Elucidation of the spatial ventricular gradient and its link with dispersion of repolarization

The ventricular gradient, a notion conceived by Wilson et al during the 1930s, has contributed considerably to a better understanding of the ECG manifestations of the cardiac repolarization process. The power of the ventricular gradient is its ability to assess the primary factors that contribute to the T wave (i.e., heterogeneity of action potential morphology throughout the ventricles) in the presence of secondary factors contributing to the T wave (i.e., heterogeneity in ventricular depolarization instants). Where T-wave morphology is an ECG expression of heterogeneity of the repolarization, the ventricular gradient discriminates between primary or secondary causes of such heterogeneity. Besides the spatial ventricular gradient (Burger’s three-dimensional elaboration of Wilson’s two-dimensional concept), body surface mapping of local components of the ventricular gradient has emerged as a technique for assessing local ventricular action potential duration heterogeneity. The latter is believed to contribute to localization of arrhythmogenic areas in the heart. The spatial ventricular gradient, which can be computed on the basis of a regular routine ECG and does not require body surface mapping, aims to assess the overall heterogeneity of ventricular action potential morphology. This review addresses the nature and diagnostic potential of the spatial ventricular gradient. The main focus is the role of the spatial ventricular gradient in ECG assessment of dispersion of repolarization, a key factor in arrhythmogeneity.