163

Clinical and Electrophysiological Difference Between Idiopathic

Right Ventricular Outflow Tract Arrhythmias
and Pulmonary Artery Arrhythmias
YOSHIHIRO YAMASHINA, M.D.,∗ TETSUO YAGI, M.D., Ph.D.,∗ AKIO NAMEKAWA, M.D.,∗
AKIHIKO ISHIDA, M.D.,∗ HIROKAZU SATO, M.D.,∗ TAKASHI NAKAGAWA, M.D.,∗
MANJIROU SAKURAMOTO, M.D.,∗ EIJI SATO, M.D.,∗ and TOMOYUKI YAMBE, M.D., Ph.D.†
From the ∗ Division of Cardiology, Sendai City Hospital, Sendai, Japan; and †Department of Medical Engineering and Cardiology, Institute
of Development, Aging and Cancer, Tohoku University, Sendai, Japan

Characteristics of Pulmonary Artery Arrhythmias. Introduction: The precise incidence and

characteristics of ventricular arrhythmias originating from the pulmonary artery have not been fully
described. The purpose of this prospective study was to clarify these points.
Methods: Thirty-three consecutive patients with an idiopathic left bundle branch block and inferior-axis
deviation type ventricular arrhythmia were included. All patients underwent detailed electroanatomical
mapping (CARTO, Biosense-Webster, Diamond Bar, CA, USA) during sinus rhythm prior to the catheter
ablation. The precise location of the catheter tip at the successful ablation site was confirmed by both
electroanatomical mapping and contrast radiography. The clinical and electrophysiological data were
compared between the right ventricular outflow tract (RVOT) arrhythmia patients (RVOT group) and PA
arrhythmia patients (PA group).
Results: Eight patients (8/33 patients: 24.2%) had their ventricular arrhythmias successfully ablated
within the PA. The local bipolar electrogram at the successful ablation sites in the PA group exhibited
a significantly greater duration (P < 0.05) and lower amplitude (P < 0.05) than did those in the RVOT
group (n = 19). In the PA group, all patients exhibited a multicomponent electrograms composed of a
spiky potential and a dull potential, which might have consisted of near-field PA activation and a far-field
ventricular activation, respectively, at the successful ablation site. Direct ablation to the spiky electrogram
was able to eliminate the arrhythmias in all the PA group patients.
Conclusions: PA arrhythmias may be more common than previously recognized. Careful mapping and in-
terpretation of low amplitude and multicomponent electrograms are important for recognizing ventricular
arrhythmias originating from the PA. (J Cardiovasc Electrophysiol, Vol. 21, pp. 163-169, February 2010)

right ventricular outflow tract, pulmonary artery, ablation, ventricular tachycardia, premature ventricular
complex

Introduction was undertaken to clarify these points prospectively in the

Recently, a small number of cases with idiopathic ven-
tricular tachycardia (VT)/premature ventricular complexes
(PVCs) have been reported to have originated from the pul-
monary artery (PA).1-5 However, most of the previous reports
were retrospective studies in selected cases and verified the
anatomical locations of the successful ablation sites only
by means of two-dimensional right ventriculography or pul-
monary arteriography without any real-time monitoring of
the actual catheter position. Therefore, the precise incidence,
exact location of the successful ablation site, and charac-
teristics of the PA-VT/PVCs remain unknown. This study
No disclosures were made.
Address for correspondence: Tetsuo Yagi, M.D., Ph.D., Division of Car-
diology, Sendai City Hospital, Wakabayashi-ku, Shimizukouji3–1, Sendai,
Japan. Fax: 81-022-211-8972; E-mail: tetsuo.yagi@nifty.com
Manuscript received 30 May 2009; Revised manuscript received 30 July
2009; Accepted for publication 3 August 2009.
doi: 10.1111/j.1540-8167.2009.01601.x
consecutive patients.
Methods
Study Population
The study population consisted of 33 consecutive patients
(mean age 45.5 ± 17.3 years, 12 males) with symptomatic
VT/PVCs, left bundle branch block and an inferior-axis de-
viation in whom radiofrequency catheter ablation (RFCA)
was attempted between 2007 and 2008 at our institute. No
patients had any structural heart disease. All patients pro-
vided their written informed consent for the mapping and
ablation. The study was approved by the institutional review
board.
Electrophysiological Evaluation, Mapping, and Ablation
All patients were studied in the absence of any antiar-
rhythmic drug therapy. Prior to the conventional electro-
physiological evaluation and ablation, all patients underwent
detailed electroanatomical voltage mapping focused on the
right ventricular outflow tract (RVOT) and PA with a CARTO
system (Biosense-Webster, Diamond Bar, CA, USA) during
sinus rhythm (SR), as previously reported.6-10 In brief, a 7-F
164 Journal of Cardiovascular Electrophysiology Vol. 21, No. 2, February 2010
Navi-Star (Biosense-Webster) catheter with a 4-mm distal
tip electrode was introduced into the right ventricle via the
femoral vein under fluoroscopic guidance and was used as the
mapping/ablation catheter. The catheter was placed at mul-
tiple sites on the endocardial surface to record bipolar and
unipolar electrograms from the RVOT and PA. The bipolar
electrogram signals (filtered at 10 to 400 Hz and displayed
at 100 mm/sec on the CARTO system) were analyzed with
regard to their amplitude, duration, relation to the surface
QRS, and presence of multiple components. A recording was
accepted and integrated into the map when the variability in
the cycle length, local activation time stability, and maximum
beat-to-beat difference of the location of the catheter were
<2%, <3 ms, and <4 mm, respectively. Those parameters
were used to exclude any signals with a low amplitude due
to poor endocardial catheter contact. In addition, adequate
catheter contact was confirmed by (1) a concordant catheter
tip motion with the cardiac silhouette that was verified by
multiplane fluoroscopy using mainly a 30 degree right an-
terior oblique projection and 50 degree left anterior oblique
projection and (2) by a significant ST segment elevation on
the unipolar recording.
After obtaining the 3-dimensional geometry of the RVOT
and PA during SR, activation mapping was performed in
the RVOT region and site above the pulmonary valve dur-
ing spontaneous VT or PVCs. If no clinical VT or PVCs
appeared spontaneously, ventricular stimulation or an intra-
venous isoproterenol infusion (1 to 5 μg/min) was admin-
istered to provoke the arrhythmia. The choice of the abla-
tion site was based on a conventional activation mapping
method and/or pace mapping method. The activation map
was created by mapping several points during the ventric-
ular arrhythmias while using a surface electrocardiogram
(ECG) lead as a reference. The activation times were as-
signed on the basis of the onset of the bipolar electrograms
and displayed as color gradients on a 3-dimensional activa-
tion map. A suitable target for ablation was selected based on
the earliest endocardial activation times during the arrhyth-
mia and confirmed by pace mapping that exhibited ≥11 of
12 matches between the paced and spontaneous QRS com-
plexes. Ablation was performed with a 4-mm tip Navi-Star
ablation catheter using radiofrequency energy (target tem-
perature 50◦ C, maximal power 40 W) delivered for up to
120 seconds. After the elimination of the arrhythmia by a
successfully delivered radiofrequency application, success-
ful ablation sites were recorded on a 3-dimensional elec-
troanatomical map during SR. The catheter position at the
successful ablation sites was evaluated by pulmonary ar-
teriography or right ventriculography while the catheter
position was monitored in real-time on a 3-dimensional elec-
troanatomical map during SR. The minimum distance be-
tween the tip of the catheter at the successful ablation site
and the attachment of the nearest leaflet of the pulmonary
valve was measured.
Successful ablation was defined as follows: (1) absence
of any spontaneous or induced clinical RVOT arrhythmias,
both in the absence and presence of isoproterenol, at the end
of the procedure; (2) no recurrence of any clinical ventric-
ular arrhythmias during continuous ECG monitoring in the
hospital for at least 72 hours after the ablation procedure;
and (3) no recurrence of any symptomatic arrhythmias in the
absence of any antiarrhythmic drug therapy during at least
2 months of follow-up.
Comparison Between RVOT and PA Arrhythmias
Each patient with successful right-sided ablation in the
present study population was classified into the 2 groups.
The RVOT group consisted of patients with VT/PVCs ablated
successfully below the pulmonary valve. The PA group con-
sisted of patients with VT/PVCs ablated successfully above
the pulmonary valve. The patient characteristics, form of
clinical ventricular arrhythmia, characteristics of the 12-lead
ECG during the clinical VT/PVCs, and characteristics of
the local electrogram at the successful ablation site during
SR and VT/ PVCs were analyzed and compared between the
2 groups. A quantitative and morphological analysis of the lo-
cal electrogram at the successful ablation site was performed
to distinguish the characteristics of the local electrograms
between the RVOT group and PA group. As a previous re-
port described,11 the electrographic amplitude (in mV) was
defined as the maximum upward to maximum downward de-
flection on the bipolar electrogram, and the electrographic
duration (in ms) was defined as the time from the earli-
est electrical activity to the termination of the electrogram
in the bipolar electrogram. The amplification and duration
measurements were combined to give an amplitude/duration
ratio to allow for an equal emphasis to be placed on each
of those values. The local activation time from the surface
QRS onset of the VT or PVCs was measured in each pa-
tient. The intracardiac electrograms were analyzed at a paper
speed of 100 mm/sec using a computerized recording system
(Cardiolab System, Prucka Engineering Inc., Houston, TX,
USA). The bipolar electrograms were filtered at a frequency
of 30–500 Hz.
In the present study, a description of the electrogram mor-
phology at the successful ablation site was defined as follows.
A “Single” electrogram was a potential consisting of 3 elec-
trical deflections and a total electrogram duration of <50 ms
(Fig. 1A). A “multicomponent” electrogram was a poten-
tial that consisted of over 4 electrical deflections and a total
electrogram duration of ≥50 ms (Figs. 1B, 2, and 3).
Analysis of the Electrograms Above the Pulmonary Valve
Several investigators have reported supravalvar near-field
potentials as PA potentials separated from far-field ventric-
ular potentials in PA arrhythmias.1,3-5 In the present study,
the electrograms at the successful ablation sites in the PA
group were analyzed for the following points. If the local
electrogram was composed of 2 electrical components, the
sequence pattern of the 2 components at the successful ab-
lation site was noted during both SR and VT/PVCs (Figs. 2
and 3), and the duration from the onset of the first compo-
nent to the second component was measured in each case
during SR (Figs. 2 and 3). The difference in the morphol-
ogy of the local electrogram at the successful ablation site
was also noted before and after a successful ablation (Figs. 2
and 3).
Statistical Analysis
The continuous variables are expressed as the mean ±
SD. Mann-Whitney’s U tests were used to compare the
2 groups. A frequency analysis was performed with a Fisher’s
exact test. A Pearson’s correlation coefficient was used to de-
termine the relationship between the 2 parameters. P value
<0.05 was considered significant.
 Yamashina et al. Characteristics of Pulmonary Artery Arrhythmias 165

Figure 1. Representative cases of ventricular tachycardia (VT) successfully ablated within the right ventricular outflow tract (RVOT) below the pulmonary
valve (RVOT group). (A) Data from the successful ablation site in a 33-year-old male. The intracardiac electrogram revealed a “single” electrogram during
both sinus rhythm (SR) and premature ventricular complexes (PVCs) at the success site. The radiogram and electroanatomical voltage map show the
ablation catheter position at the success site. The white arrow indicates the pulmonary valve position. The successful ablation site was located 4 mm below
the pulmonary valve. (B) Data from the successful ablation site in a 53-year-old male. The intracardiac electrogram appeared to be a “multicomponent”
electrogram consisting of 2 components (arrow and arrowhead). The sequence of those components did not change during SR and PVCs. The successful
ablation site was located 6 mm below the pulmonary valve. A = anterior; ABL = ablation catheter; d = distal; F = free-wall side; P = posterior; p =
proximal; S = septum side; RAO = right anterior oblique projection.

Results group (Table 1). Although we compared the 12-lead surface

Ablation Outcome and Prevalence of PA-VT/PVCs
Among the total 33 patients, 29 patients (29/33: 87.8%)
met the successful ablation criteria. In the successful ablation
group patients, 8 patients (8/33 patients: 24.2%) had their
VT/PVCs successfully ablated within the PA (PA group).
Among the remaining 21 patients, 19 patients (19/33 pa-
tients: 57.5%) had their VT/PVCs successfully ablated from
within the RVOT (RVOT group) and 2 (2/33 patients: 6.0%)
had their PVCs ablated from within the left ventricular
outflow tract (LVOT). In the unsuccessful ablation group
(4/33 patients: 12.1%), 2 patients exhibited recurrences of
their clinical VT/PVCs during the follow-up period. Al-
though both of the patients had their VT ablated temporar-
ily from within the RVOT, they had relapses of their PVCs
after the procedure. In the remaining 2 patients in the un-
successful ablation group, 1 procedure was stopped be-
cause no arrhythmias could be induced in the laboratory.
Although another 1 was mapped and ablated from both
the RVOT side and LVOT side, the targeted PVCs were
not affected at all by the RFCA during the procedure. No
procedure-related complications were observed in any of the
patients.
Comparison of the Clinical, Electrocardiographic and
Electrophysiological Characteristics Between the RVOT
Group and PA Group
There were no significant differences in the gender, age,
or form of the arrhythmias between the RVOT group and PA
ECG characteristics of the clinical VT/PVCs between the
2 groups, no significant differences were observed in the R-
wave amplitude, QRS duration, Q-wave ratio of aVR/aVL,
R/S ratio in leads V1, V2, and V3, and precordial transitional
zones (data are not shown). On the other hand, there were
some significant differences in the intracardaic electrograms
between the RVOT group and PA group. The local bipolar
electrograms at the successful ablation sites in the PA group
exhibited a significantly greater duration and lower amplitude
during both SR and VT/PVCs than did those in the RVOT
group (Table 2). The mean amplitude/duration ratio was also
significantly lower in the PA group than in the RVOT group
(Table 2). Moreover, there was a higher incidence of mul-
ticomponent electrograms at the successful ablation sites in
the PA group than in the RVOT group (Table 2). Although a
pacing stimuli from a conventional pacing unit using a max-
imal output (9.9 V/2.0 ms) could be captured in all patients
of the RVOT group, in 3 of 8 patients (37.5%) in the PA
group it did not capture even with maximal output pacing at
the successful ablation sites (Table 3). There were no signif-
icant differences in the mean local activation time from the
QRS onset during the VT/PVCs between the RVOT group
and PA group. The mean distance of the successful ablation
sites from the pulmonary valve in the RVOT group was 6.2 ±
3.7 mm (range 1–14 mm) below the pulmonary valve. The
mean distance of the successful ablation sites from the pul-
monary valve in the PA group was 7.5 ± 4.8 mm (range
4–15 mm) above the pulmonary valve. The distribution of
the successful ablation sites for each distance from the pul-
monary valve is shown in Figure 4.
166 Journal of Cardiovascular Electrophysiology Vol. 21, No. 2, February 2010

Figure 2. Representative cases of VT/PVCs arising from the pulmonary artery (PA) (PAgroup). (A) Data from the successful ablation site in patient number
4 in Table 3. The intracardiac electrogram exhibited a multicomponent electrogram with a tiny dull potential (arrowhead) and spiky potential (arrow). The
spiky potential was almost buried in the dull potential during SR (duration between each potential = 30 ms), and the sequence of the 2 components became
reversed during the PVC. (A’) The intracardiac electrograms after a successful ablation. The spiky potential became diminished leaving a dull potential. A
radiogram and electroanatomical voltage map showing the ablation catheter position at the success site. The white arrow indicates the pulmonary valve
position. The successful ablation site was located 4 mm above the pulmonary valve. (B) Ablation data from patient number 5 (6 mm above the pulmonary
valve). The asterisk indicates the far-field atrial potential. (B’) After the successful ablation. (C) Ablation data from patient number 6 (8 mm above the
pulmonary valve). (C’) After the successful ablation. (D) Ablation data from patient number 7 (15 mm above the pulmonary valve). This patient had coexisting
complete right bundle branch block during SR (shown in V1), and depolarization of the right ventricle might have been delayed and fused with the dull and
sharp potentials during SR. (D’) After the successful ablation. The abbreviations are as shown in the prior figure. See the text and Table 3 for a detailed
analysis in each patient.

Analysis of the Electrograms in the PA Group
The electrophysiological characteristics of the PA-
VT/PVC cases are summarized in Table 3. Among the 8
PA-VT/PVCs cases, 7 had their arrhythmias ablated success-
fully along the septal side of the PA and 1 on the posterior
free-wall side. As for morphological characteristics of the
local electrograms at the successful ablation site in the PA
group, 7 of 8 patients exhibited tiny dull potentials preceding
the spiky potentials during SR (dull/spiky pattern) (Table 3,
Fig. 2). In those patients, all exhibited a reversed sequence
(spiky/dull pattern) during the VT/PVCs. Although patient
number 8 had a single potential during the late phase of the
QRS complex at the successful ablation site during SR, in-
creasing the gain revealed a very tiny dull potential preceding
the spiky potential (a detailed analysis is shown in Fig. 4).
 Yamashina et al. Characteristics of Pulmonary Artery Arrhythmias 167

Figure 3. Ablation data from patient number 8. (A) An intracardiac electrogram from a failed ablation site above the pulmonary valve. This site corresponds
to a failed site [ABL(A)] on the electroanatomical voltage map. At that site, ABL-d exhibited a dull (arrowhead)/spiky (arrow) potential during SR and had
a reversed sequence during the PVC. (B) Intracardiac electrograms at the successful ablation site (8 mm above the site in panel A). During SR, the dull
potential is nearly gone, and the spiky potential is 10 ms later from the QRS than the spiky potential in panel A. An increased gain (square) revealed a dull
potential preceding the spiky potential. The radiogram shows the successful ablation site. The white arrow indicates the pulmonary valve position. LAO =
left anterior oblique projection. The other abbreviations are as shown in the prior figures.

The duration from the onset of the dull potential to the spiky
potential during SR correlated with the distance between the
ablation site within the PA and base of the pulmonary valve
(r = 0.77, P < 0.05). After the successful ablation within the
PA, a spiky potential during the late phase of the QRS in SR
was still recorded in 3 (37.5%) patients but disappeared in
the remaining 5 (62.5%) (Fig. 2).
Discussion
16.2% in idiopathic ventricular arrhythmias that were treated
by RFCA.2,3 However, most previous reports were retro-
spective studies in selected cases and evaluated the rela-
tionship between the pulmonary valve position and success-
ful ablation sites only by means of contrast enhancement
without real-time monitoring of the catheter position. This
prospective study using both an electroanatomical mapping
system and contrast enhancement demonstrated that approxi-
mately 25% of VT/PVCs were ablated successfully above the

The Prevalence of PA-VT/PVCs

This prospective study demonstrated that the prevalence TABLE 2
of PA-VT/PVCs might be more common than previously Comparison of the Local Bipolar Electrograms at the Successful Ablation
recognized. Although it is well known that most idiopathic Sites Between the Groups
VT or PVCs originate from the RVOT just below the pul-
RVOT PA P
monary valve,12-15 a small number of cases of idiopathic Variables Group Group Value
VT/PVCs have been recently reported to have originated
from the PA.1-5 Several previous reports explained that PA- Amplitude (mV)
During SR 1.31 ± 0.50 0.64 ± 0.35 <0.01
VT/PVCs were rare entities and their prevalence was 4 ∼ During VT/PVC 1.42 ± 0.88 0.63 ± 0.39 <0.05
Duration (ms)
During SR 37 ± 7 71 ± 10 <0.01
During VT/PVC 49 ± 15 75 ± 19 <0.05
TABLE 1 Amplitude/Duration Ratio (mV/ms)
Comparison of the Clinical Characteristics Between the Groups During SR 0.029 ± 0.012 0.0085 ± 0.0036 <0.01
During VT/PVC 0.032 ± 0.021 0.0082 ± 0.0048 <0.01
Variables RVOT Group PA Group P Value Morphology During SR
Single electrogram 16 (84%) 1 (12.5%)
Age (year) 45.8 ± 15.3 44.6 ± 21.5 NS Multicomponent electrogram 3 (15%) 7 (87.5%) <0.01
Gender (M/F) 6/13 4/4 NS Morphology During VT/PVC
VT/PVC 9/10 3/5 NS Single electrogram 14 (73%) 0 (0%)
Multicomponent electrogram 5 (26%) 8 (100%) <0.01
PA = pulmonary artery; PVC = premature ventricular contraction;
RVOT = right ventricular outflow tract; VT = ventricular tachycardia. SR = sinus rhythm. The other abbreviations are as shown in Table 1.
168 Journal of Cardiovascular Electrophysiology Vol. 21, No. 2, February 2010

TABLE 3
Electrophysiological Characteristics of the Successful Ablation Sites in the PA Arrhythmia Cases
Maximal Output Component Pattern
Pacing Component Distance
Patient Location (9.9V/2.0 ms) SR VT/PVC Interval (ms) AT (ms) (mm)

1 PS Failure Dull/spiky Spiky/dull 36 −19 4

2 AS Captured Dull/spiky Spiky/dull 33 −28 4
3 MS Captured Dull/spiky Spiky/dull 34 −20 4
4 PS Failure Dull/spiky Spiky/dull 30 −39 4
5 PS Captured Dull/spiky Spiky/dull 40 −32 6
6 PF Captured Dull/spiky Spiky/dull 56 −40 8
7 AS Failure Dull/spiky Spiky/dull 45 −45 15
8 PS Captured (Dull)/spiky Spiky/dull 61 −42 15
AS = anterior-septal side; AT = activation time from the QRS onset of the VT or PVC; Component Pattern = Pattern of the sequence between the far-field
potential (dull potential) and near-field potential (spiky potential). Examples are shown in Figures 2 and 3. Component Interval = intercomponent time from
the onset of the dull potential to spiky potential during SR. Distance = distance from the pulmonary valve. MS = midseptal side; PF = posterior-free wall
side; PS = posterior-septal side. The other abbreviations are as shown in the prior tables.

pulmonary valve in consecutive patients who were treated
with catheter ablation.
Commonly, an ablation catheter is inserted into the RVOT
region antegradely. Therefore, the ablation effect from under
the pulmonary valve might affect the origin above the pul-
monary valve in some cases. It is suggested that some PA ar-
rhythmias have been inadvertently treated as RVOT arrhyth-
mias in previous studies. We believe that detailed PA mapping
should be considered when high-power energy or repeated
RFCA applications are needed to eliminate VT/PVCs below
the pulmonary valve. In the case of the PA mapping, careful
mapping must be performed because even high-output pac-
ing might not capture the optimal ablation site, which would
lead to difficulty in performing pace mapping.
It has been previously demonstrated that in animals dur-
ing the embryogenesis of the heart the distal part of the out-
flow tract loses its myocardial phenotype and becomes the
proximal part of the ascending aorta and pulmonary trunk.16
In contrast to the myocardium of the atrial and ventricular
chambers, this myocardium retains its embryonic features
(i.e., slow propagation of the depolarizing impulse owing to
the poor intercellular coupling of the cardiac muscle cells).
Myocardial regression in the outflow tract continues until af-
ter birth, as revealed by the disappearance of the myocardial
cuff surrounding the semilunar sinuses.16 Incomplete my-
ocardial regression might be the reason for the presence of
a myocardial sleeve in the main stem of the PA and the aor-
tic sinuses, which were connected to the rest of the related
ventricles. Recently, an anatomic study has shown that ven-
tricular myocardial extensions extend into the PA in humans.
The study demonstrated that ventricular myocardial exten-
sions into the PA were relatively common, with a prevalence
of 17% in patients without idiopathic VT/PVCs.17 These
anatomical studies suggested that the myocardial extensions
above the pulmonary valve might play an important role as
arrhythmogenic origins for PA-VT/PVCs.

Characteristics of the PA-VT/PVCs

Figure 4. Distribution of the successful ablation sites. PV = pulmonary
valve. The black dots indicate the ablation sites.
In the present study, there were no significant differences
between the RVOT group and PA group in terms of the age,
sex, form of arrhythmia, and ECG characteristics. One previ-
ous report demonstrated that PA arrhythmias were well rec-
ognized among young patients.3 However, Hasdemir et al.
revealed that no age or gender differences were observed in
the prevalence of ventricular myocardial extensions, which
might be an arrhythmogenic source of PA-VT/PVCs, into the
pulmonary artery.17 As for the 12-lead ECG characteristics,
1 previous report demonstrated that the R-wave amplitude in
the inferior ECG leads, aVL/aVR ratio of the Q-wave am-
plitude, and R/S ratio in lead V2 were statistically larger in
PA-VT/PVCs than RVOT-VT/PVCs.2 However, other previ-
ous reports demonstrated no specific ECG findings for PA-
VT/PVCs.1,3 It might be difficult to discriminate between
RVOT-VT/‘PVCs and PA-VT/PVCs using those ECG pa-
rameters because the RVOT and PA are a contiguous three-
dimensional tube-like structure.
On the other hand, some significant characteristics were
observed in the local electrogram at the successful ablation
 Yamashina et al.
sites in the PA group. The local ventricular bipolar elec-
trograms recorded at the successful ablation sites showed
a significantly lower amplitude and greater duration in the
PA group than those in the RVOT group. Most of the local
electrograms at the successful ablation sites in the RVOT
group exhibited a single component right ventricle electro-
gram (Fig. 1A). All patients in the PA group exhibited a
multicomponent electrogram composed of a dull potential
and spiky potential above the pulmonary valve (Figs. 2 and
3). These multicomponent electrograms in the PA group had
unique characteristics: (1) a spiky potential was seen after
a dull potential during SR (dull/spiky pattern), and the se-
quence was reversed during VT/PVCs (spiky/dull pattern);
(2) the spiky potential became diminished leaving a dull po-
tential after a successful ablation above the pulmonary valve
(Fig. 2); and (3) when the successful ablation sites were lo-
cated at more distant sites from the pulmonary valve, the
2 components were more separated (Table 3, Figs. 2 and
3). These findings indicate that a spiky potential recorded
above the pulmonary valve reflects the near-field activation
of the myocardial extension into the PA, and that the dull
potential reflects the far-field ventricular activation. Several
previous studies also demonstrated that tiny multicompo-
nent or discrete potentials recorded above the pulmonary
valve have consisted of PA potentials and far-field RV po-
tentials.1,3-5 They mentioned that mapping and direct ab-
lation of the PA potential were useful to eliminate the PA
arrhythmias.
Distribution of the Successful Ablation Sites of the
RVOT-VT/PVCs and PA-VT/PVCs
In the present study, most of the successful ablation sites
of the RVOT-VT/PVCs were located within 6 mm below the
pulmonary valve (73%), and most of the successful ablation
sites of the PA-VT/PVCs were located within 6 mm above the
pulmonary valve (62.5%). We speculated that this distribu-
tion pattern of the successful ablation sites suggested that the
possible origin of idiopathic right-sided outflow tract arrhyth-
mias, including both RVOT arrhythmias and PA arrhyth-
mias, often arise from active tissue around the pulmonary
valve.
Study Limitations
The study population in the present study was small. Fur-
ther evaluation is needed in a larger study population. In
addition, all patients in the present study were Japanese. We
could not analyze the relationship between the prevalence of
PA-VT/PVCs and genetic/ethnic differences. However, all
patients in the present study had no familial history of car-
diac sudden death, inherited cardiac diseases, or ventricular
arrhythmias.
Conclusions
PA arrhythmias may be more common than previ-
ously recognized. Careful mapping and interpretation of
low voltage and multicomponent potentials recorded above
the pulmonary valve are important so as not to over-
look any PA-VT/PVCs. It will contribute to the in-
Characteristics of Pulmonary Artery Arrhythmias 169
creased success rate of the RFCA and will help avoid
complications.
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