Inc. All rights reserved. Figure 4. QRS morphology and interval values for ENDO and EPI pace maps from basal superior and lateral LV sites in patients with NICM. Each interval measurement (the 5 top variables in the figure) was observed to be longer from the EPI than from the ENDO. However, the sensitivity/specificity values (right box) using the reported cutoffs for interval criteria were limited. Ermengol Vallès et al. Circ Arrhythm Electrophysiol. 2010;3:63-71 Copyright © American Heart Association, Inc. All rights reserved. Figure 5. Morphological features suggesting EPI versus ENDO origin during pace mapping in basal superior and lateral LV in patients with NICM. A and B, Pace maps from superior basal and lateral basal ENDO LV, respectively. Ermengol Vallès et al. Circ Arrhythm Electrophysiol. 2010;3:63-71 Copyright © American Heart Association, Inc. All rights reserved. Figure 6. QRS morphology and interval values for ENDO and EPI VT from basal superior and lateral LV sites in patients with NICM. Only the QRSd and the SRS complex duration were observed to be significantly longer from the EPI than from the ENDO. The rest of the interval criteria measurements were not significantly different when comparing EPI and ENDO origin. Ermengol Vallès et al. Circ Arrhythm Electrophysiol. 2010;3:63-71 Copyright © American Heart Association, Inc. All rights reserved. Figure 7. Twelve-lead ECG showing characteristic morphological features of VT originating from epicardium versus endocardium. Ermengol Vallès et al. Circ Arrhythm Electrophysiol. 2010;3:63-71 Copyright © American Heart Association, Inc. All rights reserved. Figure 8. Four-step algorithm for identifying EPI origin from basal superior and lateral LV in the setting of NICM. The 3 top steps have a high specificity and the last step is the most accurate. Ermengol Vallès et al. Circ Arrhythm Electrophysiol. 2010;3:63-71 Copyright © American Heart Association, Inc. All rights reserved.