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RVOT PVC ECG Localisation — EECC MCQ

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ModerateCardiac ImagingRVOT PVC ECG LocalisationEECC

A 30-year-old man with a structurally normal heart presents with palpitations. Holter shows frequent PVCs with an LBBB morphology and inferior axis. The PVCs have a characteristic R-wave transition at V3. Where is the most likely PVC origin?

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Correct answer: C — Right ventricular outflow tract (RVOT) — LBBB morphology (originating from the RV), inferior axis (superior origin pointing inferiorly), and transition at V3 are characteristic of RVOT PVCs; they are the most common idiopathic PVC type

PVC localisation uses ECG morphology: (1) Bundle branch morphology: LBBB = RV origin; RBBB = LV origin. (2) Axis: inferior axis (positive in II, III, aVF) = outflow tract origin (superior location → depolarisation travels inferiorly); superior axis (negative in inferior leads) = apical/inferior origin. (3) Precordial transition: RVOT PVCs typically transition at V3-V4; LVOT/aortic cusp PVCs transition earlier (V1-V2). This patient's PVCs (LBBB + inferior axis + V3 transition) are classic RVOT PVCs — the most common idiopathic PVC type (~70-80% of all idiopathic PVCs). RVOT PVCs arise from the subpulmonary region and are typically benign (no underlying structural disease), though high burden (>10-15%) can cause PVC-induced cardiomyopathy. Catheter ablation has >85-90% success rates for RVOT PVCs.

Reference: ESC (2022): VA/SCD Guidelines