Journal of Electrocardiology Vol. 36 No.

4 2003

Electrocardiographic Predictors of Failure

and Recurrence in Patients With Idiopathic
Right Ventricular Outflow Tract
Tachycardia and Ectopy Who Underwent
Radiofrequency Catheter Ablation

Marivic Vestal, MD, Ming-Shien Wen, MD, San-Jou Yeh, MD,

Chun-Chieh Wang, MD, Fun-Chung Lin, MD, and Delon Wu, MD

Abstract: This study reports new electrocardiographic (ECG) predictors of

radiofrequency catheter ablation failure and recurrence in idiopathic right
ventricular outflow tract (RVOT) ventricular tachycardia (VT) or ectopy based
on 91 consecutive patients. Procedural success and failure rates were 85%
(77/91) and 15% (14/91), respectively. Twenty three percent (18/77) had
recurrence during the follow-up period of 1 to 120 months (mean 56 ⫾ 31
months). Baseline RVOT VT/ectopy on 12-lead ECG taken prior to ablation
from 91 patients were retrospectively analyzed. Ablation performed with
RVOT ectopy (isolated ectopies, bigeminy, trigeminy, or couplets) as template
arrhythmia was more likely to fail (30% vs. 8%, P ⫽ .02) as opposed to RVOT
VT (sustained or nonsustained). VT/ectopy-QRS morphology variation was
more observed in failed ablations (36% vs. 7%, P ⫽ .001). Significantly wider
mean VT/ectopy QRS in leads I, II, AVR, V2, V3, V5, and V6 were noted in
failed ablation group. Mean R wave amplitude reached statistical significance
only in lead II (22.0 ⫾ 5.1 mV for failed vs. 17.8 ⫾ 5.2 mV for successful
outcomes; P ⫽ .009). QRS morphologic variation (47% vs. 16%; P ⫽ .009) was
the only statistically significant ECG to be more common in patients with
arrhythmia recurrence. In conclusion, ablation with ectopy over VT as tem-
plate arrhythmia, presence of QRS morphologic variation, wider mean QRS
width, and taller mean R-wave amplitude in lead II were identified ECG
predictors of failed RVOT VT/Ectopy ablation. The only ECG predictor of
recurrence was the presence of RVOT VT or ectopy QRS morphologic varia-
tion. Key words: Radiofrequency catheter ablation, ventricular tachycardia.

From the Department of Medicine, Second Section of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei,
Taiwan.
This work supported in part by grants from the National Science Council (NSC90-2314-B182-083, NSC90-2314-B182-057 and
NSC90-2314-B182-056) of the Republic of China, Taipei.
M.V. is an International Fellow in Electrophysiology from Cebu Heart Institute-Perpetual Succour Hospital, Cebu City, Cebu,
Philippines.
Reprint requests: Delon Wu, MD, Chang Gung Memorial Hospital, 199 Tung Hwa North Rd, Taipei, Taiwan; e-mail:
dw0917@mail.cgu.edu.tw.
© 2003 Elsevier Inc. All rights reserved.
0022-0736/03/3604-0006$30.00/0
doi:10.1054/S0022-0736(03)00087-6

327
328 Journal of Electrocardiology Vol. 36 No. 4 October 2003
The efficacy and safety of catheter radiofrequency
ablation for idiopathic ventricular tachycardia (IVT)
and ectopy of right ventricular outflow tract
(RVOT) origin have been extensively described in
the literature. Reported success rate ranges from
83%-100% while recurrence rates from 0%–31%
on a variable follow-up period (mean follow-up
range of 8 – 41 months) (1– 4). With its proven
effectiveness, radiofrequency ablation is now a rec-
ognized therapy of choice for these patients. Opti-
mal pace map score of ⱖ11/12 has been consis-
tently shown as a predictor of successful outcome
(4). Wen et al. (5) have shown that poor pace map
score of ⱕ10/12, reliance on pace map alone in
patients with no sufficient ventricular tachycardia
for identification of ablation sites, and shorter local
endocardial activation time at ablation site were
predictors of recurrence. However, published data
on electrocardiographic (ECG) predictors of radio-
frequency ablation outcome in this patient group is
limited and on that of recurrence is absent (4 – 6).
Furthermore, analysis of these predictors has not
been made on a large patient population with a
long period of follow-up. Therefore, this study
intended to retrospectively identify ECG predictors
for failure and recurrence in a large cohort of
patients with RVOT VT and ectopy who underwent
radiofrequency ablation.
Materials and Methods
Ninety-one consecutive patients with idiopathic
RVOT VT or ectopy (left bundle branch block pat-
tern, inferior or normal axis) who underwent cath-
eter radiofrequency ablation from July 1991- No-
vember 2001 were initially considered in this study.
Five patients were subsequently excluded because
of unavailability of optimal ECG documentation of
VT or ectopy on the day of ablation. Baseline ECGs
taken prior to catheter placement for patients with
spontaneously occurring arrhythmia or prior to
positioning of ablation and reference catheters to
RVOT area for those with induced arrhythmia by
programmed stimulation or cathecolamine were
retrospectively analyzed. This is to ascertain that
the influence of catheter-induced artifactual QRS
changes was nil. All ECGs recorded (at a paper
speed of 25 mm/s) were categorized as VT (sus-
tained and nonsustained) or ectopy (isolated pre-
mature ventricular depolarizations, QRS couplets,
bigeminy, or trigeminy). Differences of ECG param-
eters such as QRS morphologies, durations, mor-
phologic variations, polarities, R-wave amplitudes,
axis, precordial transition zone, presence of notch-
ing, template arrhythmia during ablation (VT vs.
ectopy) and AVR:AVL (QS or rS amplitude) ratio
were compared to acute outcome and recurrence.
Induction of another RVOT VT after successful
ablation of a clinical VT was likewise noted. Elec-
trocardiographic parameters were examined by
three observers and differences were resolved by a
consensus. Continuous variables were expressed as
mean ⫾ SD and compared by unpaired Student’s t
test. Discrete variables were compared by Fisher’s
exact test or Pearson’s Chi2-test. A P value of ⬍ .05
was considered statistically significant.
Electrophysiologic study and programmed stim-
ulation (on and off isoproterenol) were performed
prior to and after ablation in all patients. The
ablation catheter was 7 Fr. steerable quadripolar
electrode with either a 4- or 5-mm tip and 2 mm
interelectrode spacing between distal 2 electrodes.
The ablation catheter was retrogradely advanced to
the RVOT area and positioned to the ablation site
via the right femoral vein access. Ablation site was
identified by exact or closest QRS pace map
matched to the tachycardia or ectopy QRS and/or
earliest endocardial activation preceding the QRS.
Radiofrequency currents from an electrosurgical
unit (Radionics RFG-3C, Burlington, MA; and
OSYPKA HAT 300, Rheinfelden-Herten, Germany)
of 20 to 35 W were initially delivered for 10 to 20 s
duration. If tachycardia was terminated or ectopy
disappeared in 10 s, additional currents were given
for another 60 s. Radiofrequency current delivery
was stopped when chest pains occurs, impedance
rise of ⱖ 150 ohms, ablation success endpoints were
reached, and conversely when endpoints were not
attained after repeated attempts.
All patients were followed up regularly in the
outpatient clinic in an antiarrhythmic drug-free
state. Serial 24-hour ambulatory Holter monitoring,
event recording, treadmill exercise test, and resting
ECGs were performed during follow-up upon rec-
ognition of symptomatic recurrence and routinely 1
day, 1-2 months postablation, and every 6 to12-
month interval thereafter. Repeat electrophysi-
ologic study (EPS) was performed on some patients
with frequent symptoms in whom noninvasive
diagnostic evaluation (serial resting, event record-
ing and ambulatory ECGs and treadmill exercise)
failed to document any arrhythmia.
Definition of Terms
Acute success was defined as: 1) complete disap-
pearance of spontaneous, or noninducibility by
 RVOT Tachycardia and Ectopy • Vestal et al. 329

Table 1. Demographics and Electrocardiographic Parameters of Patients Between Radiofrequency Ablation

Outcomes and Recurrence
Acute Outcome Recurrence
Successful Failed P Recurrence Recurrence P
Parameters N ⫽ 73 N ⫽ 13 Value N ⫽ 17 N ⫽ 56 Value

Age (yrs) 47 ⫾ 16 58 ⫾ 17 .02 44 ⫾ 15 48 ⫾ 15 .22

Men/Women 23/50 8/5 .04 5/12 18/38 1.0
Normal Axis/RAD 40/33 10/3 .22 8/9 32/24 .58
Transition Zone
ⱕV3/⬎V3 12/61 4/9 .25 4/13 8/48 .46
AVR: AVL Ratio (QS or rS amplitude) .35 .89
⬍1 48 7 12 36
1 10 1 2 8
⬎1 15 5 3 12
Template Arrhythmia during RFA
VT/Ectopy 54/19 5/8 .02 12/5 42/14 .76
VT Cycle Length (ms) 304 ⫾ 51 323 ⫾ 43 .38 300 ⫾ 43 306 ⫾ 53 .70
⫹/⫺ QRS Morphologic Variation 16/57 9/4 .001 8/9 9/47 .009

RAD, right axis deviation; RFA, radiofrequency ablation; VT, ventricular tachycardia; ⫹/⫺ with and without.

programmed stimulation on and off isoproterenol
of, sustained or nonsustained VT, or 2) complete
disappearance of ectopy on and off isoproterenol
immediately (at least 20 minutes) during the obser-
vation period post ablation. Recurrence was defined
as: 1) spontaneous or induced VT of RVOT origin
(which may or may not be of same QRS configura-
tion to prior documented arrhythmia) by treadmill
exercise, isoproterenol infusion, or programmed
stimulation on follow-up diagnostic evaluation, or
2) increased or increasing frequency of ectopy com-
parable to baseline documented by Holter monitor-
ing, treadmill exercise, or isoproterenol infusion.
Sustained VT was defined as VT lasting ⬎ 30 s.
Nonsustained VT was defined as VT of 3 beats to
30-s duration. Morphological VT or ectopy QRS
variation is one that is deemed not because of
phasic respiratory variation, fusion with supraven-
tricular beats, cycle length variation or catheter-
induced artifactual change. Overt morphological
QRS variation was defined as variation in morphol-
ogy, duration or amplitude with change of axis
and/or shift of precordial transition zone or separate
induction of another monomorphic RVOT VT per
se. Subtle morphological QRS variation was defined
as slight changes in morphology, duration and
amplitude with no overt change in axis and/or shift
of transition zone. Slight variations in QRS ampli-
tude alone were attributed to phasic QRS variation.
Results
Procedural acute success and failure rates were
85% (77/91) and 15% (14/91), respectively. Out of
the successful outcome, 18 (23%) patients had a
recurrence during the follow-up period of 1 to 120
months (mean 56 ⫾ 31 months). The long-term
procedural success rate was 77% (59/77). After the
exclusion of five patients due to incomplete data, a
total of 86 patients (73 successful and 13 failed
outcomes with 17 recurrences) and corresponding
electrocardiograms were subjected to analyses.
Thus, the study population consisted of 55 women
and 31 men with ages ranging from 9 to 80 years
(mean 49 ⫾ 16 years). All complained of recurrent
palpitations. Forty-seven reported concomitant
syncopal and/or near syncopal episodes and 21
others of dizziness. There was a preponderance of
males over the females in the failure group and
patients tend to be older compared to those with
successful outcome (Table 1). Patients with RVOT
ectopy (30% vs. 8%, P ⫽ .02) as template arrhyth-
mia during ablation were more likely to have a
failed ablation (Table 1). More patients with mor-
phological VT/ectopy-QRS variation have failed ab-
lations (36% vs. 7%, P ⫽ .001). The mean QRS
duration (Table 2) was wider in all leads among the
failed outcomes compared to successful ones and
differences attained statistical significance in leads I,
II, AVR, V2, V3, V5, and V6. The mean R amplitude
(Table 3) was found to be significantly different
only in lead II with failed outcome having taller
mean amplitude (22.0 ⫾ 5.1 vs. 17.8 ⫾ 5.2 mV, P ⫽
.009). ECG parameters such as QRS lead morphol-
ogies, polarities, presence of notching, axis, precor-
dial transition zone ⱕ V3, and AVR:AVL (QS or rS
amplitude) ratio were not significantly different
between ablation outcomes.
Ventricular Tachycardia/ectopy-QRS morpho-
330 Journal of Electrocardiology Vol. 36 No. 4 October 2003

Table 2. Mean VT/Ectopy QRS Duration (msec) another RVOT VT induced after successful ablation
between Successful and Failed Radiofrequency of a clinical VT (4,10). In some patients, a sudden
Ablation Outcomes
change in QRS morphology and axis of VT were
Lead Success Failure P Value evident during the delivery of RF currents(10).
I 107 ⫾ 16 118 ⫾ 24 .03 Spontaneous shift in the QRS configuration is not
II 113 ⫾ 10 122 ⫾ 15 .008 uncommon during the episodes of ventricular
III 114 ⫾ 10 117 ⫾ 19 .44 tachycardia. Even the subtle changes in morphol-
AVR 112 ⫾ 13 1242 ⫾ 15 .016
AVL 114 ⫾ 13 117 ⫾ 13 .52 ogy are frequently accompanied by marked changes
AVF 115 ⫾ 11 120 ⫾ 13 .17 in endocardial activation sequence (11). Mapping
V1 117 ⫾ 15 124 ⫾ 22 .11 studies on ischemic VT have shown that shift of
V2 124 ⫾ 15 134 ⫾ 21 .04
V3 124 ⫾ 16 136 ⫾ 19 .01 configuration of surface ECG were brought about
V4 120 ⫾ 17 123 ⫾ 20 .50 by either a change in tachycardia site of origin or
V5 114 ⫾ 12 123 ⫾ 16 .01 alterations in activation patterns from a relatively
V6 112 ⫾ 12 125 ⫾ 19 .002
constant endocardially located VT origin (11–15).
Significant alterations in endocardial activation pat-
terns, transmural conduction patterns, site of epi-
cardial breakthrough or sequence of epicardial
logic variation was observed to be more frequent activation can all be contributory to these morpho-
(47% vs. 16%; P ⫽ .009) among the recurrent cases logical variations (12). In ischemic VT, changes in
(Table 1). QRS morphologies and polarities, notch- epicardial breakthrough patterns have been found
ing, axis, precordial zone, AVR:AVL QS, or rS to strongly influence the configuration of surface
amplitude ratio were not significantly different VT-QRS complex (12,14). In structurally normal
when matched against the recurrent and the non- hearts however, tachycardia QRS morphology usu-
recurrent cases. ally indicates the region of VT origin as proven by
how effective pace mapping technique is in identi-
fying successful ablation sites. Thus the QRS mor-
Discussion phology may be more closely related to endocardial
activation sequence than epicardial activation se-
Template Arrhythmia for Ablation quence/breakthrough. The RVOT VT-QRS morpho-
logic variation has not been extensively addressed
In this study, patients with sustained or nonsus- previously. But like in ischemic VT, different sites of
tained RVOT VT during ablation were more likely to VT origin or different VT exits have been quoted to
have successful outcome compared to those with account for these QRS variations (8 –10). The direct
RVOT ectopy. Experience has shown that combina- effect of radiofrequency currents on the VT QRS
tion of exact pace map match and earliest activation morphology for those variations observed during
time optimizes target site identification. The likeli- and after the delivery of RF currents also cannot be
hood of success therefore could be related to the totally ruled out. Furthermore, little is known as to
fact that these parameters are better evaluated the implications of this RVOT VT/ectopy-QRS vari-
during sustained VT than in the setting of less ation. This study has shown that patients with these
frequently occurring ectopic beats. Furthermore,
when ventricular ectopy is the reference arrhyth-
Table 3. Mean R Amplitude (mV) During VT/Ectopy
mia, matching coupling intervals during ventricular Between Successful and Failed Radiofrequency
pace mapping to attain optimal pace maps cannot Ablation Outcomes
be made possible at all times. Goyal et al. (7) have
Lead Success Failure P Value
shown that rate-dependent changes in QRS mor-
phology may confound the pace mapping results. I 3.0 ⫾ 2.0 4.0 ⫾ 2.5 0.19
II 17.8 ⫾ 5.2 22.0 ⫾ 5.1 0.009
III 20.8 ⫾ 7.7 23.6 ⫾ 5.8 0.21
AVR 2.2 ⫾ 1.3 — —
VT/Ectopy QRS Morphologic Variation AVL 1.6 ⫾ 0.9 1.6 ⫾ 0.9 0.98
AVF 19.4 ⫾ 6.6 23.0 ⫾ 5.0 0.06
V1 2.3 ⫾ 1.6 2.4 ⫾ 1.5 0.84
Subtle surface ECG morphologic QRS variation of V2 3.2 ⫾ 2.7 4.6 ⫾ 3.3 0.10
RVOT VT with concomitant variations in early V3 5.8 ⫾ 4.6 7.3 ⫾ 5.4 0.27
activation time at site of VT origin was first reported V4 10.7 ⫾ 6.8 10.9 ⫾ 5.3 0.89
V5 14.4 ⫾ 6.9 13.2 ⫾ 5.7 0.55
by Chinushi et al.(8). Overt QRS morphologic vari- V6 14.9 ⫾ 5.6 15.3 ⫾ 8.1 0.83
ation was also described by other investigators as

electrocardiographic features were more likely to
have a failed ablation or if successfully ablated have
a more likelihood of recurrence.
QRS Width in Idiopathic RVOT VT/Ectopy
Coumel et al. (16) have shown that QRS width of
idiopathic VT was narrower in contrast to ischemic
VT. Likewise, compared to arrhythmogenic right
ventricular dysplasia (ARVD) VT, the QRS duration
(correlated to the lesser degree of fibrosis compared
to ARVD) of RVOT IVT was found to be lesser (17).
These observations were consistent to the fact that
the magnitude of QRS prolongation is related to the
degree of sequential activation of ventricular myo-
cardium (less asynchronous for the more basal VT
focus) and by the muscle-to-muscle conduction
velocity (prolonged by hypertrophy, fibrosis). As
observed by others, the QRS durations measured
per lead in our patients were generally less wide.
When the differences of mean QRS durations
between successful and failed outcomes were com-
pared, the QRS width was significantly wider in the
latter. This is contrary to the findings of Flemming
et al. (6). In their study, the best discriminator of
outcome was the QRS duration in lead V2 with
more successful ablation performed in patients with
VT/bigeminy QRS duration of ⱖ 160 ms. They
further postulated that the association of a nar-
rower QRS and unsuccessful outcome is related to a
deeper location (nonendocardial) of the VT/ectopy
origin.
In our study, majority of the successful ablation
sites was septal in location (85%). Although over-
lap in the range of QRS duration is present, the
septal foci tend to have narrower mean QRS dura-
tion compared to free wall foci and reached statis-
tical significance in leads I, AVR and AVL. Narrower
VT QRS – complex has been shown by prior studies
to be characteristic of tachycardia arising from sep-
tal location (11,18,19).
VT/Ectopy R-wave Amplitudes
Closed chest simulated ventricular arrhythmias
using epicardial pacing made by Holt et al. (8) had
shown that QRS amplitudes are greatest when
ventricles are activated at from base and apex. Pace
maps made at the base of the RV (RVOT area)
showed tall R-wave amplitudes in the limb leads
(best evaluated in lead II). However, adjacent to the
interventricular septum, an electrocardiographic
low amplitude center was observed where QRS
complexes tend to be smaller in amplitude and
RVOT Tachycardia and Ectopy • Vestal et al. 331
duration. It is possible that shorter mean R-wave
amplitude in lead II in patients with successful
outcome observed in this study was reflective of the
septally located successful sites composing majority
of patients in this group.
Technical difficulty in catheter manipulation
posed by the anatomy of the RVOT is a recognized
limitation in the catheter ablative procedure of this
arrhythmia. Ablation failure therefore can also be
due to the inability to locate or stabilize ablation
catheter to target tachycardia origin in difficult-to-
reach areas of the RVOT. The narrower mean QRS
duration and shorter R-wave amplitude in lead II
and the likelihood of successful ablation in this
study may be related to the majority of successful
ablation foci being septally located where better
catheter accessibility and stability were attained.
Study Limitations
The present study is a retrospective study and,
thus, several important issues could not be clarified.
For example, success of radiofrequency ablation
may be more dependent on the precision of the
diagnosis rather than the morphology of ventricular
ectopy and that the failure rate might be due to a
different diagnosis (such as arrhythmogemic right
ventricular dysplasia) which is frequently associ-
ated with varying morphologies. Although the pa-
tients were not systematically studied by magnetic
resonance imaging, signal-averaged electrocardiog-
raphy or right ventricular angiography, all patients
underwent an examination of two-dimensional
Doppler echocardiography with color flow mapping
to exclude the possibility of right ventricular dys-
plasia. The possibility that failure rate might also be
caused by epicardial origin or left ventricular out-
flow tract origin of the arrhythmia. The current
study did search for the possibility of left ventricular
outflow tract origin in patients who had shown an
ECG pattern of atypical left or right bundle branch
of their arrhythmia (20).
Conclusions
Certain electrocardiographic characteristics can
be used to predict the likelihood of ablation failure
and recurrence in patients with RVOT VT or ectopy.
Ablating with ectopy over VT as template arrhyth-
mia, presence of QRS morphologic variation, wider
QRS width, and taller R wave amplitude in lead II
were identified as predictors of outcome failure.
332 Journal of Electrocardiology Vol. 36 No. 4 October 2003
The lone ECG predictor of recurrence was the
presence of RVOT VT/ectopy-QRS morphologic
variation.
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