Tóm tắt Luận án Study of relation between sites of origin of right ventricular arrythmias and surface electrocardiogram

MINISTRY OF EDUCTION AND TRAINING MINISTRY OF DEFENSE MILITARY MEDICAL UNIVERSITY VU MANH TAN STUDY OF RELATION BETWEEN SITES OF ORIGIN OF RIGHT VENTRICULAR ARRYTHMIAS AND SURFACE ELECTROCARDIOGRAM Speciality: Cardiology Code: 62 42 01 41 SUMARY OF HEALTH DOCTORAL DESSERTATION HANOI - 2015 This research was carried out in Military Medical University Promoters: 1. Assoc. Prof. PhD. Nguyen Thi Dung 2. PhD. Phạm Quốc Khánh Opponent 1: Assoc. Prof. PhD. Doan Van De Opponent 2: Prof. PhD. Nguyen Duc Cong Opponent 3: Assoc. Prof. PhD. Tran Van Riep This dessertation will be defenced in doctoral examination coucil of Military Medical University at.on the date of .. 2016 This dessertation is available to read in: 1. National library 2. Library of Military Medical University LIST OF DISCLOSURE RESEARCHS OF THE DOCTORAL DESSERTATION 1. Vu Manh Tan, Pham Quoc Khanh, Nguyen Thi Dung (2015), “Clinical features and sites of origin of right idiopathic premature ventricular complexes/ventricular tachycardias in patients treated by Radiofrequency”, Journal of 108 - clinical medicine and pharmacy, 10(2), pp. 138 - 142. 2. Nguyen Thi Dung, Pham Quoc Khanh, Vu Manh Tan et al. (2015), “Relationship betweensites of origin of right premature ventricular complexes/ventricular tachycardias and 12-lead electrocardiogram”, Vietnam Journal of Medicine, 432(2), pp. 96 - 100. 3. Vu Manh Tan, Pham Quoc Khanh, Nguyen Thi Dung (2014), “Comparison of surrface ECG of premature ventricular complexes from distinguishable sites off superior right ventricular outflow tract”, Journal of Military Pharmaco-medicine, 39(Suppl.), pp. 61-67. 4. Vu Manh Tan, Nguyen Thi Dung (2014), “Electrophysical and electrographic characteristics of premature ventricular complexes from superior right ventricular outflow tract”, The yearbook of the 17th conference in youth science-technology among Vietnamese universities, Military Medical University, pp. 253-260. 5. Vu Manh Tan, Pham Quoc Khanh, Nguyen Thi Dung (2014), “Using 12-lead ECG for locating the original site of premature ventricular complexes from distal free-wall and septal right ventricular outflow tract”, Journal of 108 - clinical medicine and pharmacy, 9(3), pp. 69-75. 6. Vu Manh Tan, Pham Quoc Khanh, Nguyen Thi Dung (2013), “Study characteristics on surface ECG of premature ventricular complexes from upper and lower right ventricular ouflow tract side”, Vietnam Journal of Medicine, 406, pp. 32-37. INTRODUCTION 1. Urgency Ventricular arrhythmias include premature ventricular complexes (PVCs), sustained and nonsustained ventricular tachycardias (VTs), polymorphic ventricular tachycardia , ventricular flutters and ventricular fibrillations. These idiopathic ventricular complexes and ventricular tachycardias occur in patients without structural heart diseases, actually benign lesions however, sometimes cause unpleasant feelings. It could affect to daily life and activities of the patients , and requires effective treatments. The method of ablation for original sites of arrhythmias using radiofrequency energy (RF) which helps to treat idiopathic ventricular complexes, VTs definitively and avoids recurrence, has been deployed in over the world and some major centers in Vietnam. However, this method requires X-ray radiation with a certain period of time, in which the majority is to set up the endothelial cardiac mapping. Analysing surface electrocardiogram (ECG) helps to determine the onset placement of ventricular arrhythmias, contributing to shorten time of X-ray radiation in order to set up endothelial map, reducing the rate of radiation exposure in patients and physicians as well, has demonstrated in such a lot of researches all over the world. Several recently domestic researches have mentioned about using surface electrocardiogram to regionalize ventricular arrhythmias’s locations but not so many and are just in outflow ventricular tachycardias. Hence, we conducted this study with two objectives: 1. To describe the clinical characteristics and original sites from right ventricular of premature ventricular complexes/ventricular tachycardias which have been successfully ablated using radiofrequency energy. 2. To analyse the relationship between the original sites and the surface electrocardiographic characteristics of premature ventricular complexes/ventricular tachycardias in group of studied patients. 2. Scientific significance   The research’s results have defined that the characteristics of the surface ECGs help to distinguish the original site of (PVCs / VTs ) in different positions of right ventricle: between right ventricular outflow tract (RVOT) and outside RVOT (QRS axis of PVCs/VTs and shapes of the QRS complex in the leads: aVL, DII, DIII, aVF); between the septal area and the free wall of RVOT (R wave’s shape of PVCs/VTs in the lower lead, QRS duration in DI); between the anterior and the posterior walls of RVOT (R wave’s amplitude in DI); between the superior and the inferior area of RVOT (R wave’s amplitude in aVF). 3. Practical significance The thesis has proposed the original site- guiding diagram of PVCs/VTs must help doctors who did ablation using RF energy to shorten time of setting up the endocardial map, to shorten time of X-ray radiation, to minimize radiation exposure for the patients and the physicians. For clinicians, the orientation of PVCs/VTs’s original site must help to consider appropriate treatments (internal or ablation), which would improve the effectiveness of treatment, reduce costs and improve patient’s prognosis. CHAPTER 1 OVERALL OF DOCUMENT 1.3. METHODS DIAGNOSING VENTRICULAR ARRHYTHMIAS 1.3.1. Diagnosing ventricular arrhythmias by surface electrocardiogram 1.3.2. Diagnosing ventricular arrhythmias by cardiac electrophysiology study 1.5. STUDIES IN THE WORLD AND IN VIETNAM ON USING SURFACE ECG TO ORIENT THE ORIGINAL SITE OF RIGHT VENTRICULAR ARRHYTHMIAS Analysing the images of 12 leads ECG helps to orient the onset locations of PVCs/VTs, Kuchar et al. who did surface ECG with original site of VTs in patients having previous myocardial infarction, has shown that: the anterior wall region had 83% appropriate, the inferior region 84%, the septal region 90% and the lateral region 82%. Apical region and basal region had relevance of 70%, the middle area 20-50%. Miler J.M. et al. showed that analysing surface ECG can prognose correctly 93% the original site of VTs. 1.5.2. Focusing on surface ECG and original site of premature ventricular complexes and ventricular tachycardias arising from the right ventricle 1.5.2.1. The original sites of right ventricular arrhythmias Most of PVCs/VTs from RV are triggered in the RVOT . Other positions much more rarely seen, are found near the His bundle and apical region of RV. In the RVOT, ventricular arrhythmias could be triggered in so many different sites. Jadonath R.L. et al based on right anterior oblique 30° and divided the RVOT into 9 regions: septal region (upper, middle, lower), anterior region (upper, middle, lower) and posterior region (upper, middle, lower). The septal region was limited by pulmonary valve superiorly and tricuspid valve inferiorly. According to Kamakura S. et al., in left anterior oblique 60o, the anterior half corresponded with free wall and the posterior one corresponded with septal region. In right anterior oblique 30o, the right half corresponded with posterolateral wall, while the left one corresponded with anterolateral wall. The region within 1 cm from pulmonary valve was identified as high region or proximal region to the RVOT. One which is more than 1cm from pulmonary valve was identified as low region or distal areas to the RVOT. With the similar determination, Shima T. et al. also divided the ROVT into 8 regions: anterior region (high and low), posterior (high and low), septal (high and low), free wall (high and low) 1.5.2.2. View of 12 -lead ECG of right ventricular arrhythmias by location On the surface ECG, typical PVCs / VTs arising from RV were shaped as left bundle branch block in V1. In addition, the researches have shown that the view of 12- lead ECG of ventricular arrhythmias in different locations were absolutely different. - Jadonath R.L. et al. distinguished original sites of VTs in the RVOT based on QRS type of VTs in DI, DIII, DIII, aVF, V6 and transition area. - Shima T. et al.: the difference of R - S waves’s amplitude in anterior wall VTs was less than in posterior wall and septal area. This negative performance would prognose anterior wall VTs Se 73,1%, Sp 94,9%. In aVF, this is higher in septal area and anterior wall than free wall and posterior wall. - Kamakura S. et al.: in DII, DIII, aVF, PVCs/VTs from septal RVOT, QRS duration > 0,14 sec, R’s amplitude was wider, the transition region was earlier than the septal region. The left RVOT area: QS in aVLwere greater than in aVR and QRSI (-); The right: QS in aVL were greater than in aVR and QRSI (+). - Yamauchi Y. et al.: PVCs / VTs arising near the His bundle, R-wave was more lessening in DIII, aVF; higher in DI, V5; QRS duration was more lessening in DII, aVF. Almost all are QS pattern in V1, V2; transition in - V3. - Ceresnak S.R. et al.: VTs originating from right ventricular inflow tract, QRS complex was shaped as left bundle branch block, inferior axis, QS or RS pattern in leads aVL and V1, late transition (V4 - V5). 1.5.3. Domestic researches in treatment of ventricular arrhythmias by radiofrequency energy and the relationship between surface ECG and the origin of ventricular arrhythmias In Vietnam, using RF energy treatment of cardiac arrhythmias was carried out since 5/1998 at the Institute of Cardiology. Researches from Pham Quoc Khanh (2001), Nguyen Hong Hanh (2010), Nguyen Duc Cong (2012) was conducted to evaluate the efficacy of ventricular arrhythmias treatment. Recently, study carried out by Truong Quang Khanh (2013), study carried out by Phan Dinh Phong et al. (2014) was about the efficacy of outflow VTs treatment by RF and showed up the features of surface ECG in VTs originating from this position but not really sufficient. CHAPTER 2 SUBJECTS AND METHODS 2.1. STUDIED SUBJECTS, TIME, LOCATION 107 patients with right PVCs or VTs were successfully ablated by radiofrequency at cardiac electrophysiology study room, Vietnam National Heart Institute, Bach Mai hospital since 12/2011 to 11/2012. 2.1.1. Selection criteria of studied patients - Those who were selected had single pattern PVCs/VTs arising from right ventricle. They were successfully treated by RF. Selecting patients was based on the standards of surface ECG’s image and the standards of cardiac electrophysiology guided by ACC/AHA/ESC in 2006 and consensus of EHRA/HRS in 2009. The studied parameters of the patients were written particularly in a very private medical record and were agreed by patients participating in the study. 2.1.2. Patients’s exclusion criteria - The cases weren’t successfully ablated by radiofrequency energy. - Polymorphic PVCs/VTs. - The cases of PVCs/VTs from other sites of origin outside right ventricle: Valsalva sinus, left ventricle outflow tract, the left ventricle chamber. - The other arrhythmias (not PVCs / VTs): atrial fibrillation, atrial flutter, supraventricular tachycardia,... - Patients with renal failure, unusable contrast medium or contrast medium allergy. - Patients do not agree to participate in the study. 2.2. RESEARCH METHODS 2.2.1. Study Design - A prospective study, cross described study. 2.2.2. Methods of selecting studied objects - The sample’s size and the objects were selected following convenient methods. 2.2.3. Research content 2.2.3.1. Clinical examination - Detection of functional symptoms: chest pain, dyspnea, anxiety, palpitations, feelings of inadequacy, fainting...; a medical history of heart disease and comorbid conditions... - Physical examination: anthropometric indices’smeasurement, examination for heart failure and cardiovascular diseases, the comorbid conditions. 2.2.3.2. Blood test 2.2.3.3. Poll image - Surface electrocardiogram was recorded at admission and recorded simultaneously in the process of ablation by RF. - Echocardiography. 2.2.3.4. Setting up electrical endothelial map of heart chambers, ablating the site of origin, radiograph the right ventricle to locate the site of origin. 2.2.4. The criteria used in the study 2.2.4.1. Standards defining successful ablation the origin of ventricular arrhythmias by radiofrequency energy According to the agreement of the European heart rhythm association (EHRA/HRS) in 2009: Images of PVCs/VTs disappeared after releasing few-second ablation energy; no appearance of PVCs/VTs with initially similar shape during the follow-up time, 30 minutes after ablation; not resulting in PVCs / VTs with original shape when stimulating ventricles with the frequency ≥ frequency of VTs or stimulating cycle time ≥ coupling intervals of initial PVCs. 2.2.4.2. Criteria defining unsuccessful ablation the origin of ventricular arrhythmias by radiofrequency energy: incessant PVCs or VTs when using RF to ablate, or after programmed ventricular stimulation; recurrence of PVCs/VTs in surface ECG after the experimental procedure. 2.2.4.3. Criteria for the site of origin of premature ventricular complexes/ventricular tachycardias - Distinguish the sites of origin at ROVT or outside ROVT: ROVT area is limited superiorly by the pulmonary valve and inferiorly by the high portion of the tricuspid valve. The PVCs/VTs originating outside this area are outside the ROVT. - Distinguish different original sites of PVCs/VTs at ROVT, according to Kamakura S.et al., Shima T. et al.: + The septal area of ROVT which are left haft and free wall positions of ROVT, located in left anterior oblique 60º . + The anteroseptum region of ROVT which are left haft and posteroseptum positions of ROVT, located n right anterior oblique 30o. + The high portion of ROVT are positions from pulmonary valve ≤ 1 cm and the low one are positions from pulmonary artery> 1 cm. 2.2.4.4. Criteria of surface ECG diagnosing monomorphic premature ventricular complexes from the right ventricle - PVCs are characterized by rhythm coming soon, with the QRS complex changes shape and widen ≥ 0,12 seconds. T-wave changes are often large and opposed with the QRS complex. There is normally no P-wave precedes QRS of PVCs, or P-wave goes previously but doesn’t lead ventricular rhythm (no contact with QRS of PVCs). P wave can be seen due to the opposite impulse conduction from ventricle resulting in atrial depolarization, but often gets into QRS complex and T-wave. - Single pattern of PVCs. - PVCs with left bundle branch block pattern at anteriorly cardiac lead. 2.2.4.5. Criteria of surface ECG diagnosing monomorphic ventricular tachycardia from right ventricle - 3 or more PVCs continuously, the QRS duration ≥ 0,12 sec, frequency ≥ 100 bpm, RR interval may be constant or changed. - No P wave or no P wave with normal shape and independence, no relationship with QRS complex (atrial - ventricular dissociation phenomenon). Some other cases show the following P-wave after QRS. - Single pattern of VTs. - PVCs with left bundle branch block pattern in priorly cardiac leads. 2.2.4.6. The criteria used in the study about characteristics of premature ventricular complexes/ventricular tachycardias in surface ECG: the Minnesota rules: 2.3. RESEARCH’S DATA HANDLING - The data of research has been processed on a computer by software SPSS 16.0 statistical medicine (Chicago, Illinois). CHAPTER III STUDY’S RESULTS 1. CLINICAL - PARACLINICAL CHARACTERISTICS OF PATIENTS WITH RIGHT PREMATURE VENTRICULAR COMPLEXES/VENTRICULAR TACHYCARDIAS 1.1 Objects age and gender specifications - Study conducted on 107 patients with PVC/ RVOT successfully treated with RF - Mean of age: 47,68 ± 13,19 (15 - 73). - Male: 39/107 patients (36,45%), Female: 68/107 (63,55%). - Age ≥ 40: 81/107 (75,70%). Age from 40 to 49: 31,78%. 1.2 Clinical symptoms - Average time for symptoms exposing: 3,14 ± 4,33 years (0,02 – 21 years) - The symptoms are described in table 3.2 Table 3.2: Studying objects clinical symptoms Symptoms (n = 107) n % Palpitation 62 57,94 Feeling of a skipping beat 14 13,08 Dyspnea 25 23,36 Chest paint 48 44,86 Fainted 4 3,74 Syncope 2 1,87 Abnormal heart sounds 0 0 Heart failure’s physical symptoms 3 2,80 1.3. Studying objects human biometric specifications Table 3.3: Height, weight, Blood pressure, heart rates Values (n = 107) ( ± SD) Max Min Height (m) 1,58 ± 0,67 1,45 1,73 Weight (kg) 53,27 ± 7,54 37,00 73,00 BMI 21,23 ± 2,51 14,86 27,52 Systolic BP (mmHg) 118,18 ± 16,73 85,00 180,00 Diastolic BP (mmHg) 73,13 ± 10,20 50,00 100,00 Heart rates (beats/minute) 78,27 ± 11,76 50,00 130,00 - Hypertension: 14,02%. Sinus tachycardia: 5/107 (4,67%); sinus bradycardia: 4/107 (3,74%). Overweight and obese (BMI ≥ 23): 21/107 (19,63%). 3.2. SITES OF ORIGIN OF RIGHT PREMATURE VENTRICULAR COMPLEXES/VENTRICULAR TACHYCARDIAS SUCCESFULY ABLATED BY RADIOFREQUENCY 3.2.4. Studying objects right premature ventricular complexes /ventricular tachycardias’s sites of origin - 102 cases of PVCs/VTs originated in the RVOT (95,33%), 5 originated outside of the RVOT (4, 67%). Table 3.6: Objects deviding using right ventricular outflow tract PVCs/VTs sites of origin Sites of origin of RVOT PVCs/VTs (n = 102) n % RVOT septal 74 72,55 RVOT free-wall 28 27,45 RVOT anterior-wall 75 73,53 RVOT posterior-wall 27 26,47 RVOT superior sites 53 51,96 RVOT inferior sites 49 48,04 3.3. SURFACE ECG CHARACTERISTICS OF RIGHT PREMATURE VENTRICULAR COMPLEXES/ VENTRICULAR TACHYCADIAS SUCCESFULY ABLATED BY RADIOFREQUENCY 3.3.1. Surface electrocardiographic common characteristics of right premature ventricular complexes/ventricular tachycardias - 95 patients with PVCs (88,79%), 12 patients with VTs (11,21%) - PVCs/VTs’s QRS complexes axis deviation: + Normal axis: 65/107 (60,75%) + Right axis deviation: 37/ 107 (34,58%) + Left axis deviation: 5/107 (4, 67%) + Unrecognizable axis: 0 - PVCs/VTs’s QRS complexes common characteristics in shape, duration, amplitude: Table 3.9: Premature ventricular complexes/ventricular tachycardias bundle branch block types Bundle branch block types(n = 107) n % Right bundle branch block 107 100 Lefft bundle branch block 0 0 Total 107 100 3.3.2. Surface ECG of premature ventricular complexes/ventricular tachycardias originating outside of the right ventricular outflow tract - QRSPVCs/VTs complexes characteristics + 5/5 originating outside of the RVOT had left superior axis deviation. - QRSPVCs/VTs complexes shape, duration, amplitude + In DI: 32,35% of PVCs/VTs from RVOT had r/R/Rs pattern; 100% of PVCs/VTs from outside of the RVOT had R/Rs pattern. 3.3.3 Comparing differences in premature ventricular complexes/ventricular tachycardias’s surface ECG between RVOT septal and free-wall group - RPVCs/VTs waves shape in inferior leads Table 3.19: Comparing the RPVCs/VTs wave shape distribution in inferior leads between PVCs/VTs from RVOT septum and free- wall RPVCs/VTs wave shape RVOT septum (n = 74) RVOT free- wall (n = 28) χ2, p-values n % n % Type 1 12 16,22 23 82,14 χ2=39,17 p=0,000 Type 2 62 83,78 5 17,86 Table 3.20: RPVCs/VTs waves shape in inferior leads value in differential diagnosis between RVOT septum and free- wall sites of origin Diagnosis test (n = 102) Se (%) Sp (%) PPV (%) NPV (%) RPVCs/VTs waves shape type 1 to differentiate sites of origin of RVOT septum and free-wall 82,14 83,78 65,71 92,54 - Comparing QRSPVCs/TVs complexes duration and RPVCs/TVs waves duration in limb leads Table 3.22: QRSPVCs/VTs complexes duration’s cut - off point in DI’s value in differential diagnosis between RVOT s