Periodicity of global ventricular activation of sinus beats in patients with coronary artery disease and sustained ventricular tachycardia

Despite increasing clinical reliance on signal-averaged electrocardiograms for determining risk for development of sustained ventricular tachycardia (VT), the periodicity of global ventricular activation during sinus rhythm has not been defined. Accordingly, epicardial and transmural ventricular electrograms during 6 consecutive sinus beats were evaluated in 10 patients with abnormal signal-averaged electrocardiograms who were undergoing surgery for VT. Bipolar electrograms were recorded with sock and needle electrodes from up to 96 epicardial and 156 transmural sites. Electrogram morphology, duration and activation were compared on a beat-to-beat basis. In all, 9,816 electrograms were analyzed. Mean durations of epicardial and transmural electrograms were 33 ± 16 ms (range 6 to 199) and 23 ± 10 ms (range 6 to 72), respectively, with a beat-to-beat variation of 1.9 ± 1.4 ms per site. Similarly, local activation times did not vary significantly during the 6 cardiac cycles analyzed (mean variation 1.7 ± 2.0 ms). Local conduction failure was not observed. Although electrograms during the terminal 40 ms of the QRS were significantly longer (36 ± 20 vs 26 ± 12 ms, p < 0.001) when compared with those recorded earlier during the QRS complex, beat-to-beat variation in duration (2.1 ± 1.6 ms) and activation (1.7 ± 2.3 ms) was not significant. Results demonstrate that epicardial and transmural electrograms recorded during sinus rhythm in patients with sustained VT are periodic signals and thus establish a physiologic basis for signal averaging of electrocardiographic waveforms in these patients.