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de Bakker JM. Electrogram recording and analyzing techniques to optimize selection of target sites for ablation of cardiac arrhythmias. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:1503-1516. [PMID: 31609005 PMCID: PMC6916598 DOI: 10.1111/pace.13817] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 10/03/2019] [Accepted: 10/09/2019] [Indexed: 12/27/2022]
Abstract
The extracellular electrogram is caused by transmembrane currents that flow into extracellular space during propagation of the electrical impulse. Electrograms are usually recorded in unipolar or bipolar mode that have different characteristics, but provide complementary information. Both recording modes have specific advantages, but also suffer from disadvantages. Techniques to circumvent some of the weaknesses are reviewed. The origin of remote and fractionated deflections and their relation with electrode characteristics are discussed. Epicardial and endocardial sites of origin and breakthrough sites as well as the effect of fatty tissue on extracellular electrograms are presented. Induction of tachycardia to assess the arrhythmogenic area is not always possible because of hemodynamic instability of the patient. Techniques to assess sites with high reentry vulnerability without induction of arrhythmias are outlined such as activation‐repolarization mapping and decremental stimulation. Pitfalls of substrate mapping and techniques to avoid them as omnipolar mapping and characterization of complex electrograms by entropy are presented. Technical aspects that influence electrogram morphology as electrode size, filtering, contact force, and catheter position are delineated. Data from the various publications suggest that a combination of unipolar and bipolar electrogram analysis techniques is helpful to optimize determination of target sites for ablation.
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Affiliation(s)
- Jacques Mt de Bakker
- Heart Center, Department of Experimental Cardiology, Academic Medical Center, Amsterdam, The Netherlands
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Mapping and Ablation of Unmappable Ventricular Tachycardia, Ventricular Tachycardia Storm, and Those in Acute Myocardial Infarction. Card Electrophysiol Clin 2019; 11:675-688. [PMID: 31706474 DOI: 10.1016/j.ccep.2019.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In stable ventricular tachycardia (VT), activation mapping and entrainment mapping are the most important strategies to describe the reentrant circuit and its critical components. In many patients, however, VT is noninducible or hemodynamically unstable and unmappable. Several technological advances have broadened ablation options in unmappable VTs. Preprocedural imaging and intraprocedural imaging play an important role in location and extent of the substrate. Electroanatomic mapping with several technological improvements allows more precise electrical assessment of the substrate. A combination of imaging and electroanatomic mapping allows substantial modification of arrhythmogenic substrate in sinus rhythm or during device pacing without hemodynamic compromise.
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Electroanatomical Mapping at a Crossroads. JACC Clin Electrophysiol 2019; 5:1168-1171. [DOI: 10.1016/j.jacep.2019.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 07/18/2019] [Indexed: 11/17/2022]
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Baldinger SH, Kumar S, Fujii A, Haeberlin A, Romero J, Epstein LM, Michaud GF, Tedrow UB, John R, Stevenson WG. Substrate mapping for scar-related ventricular tachycardia in patients with resynchronization therapy-the importance of the pacing mode. J Interv Card Electrophysiol 2019; 55:55-62. [PMID: 31020468 DOI: 10.1007/s10840-019-00548-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2018] [Accepted: 04/03/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE Targets for substrate-based catheter ablation of scar-related ventricular tachycardia (VT) include sites with fractionated and late potentials (LPs). We hypothesized that in patients with cardiac resynchronization therapy (CRT), the pacing mode may influence the timing of abnormal electrograms (EGMs) relative to the surface QRS complex. METHODS We assessed bipolar EGM characteristics in left ventricular low bipolar voltage areas (< 1.5 mV) from 10 patients with coronary disease and a CRT device undergoing catheter ablation for VT. EGMs at 81 sites were analyzed during three different pacing modes (biventricular (BiV), right ventricular (RV)-only, and left ventricular (LV)-only) pacing. RESULTS Stimulus to end of local electrogram duration (Stim-to-eEGM) depended significantly on the stimulation site (BiV, LV, or RV, p = 0.032). Single-chamber pacing unmasked LPs, not present during BiV pacing, in three patients. In another three patients, a concomitant increase in stimulus to end of surface QRS duration caused by single-site pacing compensated for the increase in Stim-to-eEGM duration, thereby prohibiting LP unmasking. CONCLUSION The sequence of ventricular activation, as determined by the pacing site in patients with CRT devices, has a major influence on the detection of late potentials during substrate-guided ablation. Further study is warranted to define the optimal approaches, including the rhythm, for substrate mapping, but our findings suggest that BiV pacing may be most likely to obscure detection of late potentials as compared to single-site pacing.
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Affiliation(s)
- Samuel H Baldinger
- Cardiac Arrhythmia Center, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA.,Department of Cardiology, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Saurabh Kumar
- Cardiac Arrhythmia Center, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Akira Fujii
- Cardiac Arrhythmia Center, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Andreas Haeberlin
- Department of Cardiology, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Jorge Romero
- Cardiac Arrhythmia Center, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Laurence M Epstein
- Cardiac Arrhythmia Center, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Gregory F Michaud
- Cardiac Arrhythmia Center, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA.,Division of Cardiology, Vanderbilt University Medical Center, 2220 Pierce Avenue, Nashville, TN, 37232-6300, USA
| | - Usha B Tedrow
- Cardiac Arrhythmia Center, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Roy John
- Cardiac Arrhythmia Center, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA.,Division of Cardiology, Vanderbilt University Medical Center, 2220 Pierce Avenue, Nashville, TN, 37232-6300, USA
| | - William G Stevenson
- Cardiac Arrhythmia Center, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA. .,Division of Cardiology, Vanderbilt University Medical Center, 2220 Pierce Avenue, Nashville, TN, 37232-6300, USA.
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Nayyar S, Downar E, Beheshti M, Liang T, Massé S, Magtibay K, Bhaskaran A, Saeed Y, Vigmond E, Nanthakumar K. Information theory to tachycardia therapy: electrogram entropy predicts diastolic microstructure of reentrant ventricular tachycardia. Am J Physiol Heart Circ Physiol 2019; 316:H134-H144. [DOI: 10.1152/ajpheart.00581.2018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
There is no known strategy to differentiate which multicomponent electrograms in sinus rhythm maintain reentrant ventricular tachycardia (VT). Low entropy in the voltage breakdown of a multicomponent electrogram can localize conditions suitable for reentry but has not been validated against the classic VT activation mapping. We examined whether low entropy in a late and diversely activated ventricular scar region characterizes and differentiates the diastolic path of VT and represents protected tissue channels devoid of side branches. Intraoperative bipolar electrogram (BiEGM) activation and entropy maps were obtained during sinus rhythm in 17 patients with ischemic cardiomyopathy and compared with diastolic activation paths of VT (total of 39 VTs). Mathematical modeling of a zigzag main channel with side branches was also used to further validate structural representation of low entropy in the ventricular scar. A median of one region per patient (range: 1–2 regions) was identified in sinus rhythm, in which BiEGMwith the latest mean activation time and adjacent minimum entropy were assembled together in a high-activation dispersion region. These regions accurately recognized diastolic paths of 34 VTs, often to multiple inducible VTs within a single individual arrhythmogenic region. In mathematical modeling, side branching from the main channel had a strong influence on the BiEGMcomposition along the main channel. The BiEGMobtained from a long unbranched channel had the lowest entropy compared with those with multiple side branches. In conclusion, among a population of multicomponent sinus electrograms, those that demonstrate low entropy and are delayed colocalize to critical long-protected channels of VT. This information is pertinent for planning VT ablation in sinus rhythm.NEW & NOTEWORTHY Entropy is a measure to quantify breakdown in information. Electrograms from a protected tissue channel can only possess a few states in their voltage and thus less information. In contrast, current-load interactions from side branches in unprotected channels introduce a number of dissimilar voltage deflections and thus high information. We compare here a mapping approach based on entropy against a rigorous reference standard of activation mapping during VT and entropy was assessed in sinus rhythm.
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Affiliation(s)
- Sachin Nayyar
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada
| | - Eugene Downar
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada
| | - Mohammadali Beheshti
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada
| | - Timothy Liang
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada
| | - Stéphane Massé
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada
| | - Karl Magtibay
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada
| | - Abhishek Bhaskaran
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada
| | - Yawer Saeed
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada
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Nayyar S, Kuklik P, Tomlinson G, Suszko A, Chauhan VS. Differential pacing from two sites to diagnose risk of ventricular arrhythmia and death. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 42:189-200. [PMID: 30515873 DOI: 10.1111/pace.13566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 11/25/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND QRS abnormalities may not be apparent in sinus rhythm in electrically stable cardiomyopathy patients who can have quiescent but highly arrhythmogenic substrate. Here, we test the hypothesis that differential changes in QRS construction during right-ventricular apex pacing (RVP) as opposed to atrial pacing (AP) will identify latent substrate for ventricular arrhythmias (VA) and death. METHODS Forty patients with cardiomyopathy free of VA underwent baseline 114-electrode body-surface electrocardiogram during AP (100 beats per minute [bpm]) and RVP (100 and 120 bpm). The filtered-averaged QRS at each electrode was deconstructed into individual intra-QRS and post-QRS ventricular myopotentials (VMP ). The primary outcome was VA or death. Prognostic accuracy of VMP was validated using V1 to V6 leads in another prospective cohort of 44-cardiomyopathy patients. RESULTS Twenty-six patients were eligible for initial analysis. After 5 ± 2 years of follow-up, eight (31%) patients had VA (VAPos ) while rest were uneventful (VANeg ). During AP100 , VAPos patients expressed more VMP than VANeg patients (16 ± 1 vs 12 ± 1, P = 0.02). RVP100 and RVP120 in VAPos patients introduced an additional 5.5 ± 0.5 and 6.0 ± 0.5 VMP (P < 0.0001 vs AP100 ). The relative change with RVP120 versus AP100 in VANeg patients exceeded VAPos patients by 1.2 ± 0.5 VMP (P = 0.03). Increment in VMP count of <8 in lead-V5 with RVP120 compared to AP100 best predicted VA (area under curve 0.81, P = 0.01). In the validation cohort, primary outcome occurred in 13 (33%) patients. Native QRS features and AP100 alone failed to predict primary outcome. Patients with increment in VMP count of <8 in lead-V5 with RVP120 versus AP100 had 7.9-fold increased risk of primary outcome (95% confidence interval 1.01, 61.61; P = 0.049). CONCLUSION Cardiomyopathy patients at risk of VA or death perturb the QRS less than low-risk patients with differential pacing. This functional response may be useful to identify arrhythmogenic substrate.
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Affiliation(s)
- Sachin Nayyar
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Pawel Kuklik
- Department of Cardiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - George Tomlinson
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Adrian Suszko
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Vijay S Chauhan
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
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Acosta J, Andreu D, Penela D, Cabrera M, Carlosena A, Korshunov V, Vassanelli F, Borras R, Martínez M, Fernández-Armenta J, Linhart M, Tolosana JM, Mont L, Berruezo A. Elucidation of hidden slow conduction by double ventricular extrastimuli: a method for further arrhythmic substrate identification in ventricular tachycardia ablation procedures. Europace 2018; 20:337-346. [PMID: 28017938 DOI: 10.1093/europace/euw325] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 09/21/2016] [Indexed: 11/12/2022] Open
Abstract
Aims Identification of local abnormal electrograms (EGMs) during ventricular tachycardia substrate ablation (VTSA) is challenging when they are hidden within the far-field signal. This study analyses whether the response to a double ventricular extrastimulus during substrate mapping could identify slow conducting areas that are hidden during sinus rhythm. Methods and results Consecutive patients (n = 37) undergoing VTSA were prospectively included. Bipolar EGMs with >3 deflections and duration <133 ms were considered as potential hidden slow conduction EGMs (HSC-EGM) if located within/surrounding the scar area. Whenever a potential HSC-EGM was identified, a double ventricular extrastimulus was delivered. If the local potential delayed, it was annotated as HSC-EGM. The incidence of HSC-EGM in core, border-zone, and normal-voltage regions was determined. Ablation was delivered at conducting channel entrances and HSC-EGMs. VT inducibility after VTSA obtained was compared with data from a historic control group. 2417 EGMs were analyzed. 575 (23.7%) qualified as potential HSC-EGM, and 198 of them were tagged as HSC-EGMs. Scars in patients with HSC-EGMs (n = 21, 56.7%) were smaller (35.424.7 vs 67.639.1 cm2; P = 0.006) and more heterogeneous (core/scar area ratio 0.250.2 vs 0.450.19; P = 0.02). 28.8% of HSC-EGMs were located in normal-voltage tissue; 81.3% were targeted for ablation. Patients undergoing VTSA incorporating HSC analysis needed less radiofrequency time (17.411 vs 2310.7 minutes; P = 0.016) and had a lower rate of VT inducibility after VTSA than the historic controls (24.3% vs 50%; P = 0.018). Conclusion Ventricular tachycardia substrate ablation incorporating HSC analysis allowed further arrhythmic substrate identification (especially in normal-voltage areas) and reduced RF time and VT inducibility after VTSA.
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Affiliation(s)
- Juan Acosta
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), C/Villarroel 170, 08036 Barcelona, Catalonia, Spain
| | - David Andreu
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), C/Villarroel 170, 08036 Barcelona, Catalonia, Spain
| | - Diego Penela
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), C/Villarroel 170, 08036 Barcelona, Catalonia, Spain
| | - Mario Cabrera
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), C/Villarroel 170, 08036 Barcelona, Catalonia, Spain
| | - Alicia Carlosena
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), C/Villarroel 170, 08036 Barcelona, Catalonia, Spain
| | - Viatcheslav Korshunov
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), C/Villarroel 170, 08036 Barcelona, Catalonia, Spain
| | - Francesca Vassanelli
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), C/Villarroel 170, 08036 Barcelona, Catalonia, Spain
| | - Roger Borras
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), C/Villarroel 170, 08036 Barcelona, Catalonia, Spain
| | - Mikel Martínez
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), C/Villarroel 170, 08036 Barcelona, Catalonia, Spain
| | - Juan Fernández-Armenta
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), C/Villarroel 170, 08036 Barcelona, Catalonia, Spain
| | - Markus Linhart
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), C/Villarroel 170, 08036 Barcelona, Catalonia, Spain
| | - José M Tolosana
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), C/Villarroel 170, 08036 Barcelona, Catalonia, Spain
| | - Lluis Mont
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), C/Villarroel 170, 08036 Barcelona, Catalonia, Spain
| | - Antonio Berruezo
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), C/Villarroel 170, 08036 Barcelona, Catalonia, Spain
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Shariat MH, Gupta D, Gul EE, Glover B, Hashemi J, Abdollah H, Baranchuk A, Simpson C, Michael KA, Redfearn DP. Ventricular substrate identification using close-coupled paced electrogram feature analysis. Europace 2018; 21:492-501. [DOI: 10.1093/europace/euy265] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 10/15/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Mohammad Hassan Shariat
- Heart Rhythm Service, Queen’s University, Armstrong 3, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, Ontario, Canada
| | - Divyanshu Gupta
- Heart Rhythm Service, Queen’s University, Armstrong 3, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, Ontario, Canada
| | - Enes E Gul
- Heart Rhythm Service, Queen’s University, Armstrong 3, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, Ontario, Canada
| | - Benedict Glover
- Heart Rhythm Service, Queen’s University, Armstrong 3, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, Ontario, Canada
| | - Javad Hashemi
- Heart Rhythm Service, Queen’s University, Armstrong 3, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, Ontario, Canada
| | - Hoshiar Abdollah
- Heart Rhythm Service, Queen’s University, Armstrong 3, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, Ontario, Canada
| | - Adrian Baranchuk
- Heart Rhythm Service, Queen’s University, Armstrong 3, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, Ontario, Canada
| | - Christopher Simpson
- Heart Rhythm Service, Queen’s University, Armstrong 3, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, Ontario, Canada
| | - Kevin A Michael
- Heart Rhythm Service, Queen’s University, Armstrong 3, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, Ontario, Canada
| | - Damian P Redfearn
- Heart Rhythm Service, Queen’s University, Armstrong 3, Kingston Health Sciences Centre, 76 Stuart Street, Kingston, Ontario, Canada
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Anter E, Kleber AG, Rottmann M, Leshem E, Barkagan M, Tschabrunn CM, Contreras-Valdes FM, Buxton AE. Infarct-Related Ventricular Tachycardia. JACC Clin Electrophysiol 2018; 4:1033-1048. [DOI: 10.1016/j.jacep.2018.04.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 04/19/2018] [Accepted: 04/26/2018] [Indexed: 10/28/2022]
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Ene E, Halbfaß P, Nentwich K, Sonne K, Berkovitz A, Wolf AK, Deneke T. [Epicardial VT ablation : In whom, when, how and why?]. Herzschrittmacherther Elektrophysiol 2018; 29:300-306. [PMID: 29946891 DOI: 10.1007/s00399-018-0578-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 06/08/2018] [Indexed: 11/26/2022]
Abstract
Ventricular tachycardia (VT) is a leading cause of cardiovascular death and remains the main cause of sudden cardiac death. Implanted cardiac defibrillators (ICD) improve survival but the recurrent ICD therapies, mostly ICD shocks, are associated with an increased mortality and deleterious psychological effects. In this regard and based on the results of multicenter studies, the current European guidelines recommend early referral for catheter ablation. The ablation strategy (isolated endocardial approach or combined epi-/endocardial) depends mostly on the underlying myocardial disease. Thus, almost all patients with right ventricular dysplasia and Chagas disease, the majority of those with dilative cardiomyopathy, and some patients with ischemic cardiomyopathy (mostly posterior wall infarction or large transmural anterior wall infarction) have an epicardial scar as the underlying substrate for recurrent VT episodes. Thus, in this group of patients, isolated endocardial VT ablation may be associated with an increased VT recurrence and therefore an epicardial approach is also needed. Cardiac imaging (cardio-CT/MRI with late enhancement[MRI LE]) can reliably identify the distribution and characteristics of the myocardial scar and may be helpful in planning the ablation strategy. When performed in highly specialized centers, epicardial catheter ablation of VT leads to a significant reduction of recurrent VT episodes compared to the endocardial VT ablation alone and with lower complication rates.
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Affiliation(s)
- E Ene
- Klinik für interventionelle Elektrophysiologie, Herz- und Gefäß-Klinik GmbH Bad Neustadt, Salzburger Leite 1, 97616, Bad Neustadt a. d. Saale, Deutschland
| | - P Halbfaß
- Klinik für interventionelle Elektrophysiologie, Herz- und Gefäß-Klinik GmbH Bad Neustadt, Salzburger Leite 1, 97616, Bad Neustadt a. d. Saale, Deutschland
| | - K Nentwich
- Klinik für interventionelle Elektrophysiologie, Herz- und Gefäß-Klinik GmbH Bad Neustadt, Salzburger Leite 1, 97616, Bad Neustadt a. d. Saale, Deutschland
| | - K Sonne
- Klinik für interventionelle Elektrophysiologie, Herz- und Gefäß-Klinik GmbH Bad Neustadt, Salzburger Leite 1, 97616, Bad Neustadt a. d. Saale, Deutschland
| | - A Berkovitz
- Klinik für interventionelle Elektrophysiologie, Herz- und Gefäß-Klinik GmbH Bad Neustadt, Salzburger Leite 1, 97616, Bad Neustadt a. d. Saale, Deutschland
- Sacre-Coeur Krankenhaus, Montreal, Kanada
| | - A-K Wolf
- Klinik für interventionelle Elektrophysiologie, Herz- und Gefäß-Klinik GmbH Bad Neustadt, Salzburger Leite 1, 97616, Bad Neustadt a. d. Saale, Deutschland
| | - T Deneke
- Klinik für interventionelle Elektrophysiologie, Herz- und Gefäß-Klinik GmbH Bad Neustadt, Salzburger Leite 1, 97616, Bad Neustadt a. d. Saale, Deutschland.
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Williams SE, Linton NWF, Niederer S, O'Neill MD. Simultaneous display of multiple three-dimensional electrophysiological datasets (dot mapping). Europace 2018; 19:1743-1749. [PMID: 27702855 PMCID: PMC5834094 DOI: 10.1093/europace/euw190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 05/30/2016] [Indexed: 11/14/2022] Open
Abstract
Aims Complex ablation procedures are supported by accurate representation of an increasing variety of electrophysiological and imaging data within electroanatomic mapping systems (EMS). This study aims to develop a novel method for representing multiple complementary datasets on a single cardiac chamber model. Validation of the system and its application to both atrial and ventricular arrhythmias is examined. Methods and results Dot mapping was conceived to display multiple datasets by utilizing quantitative surface shading to represent one dataset and finely spaced dots to represent others. Dot positions are randomized within triangular (surface meshes) or tetrahedral (volumetric meshes) simplices making the approach directly transferrable to contemporary EMS. Test data representing uniform electrical activation (n = 10) and focal scarring (n = 10) were used to test dot mapping data perception accuracy. User experience of dot mapping with atrial and ventricular clinical data is evaluated. Dot mapping ensured constant screen dot density for regions of uniform dataset values, regardless of user manipulation of the cardiac chamber. Perception accuracy of dot mapping was equivalent to colour mapping for both propagation direction (1.5 ± 1.8 vs. 4.8 ± 5.3°, P = 0.24) and focal source localization (1.1 ± 0.7 vs. 1.4 ± 0.5 mm, P = 0.88). User acceptance testing revealed equivalent diagnostic accuracy and display fidelity when compared with colour mapping. Conclusion Dot mapping provides the unique ability to display multiple datasets from multiple sources on a single cardiac chamber model. The visual combination of multiple datasets may facilitate interpretation of complex electrophysiological and imaging data.
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Affiliation(s)
- Steven E Williams
- Division of Imaging Sciences and Biomedical Imaging, King's College London, 4th Floor, North Wing, St. Thomas' Hospital, 249 Westminster Bridge Road, London SE1 7EH, UK
| | - Nick W F Linton
- Division of Imaging Sciences and Biomedical Imaging, King's College London, 4th Floor, North Wing, St. Thomas' Hospital, 249 Westminster Bridge Road, London SE1 7EH, UK
| | - Steven Niederer
- Division of Imaging Sciences and Biomedical Imaging, King's College London, 4th Floor, North Wing, St. Thomas' Hospital, 249 Westminster Bridge Road, London SE1 7EH, UK
| | - Mark D O'Neill
- Division of Imaging Sciences and Biomedical Imaging, King's College London, 4th Floor, North Wing, St. Thomas' Hospital, 249 Westminster Bridge Road, London SE1 7EH, UK
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Quantifying the determinants of decremental response in critical ventricular tachycardia substrate. Comput Biol Med 2018; 102:260-266. [PMID: 29871758 DOI: 10.1016/j.compbiomed.2018.05.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 05/26/2018] [Accepted: 05/26/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Decremental response evoked with extrastimulation (DEEP) is a useful tool for determining diastolic return path of ventricular tachycardia (VT). Though a targeted VT ablation is feasible with this approach, determinants of DEEP response have not been studied OBJECTIVES: To elucidate the effects of clinically relevant factors, specifically, the proximity of the stimulation site to the arrhythmogenic scar, stimulation wave direction, number of channels open in the scar, size of the scar and number of extra stimuli on decrement and entropy of DEEP potentials. METHODS In a 3-dimensional bi-domain simulation of human ventricular tissue (TNNP cell model), an irregular subendocardial myopathic region was generated. An irregular channel of healthy tissue with five potential entry branches was shaped into the myopathic region. A bipolar electrogram was derived from two electrodes positioned in the centre of the myopathic region. Evoked delays between far-field and local Electrogram (EGM) following an extrastimulus (S1-S2, 500-350 ms) were measured as the stimulation site, channel branches, and inexcitable tissue size were altered. RESULTS Stimulation adjacent to the inexcitable tissue from the side opposite to the point-of-entry produces longest DEEP delay. The DEEP delay shortens when the stimulation point is farther away from the scar, and it decreases maximally when stimulation is done from a site beside a conduction barrier. Entropy increases with S2 when stimulation site is from farther away. An unprotected channel structure with multiple side-branch openings had shorter DEEP delay compared to a protected channel structure with a paucity of additional side-branch openings and a point-of-entry on the side opposite to the pacing source. Addition of a second shorter extrastimulus did not universally lead to higher DEEP delay CONCLUSIONS: Location and direction of the wavefront in relation to scar entry and size of scar determine the degree of evoked response while the number of extrastimuli has a small additional decremental effect.
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Aziz Z, Tung R. Novel Mapping Strategies for Ventricular Tachycardia Ablation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:34. [PMID: 29572643 DOI: 10.1007/s11936-018-0615-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Despite advances in antiarrhythmic and device therapy, ventricular tachycardia (VT) continues to be a major cause of increased morbidity and mortality. During scar-mediated monomorphic ventricular tachycardia ablation, the search for critical isthmus sites continues to be the primary goal during successful ablative procedures. However, given the overwhelming hemodynamic instability of most ventricular arrhythmias (> 70%), VT ablation is increasingly performed during sinus rhythm. This technique requires either a greater reliance on isthmus surrogates, or more extensive ablation techniques and is a more probabilistic approach to substrate modification. We believe that a better understanding of scar physiology and activation during sinus rhythm has important implications for clinical workflow and mechanistic improvements with current ablation strategies. With advancements in high-density mapping and multi-electrode catheter technology, mapping of VT substrates is performed with higher resolution, with improved visualization of local abnormal ventricular activities (LAVA), and with a more nuanced functional understanding of late potentials. As a prerequisite, our practice for VT ablation starts with a high-density structural map to identify voltage abnormalities as well as an isochronal functional map of sinus rhythm activation to identify region of discontinuous wavefront propagation. As the era of increased automation has emerged, there continues to be vast array of customizable features, and we have adopted the use of multiple wavefront mapping to further elucidate possible arrhythmogenic substrate. Our emerging understanding of how scar propagation patterns relate to areas of abnormal signals and critical isthmuses may greatly improve the ability to identify surrogates during sinus rhythm and help localize the most arrhythmogenic regions within a given scar. In the hemodynamically unstable patients, we routinely integrate isochronal late activation mapping (ILAM) to identify areas of slow conduction to initiate our targeted ablation and substrate modification. Multi-electrode delineation of the entire reentrant VT circuit has value in understanding the size of the circuit, rotational nature, and transmural extent of human reentry. Correlative studies between the activation of the complete VT circuit and sinus rhythm are likely to provide important mechanistic insights on where fixed and/or functional block occurs within a complex scar substrate.
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Affiliation(s)
- Zaid Aziz
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, 5841 S. Maryland Ave. MC 6080, Chicago, IL, 60637, USA
| | - Roderick Tung
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, 5841 S. Maryland Ave. MC 6080, Chicago, IL, 60637, USA.
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Porta-Sánchez A, Jackson N, Lukac P, Kristiansen SB, Nielsen JM, Gizurarson S, Massé S, Labos C, Viswanathan K, King B, Ha AC, Downar E, Nanthakumar K. Multicenter Study of Ischemic Ventricular Tachycardia Ablation With Decrement-Evoked Potential (DEEP) Mapping With Extra Stimulus. JACC Clin Electrophysiol 2018; 4:307-315. [DOI: 10.1016/j.jacep.2017.12.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 12/07/2017] [Accepted: 12/11/2017] [Indexed: 10/18/2022]
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65
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Martin CA, Sacher F. Extra-Stimulus Pacing. JACC Clin Electrophysiol 2018; 4:328-330. [DOI: 10.1016/j.jacep.2018.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 02/09/2018] [Indexed: 11/25/2022]
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Targeting the Hidden Substrate Unmasked by Right Ventricular Extrastimulation Improves Ventricular Tachycardia Ablation Outcome After Myocardial Infarction. JACC Clin Electrophysiol 2018; 4:316-327. [DOI: 10.1016/j.jacep.2018.01.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/28/2018] [Accepted: 01/29/2018] [Indexed: 11/24/2022]
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Chung FP, Lin CY, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Chao TF, Liao JN, Chang TY, Chen SA. Catheter Ablation of Ventricular Tachycardia in Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy. Korean Circ J 2018; 48:890-905. [PMID: 30238706 PMCID: PMC6158456 DOI: 10.4070/kcj.2018.0268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 09/11/2018] [Accepted: 09/12/2018] [Indexed: 12/14/2022] Open
Abstract
Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is predominantly an inherited cardiomyopathy with typical histopathological characteristics of fibro-fatty infiltration mainly involving the right ventricular (RV) inflow tract, RV outflow tract, and RV apex in the majority of patients. The above pathologic evolution frequently brings patients with ARVD/C to medical attention owing to the manifestation of syncope, sudden cardiac death (SCD), ventricular arrhythmogenesis, or heart failure. To prevent future or recurrent SCD, an implantable cardiac defibrillator (ICD) is highly desirable in patients with ARVD/C who had experienced unexplained syncope, hemodynamically intolerable ventricular tachycardia (VT), ventricular fibrillation, and/or aborted SCD. Notably, the management of frequent ventricular tachyarrhythmias in ARVD/C is challenging, and the use of antiarrhythmic drugs could be unsatisfactory or limited by the unfavorable side effects. Therefore, radiofrequency catheter ablation (RFCA) has been implemented to treat the drug-refractory VT in ARVD/C for decades. However, the initial understanding of the link between fibro-fatty pathogenesis and ventricular arrhythmogenesis in ARVD/C is scarce, the efficacy and prognosis of endocardial RFCA alone were limited and disappointing. The electrophysiologists had broken through this frontier after better illustration of epicardial substrates and broadly application of epicardial approaches in ARVD/C. In recent works of literature, the application of epicardial ablation also successfully results in higher procedural success and decreases VT recurrences in patients with ARVD/C who are refractory to the endocardial approach during long-term follow-up. In this article, we review the important evolution on the delineation of arrhythmogenic substrates, ablation strategies, and ablation outcome of VT in patients with ARVD/C.
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Affiliation(s)
- Fa Po Chung
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Chin Yu Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.,Department of Internal Medicine, Taipei Veterans General Hospital, Yuan-Shan Branch, I-LAN, Taiwan
| | - Yenn Jiang Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Shih Lin Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Li Wei Lo
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Yu Feng Hu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Ta Chuan Tuan
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Tze Fan Chao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Jo Nan Liao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Ting Yung Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Shih Ann Chen
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.
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Kumar S, Baldinger SH, Romero J, Fujii A, Mahida SN, Tedrow UB, Stevenson WG. Substrate-Based Ablation Versus Ablation Guided by Activation and Entrainment Mapping for Ventricular Tachycardia: A Systematic Review and Meta-Analysis. J Cardiovasc Electrophysiol 2016; 27:1437-1447. [PMID: 27574120 DOI: 10.1111/jce.13088] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 08/04/2016] [Accepted: 08/23/2016] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Substrate-based ablation for scar-related ventricular tachycardia (VT) has gained prominence: however, there is limited data comparing it to ablation guided predominantly by activation and entrainment mapping of inducible and hemodynamically tolerated VTs. We compared the acute procedural efficacy and outcomes of predominantly substrate-based ablation versus ablation guided predominantly by activation and entrainment mapping. METHODS AND RESULTS Database searches through April 2016 identified 6 eligible studies (enrolling 403 patients, with 1 randomized study) comparing the 2 strategies. The relative risk of VT recurrence at follow-up was assessed as the primary outcome using a random-effects meta-analysis. Secondary endpoints of acute success (based on noninducibility of VT), procedural complications, and mortality were assessed using weighted mean difference with the random effects model. At a median follow-up of 18 months, the relative risk (RR) of VT recurrence was not significantly different with substrate-based versus activation/entrainment guided VT ablation (0.72, 95% confidence interval [CI] 0.44-1.18), P = 0.2). Acute success (RR 1.02, 95% CI 0.95-1.1, P = 0.6), procedural complications (RR 0.8, 95% CI 0.35-1.82, P = 0.5) cardiovascular mortality and total mortality did not differ significantly (RR 0.83, 95% CI 0.38-1.79, P = 0.6 and RR 0.76, 95% CI 0.36-1.59, P = 0.5, respectively). CONCLUSIONS This meta-analysis demonstrates similar acute procedural efficacy, and complications, VT recurrence and mortality rates when comparing a predominantly substrate-based ablation strategy to a strategy guided predominantly by activation and entrainment mapping of inducible and hemodynamically tolerated VTs.
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Affiliation(s)
- Saurabh Kumar
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Jorge Romero
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Akira Fujii
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Saagar N Mahida
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Usha B Tedrow
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - William G Stevenson
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Gupta D, Shariat MH, Baetz-Dougan M, Hashemi J, Akl S, Redfearn D. Novel Automated Paced Fractionation Detection Algorithm for Ablating Ventricular Tachycardia. ACTA ACUST UNITED AC 2016. [DOI: 10.4236/jbise.2016.910044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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