What is the typical origin location of Premature Ventricular Contractions (PVCs) in the heart?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: January 4, 2026 • View editorial policy

Personalize

Help us tailor your experience

Which best describes you? Your choice helps us use language that's most understandable for you.

PVC Origin Locations in the Heart

The right ventricular outflow tract (RVOT) is the most common site of origin for idiopathic PVCs in patients with structurally normal hearts, accounting for the majority of outflow tract arrhythmias. 1

Primary Anatomical Origins

Right Ventricular Outflow Tract (RVOT)

  • The RVOT represents the single most frequent origin site for idiopathic PVCs and ventricular tachycardia in structurally normal hearts. 1
  • RVOT PVCs typically demonstrate a left bundle branch block (LBBB) morphology with inferior axis and later R/S transition at V4 compared to left-sided origins. 1
  • These arrhythmias have acute ablation success rates exceeding 95% when performed by experienced operators. 1
  • RVOT PVCs can extend into the pulmonary artery sinuses, requiring mapping of these structures during electrophysiology studies. 1

Left Ventricular Outflow Tract (LVOT)

  • LVOT accounts for a substantial proportion of outflow tract PVCs, with distinct anatomical complexity involving the septal LVOT, membranous septum, and muscular lateral/anterior regions. 1
  • LVOT PVCs characteristically show inferior axis with early R/S transition at V1/V2 and either LBBB (70%) or right bundle branch block (RBBB) (30%) morphology. 1
  • The LV summit (epicardial region superior to the LVOT where coronary arteries course) represents a major source of idiopathic PVCs, with approximately 10% of idiopathic ventricular arrhythmias arising from this location. 1
  • LVOT origins require more complex mapping approaches and carry higher complication risks than RVOT ablations. 1

Aortic Cusps

  • Aortic cusp origins account for approximately 20% of idiopathic outflow tract ventricular arrhythmias. 1
  • The left coronary cusp is the most common site, followed by the right coronary cusp, the right/left cusp junction, and rarely the non-coronary cusp. 1
  • These PVCs typically demonstrate broad QRS complexes with early transition at V1-V2. 1

Secondary Origin Sites

Ventricular Septum

  • Left ventricular septal PVCs represent a distinct subset with ECG morphology similar to fascicular tachycardia but different electrophysiologic characteristics. 2
  • Approximately 70% of septal PVCs manifest as ventricular parasystole. 2
  • Successful ablation sites for septal PVCs do not demonstrate Purkinje potentials, suggesting a myocardial rather than fascicular substrate. 2

Papillary Muscles

  • Both left and right ventricular papillary muscles can serve as PVC origin sites in the presence or absence of structural heart disease. 1
  • These arrhythmias are typically exercise-related and may be induced by catecholamine infusion. 1
  • Any of the three RV papillary muscles may be involved, with successful ablation reducing PVC burden from 17±20% to 0.6±0.8%. 1

Mitral and Tricuspid Annuli

  • The mitral and tricuspid annuli represent less common but ablatable sites of idiopathic PVCs. 1
  • These locations require specialized mapping techniques for successful identification and treatment. 1

Peripheral Purkinje Network

  • Purkinje-origin PVCs account for approximately 81% of PVCs that trigger ventricular fibrillation, representing a high-risk subset. 3
  • Right Purkinje PVCs demonstrate LBBB with superior axis morphology, while left Purkinje PVCs show RBBB pattern. 3
  • These PVCs are characterized by significantly shorter QRS duration (126±18 ms) and coupling intervals (292±45 ms) compared to RVOT PVCs. 3

Anatomical Proximity and Mapping Challenges

  • The close anatomical proximity of the RVOT, LVOT, and great cardiac veins limits precise localization based solely on QRS morphology, except for classic RVOT tachycardia. 1
  • Precise localization requires activation mapping and/or pace mapping during electrophysiology studies, beginning systematically in the RVOT (including pulmonary artery), followed by great cardiac veins, aortic cusps, and endocardial LVOT. 1
  • When endocardial ablation at sites with early ventricular activation fails to eliminate the arrhythmia, epicardial mapping should be considered, particularly for LV summit origins. 1

Clinical Implications by Origin

Prognostic Differences

  • PVCs originating from the outflow tract demonstrate greater likelihood of left ventricular function recovery compared to ventricular origins (odds ratio 2.01,95% CI 1.15-10.75). 4
  • RVOT PVCs have shorter cycle lengths and higher association with syncope compared to LVOT arrhythmias. 1
  • The origin site does not determine overall success of arrhythmia elimination, with similar PVC reduction rates across locations (approximately 99% reduction). 4

Procedural Considerations

  • Ventricular (non-outflow tract) ablations require longer procedure times and may necessitate additional vascular access compared to outflow tract procedures. 4
  • LVOT ablation should only be performed in highly experienced centers after failure of at least one sodium channel blocker due to anatomical complexity and complication risks including myocardial rupture, stroke, valvular damage, and coronary artery injury. 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Related Questions

What is the best way to describe Premature Ventricular Contractions (PVCs) to a patient?
How do premature ventricular contractions (PVCs) affect pulse?
Can premature ventricular contractions (PVCs) become dangerous?
Can premature ventricular contractions (PVCs) cause chest heaviness?
What is the next best treatment plan for a 39-year-old female with a past medical history of palpitations and chest pain, whose echocardiogram shows an Ejection Fraction (EF) of 63% and an extended Holter monitor reveals sinus rhythm with rare Premature Atrial Contractions (PACs), Premature Ventricular Contractions (PVCs), and Non-Sustained Ventricular Tachycardia (NSVT) with no symptoms?
Is Acebrophylline (a bronchodilator) effective in treating Paroxysmal Supraventricular Tachycardia (PSVT)?
What is the proper method for writing a comprehensive medical problem list for a patient with multiple conditions, including hypertension, diabetes, and hyperlipidemia, and taking medications such as aspirin (acetylsalicylic acid)?
What is the most important diagnostic test for a diabetic patient with a well-demarcated plantar foot ulcer, nearly diminished sensation, and signs of healing with central erythema?
How to define the origin of a premature ventricular contraction (PVC) in a patient with a history of cardiac arrhythmias?
What is the role of alprostadil (prostaglandin E1) in a patient with chronic arterial occlusion of the upper limb, who has failed revascularization attempts, considering their overall vascular health and potential comorbid conditions such as vascular disease, diabetes, hypertension, or smoking?
How should a patient with severe hypertension take minoxidil?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question