ECG Case 1: Can you identify the origin of arrhythmia?

Welcome to a series of ECG Learning videos. This ECG Case is of a person referred for ablation of the arrhythmia, identify the site of abnormal looking beats. Answer will be explained in the second half of the video.

Answer: Ventricular Bigeminy - origin is Infero-Apical LV

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Key points to identify origin of PVC on ECG:

1. QRS Morphology
LBBB-like pattern (negative in V1): suggests right ventricular (RV) origin
RBBB-like pattern (positive in V1): suggests left ventricular (LV) origin

2. Frontal Plane Axis (Lead I and aVF)
Inferior axis (positive in II, III, aVF): origin high in ventricles (e.g., outflow tracts)
Superior axis (negative in II, III, aVF): origin low in ventricles (e.g., apex)

3. Precordial Transition (V1–V6)
Early transition (before or in V3): posterior or lateral origin
Late transition (after V4): anterior or septal origin

4. Outflow Tract PVCs
RVOT PVCs: LBBB morphology + inferior axis
LVOT PVCs: RBBB morphology + inferior axis

if R to S ratio in lead V2 is less than 1 its RVOT, if more than 1 its LVOT.

5. Specific Leads for Localization

Lead I:
Negative = LV free wall origin
Positive = RV or septal origin


6. Coupling Interval
Fixed coupling: likely reentrant
Variable coupling: likely automatic

7. Clinical Correlation
Exercise-induced PVCs: often RVOT
In structural heart disease: more likely LV origin

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