1
|
Clayton RH, Sridhar S. Re-entry in models of cardiac ventricular tissue with scar represented as a Gaussian random field. Front Physiol 2024; 15:1403545. [PMID: 39005500 PMCID: PMC11239552 DOI: 10.3389/fphys.2024.1403545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 06/10/2024] [Indexed: 07/16/2024] Open
Abstract
Introduction: Fibrotic scar in the heart is known to act as a substrate for arrhythmias. Regions of fibrotic scar are associated with slowed or blocked conduction of the action potential, but the detailed mechanisms of arrhythmia formation are not well characterised and this can limit the effective diagnosis and treatment of scar in patients. The aim of this computational study was to evaluate different representations of fibrotic scar in models of 2D 10 × 10 cm ventricular tissue, where the region of scar was defined by sampling a Gaussian random field with an adjustable length scale of between 1.25 and 10.0 mm. Methods: Cellular electrophysiology was represented by the Ten Tusscher 2006 model for human ventricular cells. Fibrotic scar was represented as a spatially varying diffusion, with different models of the boundary between normal and fibrotic tissue. Dispersion of activation time and action potential duration (APD) dispersion was assessed in each sample by pacing at an S1 cycle length of 400 ms followed by a premature S2 beat with a coupling interval of 323 ms. Vulnerability to reentry was assessed with an aggressive pacing protocol. In all models, simulated fibrosis acted to delay activation, to increase the dispersion of APD, and to generate re-entry. Results: A higher incidence of re-entry was observed in models with simulated fibrotic scar at shorter length scale, but the type of model used to represent fibrotic scar had a much bigger influence on the incidence of reentry. Discussion: This study shows that in computational models of fibrotic scar the effects that lead to either block or propagation of the action potential are strongly influenced by the way that fibrotic scar is represented in the model, and so the results of computational studies involving fibrotic scar should be interpreted carefully.
Collapse
Affiliation(s)
- Richard H Clayton
- Insigneo Institute for in-silico Medicine and Department of Computer Science, University of Sheffield, Sheffield, United Kingdom
| | - S Sridhar
- Insigneo Institute for in-silico Medicine and Department of Computer Science, University of Sheffield, Sheffield, United Kingdom
| |
Collapse
|
2
|
Ciaccio EJ, Cedilnik N, Hsia HH, Biviano AB, Garan H, Yarmohammadi H. Wavefront curvature analysis derived from preprocedural imaging can identify the critical isthmus in patients with postinfarcted ventricular tachycardia. Heart Rhythm 2024:S1547-5271(24)02669-9. [PMID: 38848858 DOI: 10.1016/j.hrthm.2024.05.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 05/29/2024] [Accepted: 05/30/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND Where activation wavefront curvature is convexly shaped, functional conduction block can occur. OBJECTIVE The purpose of this study was to determine whether left ventricular (LV) wall thickness determined from contrast-enhanced computed tomography (CT) is useful in localizing such areas in clinical postinfarction reentrant ventricular tachycardia (VT). METHODS We evaluated data from 6 patients who underwent catheter ablation for postinfarction VT. CT imaging with inHEART processing was conducted 1-3 days before electrophysiological (EP) study to determine LV wall thickness (T). Activation wavefront curvature was approximated as ΔT/T, where ΔT represents wall thickness change. During EP study, bipolar LV VT electrograms were acquired using a high-density mapping catheter, and activation times were determined. Maps of T, ΔT/T, and VT activation were subsequently compared using statistical analyses. RESULTS Two of 6 cases exhibited dual circuit morphologies, resulting in a total of 8 VT morphologies analyzed. The LV wall near the VT isthmus location tended to be thin, on the order of a few hundred micrometers. Regions of largest ΔT/T partially coincided with the lateral isthmus boundaries where electrical conduction block occurred during VT. ΔT/T at the boundaries, measured from imaging, was significantly larger compared to values at the isthmus midline and to the global LV mean value (P <.001). CONCLUSION Wavefront curvature measured by ΔT/T and caused by source-sink mismatch is dependent on ventricular wall thickness. Areas of high wavefront curvature partly coincide with and may be helpful in locating the VT isthmus in infarct border zones using preprocedural imaging analysis.
Collapse
Affiliation(s)
- Edward J Ciaccio
- Department of Medicine, Division of Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York.
| | - Nicolas Cedilnik
- inHEART Medical, IHU Liryc, Hopital Xavier Arnozan, Pessac, France
| | - Henry H Hsia
- Cardiac Electrophysiology and Arrhythmia Service, University of California San Francisco, San Francisco, California
| | - Angelo B Biviano
- Department of Medicine, Division of Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Hasan Garan
- Department of Medicine, Division of Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Hirad Yarmohammadi
- Department of Medicine, Division of Cardiology, College of Physicians and Surgeons, Columbia University, New York, New York
| |
Collapse
|
3
|
Solimene F, Speziale G, Schillaci V, Stabile G, Shopova G, Arestia A, Salito A, D'Auria C, Coltorti F, De Simone A, Scalone A, Tola G, Casula M, Mura E, Bolao IG. An annotation-independent algorithm based on electrogram characteristics to guide the identification of ventricular tachycardia isthmuses in patients with structural heart disease. J Interv Card Electrophysiol 2024; 67:739-750. [PMID: 37775727 DOI: 10.1007/s10840-023-01657-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/20/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Criteria such as electrograms voltage or late potentials have been largely utilized in the past to help identify areas of substrate maps that are within the ventricular tachycardia (VT) isthmus; yet their specificity and positive predictive value are quite low. The Lumipoint fractionation tool of the Rhythmia system illuminates regions with fractionated electrograms irrespective of their timing and annotation. We aimed to ascertain whether the use of this tool can rapidly identify areas within VT isthmuses from substrate maps. METHODS Thirty patients with structural cardiomyopathy in whom a complete right ventricular-paced substrate map and a full reconstruction of the diastolic isthmus during VT could be obtained were enrolled. The VT isthmus border was projected on each substrate map to verify whether the areas illuminated by Lumipoint fell within those borders. The behavior of the electrograms detected at the illuminated areas of the substrate maps was studied during a right ventricular drive train and extra stimulus protocol: if the near field potentials showed a delayed conduction after a single extra stimulus, defined as a minimum of 10 ms increase of the time interval between the far field and the near field activation measured during the drive train, the electrogram was said to have a "decremental" behavior. RESULTS The logistic analysis showed that areas with fractionated electrograms illuminated by the Lumipoint software and showing the greatest decremental behavior fell within the VT isthmus borders (OR = 1.66, CI: 1.41-1.75, p<0.001; OR=1.57 CI: 1.32-1.72, p<0.001, respectively) with a sensitivity, specificity, and positive predictive value of 87%, 96%, and 97%, respectively. CONCLUSIONS Fractionated electrograms illuminated by the automated Lumipoint software on right ventricular-paced substrate maps showing the greatest decremental behavior fall within the VT isthmus borders with a probability of 0.97, irrespective of their timing, annotation, or voltage, without any need for subjective assessment of their involvement in slow conduction areas.
Collapse
Affiliation(s)
- Francesco Solimene
- Clinica Montevergine, Via M. Malzoni 5, 83013, Mercogliano, Avellino, Italy.
| | | | - Vincenzo Schillaci
- Clinica Montevergine, Via M. Malzoni 5, 83013, Mercogliano, Avellino, Italy
| | | | - Gergana Shopova
- Clinica Montevergine, Via M. Malzoni 5, 83013, Mercogliano, Avellino, Italy
| | - Alberto Arestia
- Clinica Montevergine, Via M. Malzoni 5, 83013, Mercogliano, Avellino, Italy
| | - Armando Salito
- Clinica Montevergine, Via M. Malzoni 5, 83013, Mercogliano, Avellino, Italy
| | - Carmela D'Auria
- Clinica Montevergine, Via M. Malzoni 5, 83013, Mercogliano, Avellino, Italy
| | - Fernando Coltorti
- Clinica Montevergine, Via M. Malzoni 5, 83013, Mercogliano, Avellino, Italy
| | | | - Antonio Scalone
- Cardiology and Cardiovascular Intensive Care Unit, ARNAS "G.Brotzu", Cagliari, Italy
| | - Gianfranco Tola
- Cardiology and Cardiovascular Intensive Care Unit, ARNAS "G.Brotzu", Cagliari, Italy
| | - Matteo Casula
- Cardiology and Cardiovascular Intensive Care Unit, ARNAS "G.Brotzu", Cagliari, Italy
| | | | - Ignacio Garcia Bolao
- Department of Cardiology and Cardiovascular Surgery, Clìnica Universidad de Navarra, Pamplona, Spain
| |
Collapse
|
4
|
Okada M, Tanaka K, Tanaka N. Enhanced identification of ventricular tachycardia isthmus within a scar using Ripple map and Octaray catheter. Indian Pacing Electrophysiol J 2024; 24:163-164. [PMID: 38460884 PMCID: PMC11143709 DOI: 10.1016/j.ipej.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/25/2024] [Accepted: 03/07/2024] [Indexed: 03/11/2024] Open
Abstract
•Low-amplitude complex EGMs are often observed in the VT isthmus. •Misannotation of local EGMs can lead to incorrect depiction of VT circuits. •Ripple map with Octaray catheter can enhance VT isthmus identification.
Collapse
Affiliation(s)
- Masato Okada
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan.
| | - Koji Tanaka
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan.
| | - Nobuaki Tanaka
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan.
| |
Collapse
|
5
|
Sanders D, Du-Fay-de-Lavallaz JM, Winterfield J, Santangeli P, Liang J, Rhodes P, Ravi V, Badertscher P, Mazur A, Larsen T, Sharma PS, Huang HD. Surpoint algorithm for improved guidance of ablation for ventricular tachycardia (SURFIRE-VT): A pilot study. J Cardiovasc Electrophysiol 2024; 35:625-638. [PMID: 38174841 DOI: 10.1111/jce.16165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/27/2023] [Accepted: 12/16/2023] [Indexed: 01/05/2024]
Abstract
INTRODUCTION The utility of ablation index (AI) to guide ventricular tachycardia (VT) ablation in patients with structural heart disease is unknown. The aim of this study was to assess procedural characteristics and clinical outcomes achieved using AI-guided strategy (target value 550) or conventional non-AI-guided parameters in patients undergoing scar-related VT ablation. METHODS Consecutive patients (n = 103) undergoing initial VT ablation at a single center from 2017 to 2022 were evaluated. Patient groups were 1:1 propensity-matched for baseline characteristics. Single lesion characteristics for all 4707 lesions in the matched cohort (n = 74) were analyzed. The impact of ablation characteristics was assessed by linear regression and clinical outcomes were evaluated by Cox proportional hazard model. RESULTS After propensity-matching, baseline characteristics were well-balanced between AI (n = 37) and non-AI (n = 37) groups. Lesion sets were similar (scar homogenization [41% vs. 27%; p = .34], scar dechanneling [19% vs. 8%; p = .18], core isolation [5% vs. 11%; p = .4], linear and elimination late potentials/local abnormal ventricular activities [35% vs. 44%; p = .48], epicardial mapping/ablation [11% vs. 14%; p = .73]). AI-guided strategy had 21% lower procedure duration (-47.27 min, 95% confidence interval [CI] [-81.613, -12.928]; p = .008), 49% lower radiofrequency time per lesion (-13.707 s, 95% CI [-17.86, -9.555]; p < .001), 21% lower volume of fluid administered (1664 cc [1127, 2209] vs. 2126 cc [1750, 2593]; p = .005). Total radiofrequency duration (-339 s [-24%], 95%CI [-776, 62]; p = .09) and steam pops (-155.6%, 95% CI [19.8%, -330.9%]; p = .08) were nonsignificantly lower in the AI group. Acute procedural success (95% vs. 89%; p = .7) and VT recurrence (0.97, 95% CI [0.42-2.2]; p = .93) were similar for both groups. Lesion analysis (n = 4707) demonstrated a plateau in the magnitude of impedance drops once reaching an AI of 550-600. CONCLUSION In this pilot study, an AI-guided ablation strategy for scar-related VT resulted in shorter procedure time and average radiofrequency time per lesion with similar acute procedural and intermediate-term clinical outcomes to a non-AI-guided approach utilizing traditional ablation parameters.
Collapse
Affiliation(s)
- David Sanders
- Department of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Jeffrey Winterfield
- Department of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Jackson Liang
- Department of Cardiology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Venkatesh Ravi
- Department of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Alexander Mazur
- Department of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Timothy Larsen
- Department of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Parikshit S Sharma
- Department of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Henry D Huang
- Department of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| |
Collapse
|
6
|
Grade Santos J, Mills MT, Calvert P, Worthington N, Phenton C, Modi S, Ashrafi R, Todd D, Waktare J, Mahida S, Gupta D, Luther V. Delineating postinfarct ventricular tachycardia substrate with dynamic voltage mapping in areas of omnipolar vector disarray. Heart Rhythm O2 2024; 5:224-233. [PMID: 38690145 PMCID: PMC11056467 DOI: 10.1016/j.hroo.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
Background Defining postinfarct ventricular arrhythmic substrate is challenging with voltage mapping alone, though it may be improved in combination with an activation map. Omnipolar technology on the EnSite X system displays activation as vectors that can be superimposed onto a voltage map. Objective The study sought to optimize voltage map settings during ventricular tachycardia (VT) ablation, adjusting them dynamically using omnipolar vectors. Methods Consecutive patients undergoing substrate mapping were retrospectively studied. We categorized omnipolar vectors as uniform when pointing in one direction, or in disarray when pointing in multiple directions. We superimposed vectors onto voltage maps colored purple in tissue >1.5 mV, and the voltage settings were adjusted so that uniform vectors appeared within purple voltages, a process termed dynamic voltage mapping (DVM). Vectors in disarray appeared within red-blue lower voltages. Results A total of 17 substrate maps were studied in 14 patients (mean age 63 ± 13 years; mean left ventricular ejection fraction 35 ± 6%, median 4 [interquartile range 2-8.5] recent VT episodes). The DVM mean voltage threshold that differentiated tissue supporting uniform vectors from disarray was 0.27 mV, ranging between patients from 0.18 to 0.50 mV, with good interobserver agreement (median difference: 0.00 mV). We found that VT isthmus components, as well as sites of latest activation, isochronal crowding, and excellent pace maps colocated with tissue along the DVM border zone surrounding areas of disarray. Conclusion DVM, guided by areas of omnipolar vector disarray, allows for individualized postinfarct ventricular substrate characterization. Tissue bordering areas of disarray may harbor greater arrhythmogenic potential.
Collapse
Affiliation(s)
- Joao Grade Santos
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Cardiology, Hospital Garcia de Orta, Almada, Portugal
| | - Mark T. Mills
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Peter Calvert
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | | | | | - Simon Modi
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Reza Ashrafi
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Derick Todd
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Johan Waktare
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Saagar Mahida
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Cardiology, Hospital Garcia de Orta, Almada, Portugal
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| | - Vishal Luther
- Department of Cardiology, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
| |
Collapse
|
7
|
Francia P, Falasconi G, Penela D, Viveros D, Alderete J, Saglietto A, Bellido AF, Martí-Almor J, Franco-Ocaña P, Soto-Iglesias D, Zaraket F, Turturiello D, Berruezo A. Scar architecture affects the electrophysiological characteristics of induced ventricular arrhythmias in hypertrophic cardiomyopathy. Europace 2024; 26:euae050. [PMID: 38375690 PMCID: PMC10914403 DOI: 10.1093/europace/euae050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 02/09/2024] [Indexed: 02/21/2024] Open
Abstract
AIMS Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) detects myocardial scarring, a risk factor for ventricular arrhythmias (VAs) in hypertrophic cardiomyopathy (HCM). The LGE-CMR distinguishes core, borderzone (BZ) fibrosis, and BZ channels, crucial components of re-entry circuits. We studied how scar architecture affects inducibility and electrophysiological traits of VA in HCM. METHODS AND RESULTS We correlated scar composition with programmed ventricular stimulation-inducible VA features using LGE intensity maps. Thirty consecutive patients were enrolled. Thirteen (43%) were non-inducible, 6 (20%) had inducible non-sustained, and 11 (37%) had inducible sustained mono (MMVT)- or polymorphic VT/VF (PVT/VF). Of 17 induced VA, 13 (76%) were MMVT that either ended spontaneously, persisted as sustained monomorphic, or degenerated into PVT/VF. Twenty-seven patients (90%) had LGE. Of these, 17 (57%) had non-sustained or sustained inducible VA. Scar mass significantly increased (P = 0.002) from non-inducible to inducible non-sustained and sustained VA patients in both the BZ and core components. Borderzone channels were found in 23%, 67%, and 91% of non-inducible, inducible non-sustained, and inducible sustained VA patients (P = 0.003). All 13 patients induced with MMVT or monomorphic-initiated PVT/VF had LGE. The origin of 10/13 of these VTs matched scar location, with 8/10 of these LGE regions showing BZ channels. During follow-up (20 months, interquartile range: 7-37), one patient with BZ channels and inducible PVT had an ICD shock for VF. CONCLUSION Scar architecture determines inducibility and electrophysiological traits of VA in HCM. Larger studies should explore the role of complex LGE patterns in refining risk assessment in HCM patients.
Collapse
Affiliation(s)
- Pietro Francia
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
- Cardiology Unit, Department of Clinical and Molecular Medicine, Sant’Andrea Hospital, University Sapienza, Rome, Italy
| | - Giulio Falasconi
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
- IRCCS Humanitas Research Hospital, Cardiovascular Department, Milan, Italy
| | - Diego Penela
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
- IRCCS Humanitas Research Hospital, Cardiovascular Department, Milan, Italy
| | - Daniel Viveros
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| | - José Alderete
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| | - Andrea Saglietto
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
- Division of Cardiology, Cardiovascular and Thoracic Department, ‘Citta della Salute e della Scienza Hospital, Turin, Italy
| | - Aldo Francisco Bellido
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| | - Julio Martí-Almor
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| | - Paula Franco-Ocaña
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| | - David Soto-Iglesias
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| | - Fatima Zaraket
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| | - Dario Turturiello
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| | - Antonio Berruezo
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| |
Collapse
|
8
|
Donahue JK, Chrispin J, Ajijola OA. Mechanism of Ventricular Tachycardia Occurring in Chronic Myocardial Infarction Scar. Circ Res 2024; 134:328-342. [PMID: 38300981 PMCID: PMC10836816 DOI: 10.1161/circresaha.123.321553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Cardiac arrest is the leading cause of death in the more economically developed countries. Ventricular tachycardia associated with myocardial infarct is a prominent cause of cardiac arrest. Ventricular arrhythmias occur in 3 phases of infarction: during the ischemic event, during the healing phase, and after the scar matures. Mechanisms of arrhythmias in these phases are distinct. This review focuses on arrhythmia mechanisms for ventricular tachycardia in mature myocardial scar. Available data have shown that postinfarct ventricular tachycardia is a reentrant arrhythmia occurring in circuits found in the surviving myocardial strands that traverse the scar. Electrical conduction follows a zigzag course through that area. Conduction velocity is impaired by decreased gap junction density and impaired myocyte excitability. Enhanced sympathetic tone decreases action potential duration and increases sarcoplasmic reticular calcium leak and triggered activity. These elements of the ventricular tachycardia mechanism are found diffusely throughout scar. A distinct myocyte repolarization pattern is unique to the ventricular tachycardia circuit, setting up conditions for classical reentry. Our understanding of ventricular tachycardia mechanisms continues to evolve as new data become available. The ultimate use of this information would be the development of novel diagnostics and therapeutics to reliably identify at-risk patients and prevent their ventricular arrhythmias.
Collapse
Affiliation(s)
| | - Jonathan Chrispin
- The Johns Hopkins University School of Medicine, Baltimore, MD (J.C.)
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA (O.A.A.)
| |
Collapse
|
9
|
Ueda N, Ishibashi K, Noda T, Oka S, Miyazaki Y, Shimamoto K, Wakamiya A, Nakajima K, Kamakura T, Wada M, Inoue Y, Miyamoto K, Nagase S, Aiba T, Kanzaki H, Izumi C, Noguchi T, Kusano K. Implications of ventricular arrhythmia after cardiac resynchronization therapy. Heart Rhythm 2024; 21:163-171. [PMID: 37739199 DOI: 10.1016/j.hrthm.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 09/02/2023] [Accepted: 09/16/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Conflicting data are available on whether ventricular arrhythmia (VA) or shock therapy increases mortality. Although cardiac resynchronization therapy (CRT) reduces the risk of VA, little is known about the prognostic value of VA among patients with CRT devices. OBJECTIVES The purpose of this study was to evaluate the implications of VA as a prognostic marker for CRT. METHODS We investigated 330 CRT patients within 1 year after CRT device implantation. The primary endpoint was the composite endpoint of all-cause death or hospitalization for heart failure. RESULTS Forty-three patients had VA events. These patients had a significantly higher risk of the primary endpoint, even among CRT responders (P = .009). Fast VA compared to slow VA was associated with an increased risk of the primary endpoint (hazard ratio [HR] 2.14; 95% confidence interval [CI] 1.06-4.34; P = .035). Shock therapy was not associated with a primary endpoint (shock therapy vs antitachycardia pacing: HR 1.49; 95% CI 0.73-3.03; P = .269). The patients with VA had a lower prevalence of response to CRT (23 [53%] vs 202 [70%]; P = .031) and longer left ventricular paced conduction time (174 ± 23 ms vs 143 ± 36 ms; P = .003) than the patients without VA. CONCLUSION VA occurrence within 1 year was related to paced electrical delay and poor response to CRT. VA could be associated with poor prognosis among CRT patients.
Collapse
Affiliation(s)
- Nobuhiko Ueda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.
| | - Kohei Ishibashi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Oka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuichiro Miyazaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Keiko Shimamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Akinori Wakamiya
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kenzaburo Nakajima
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Tsukasa Kamakura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mitsuru Wada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yuko Inoue
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Koji Miyamoto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Satoshi Nagase
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Aiba
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hideaki Kanzaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| |
Collapse
|
10
|
Ciaccio EJ, Saluja DS, Peters NS, Yarmohammadi H. Role of activation signatures in re-entrant ventricular tachycardia circuits. J Cardiovasc Electrophysiol 2024; 35:267-277. [PMID: 38073065 DOI: 10.1111/jce.16146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 11/07/2023] [Accepted: 11/21/2023] [Indexed: 02/07/2024]
Abstract
INTRODUCTION Development of a rapid means to verify the ventricular tachycardia (VT) isthmus location from heart surface electrogram recordings would be a helpful tool for the electrophysiologist. METHOD Myocardial infarction was induced in 22 canines by left anterior descending coronary artery ligation under general anesthesia. After 3-5 days, VT was inducible via programmed electrical stimulation at the anterior left ventricular epicardial surface. Bipolar VT electrograms were acquired from 196 to 312 recording sites using a multielectrode array. Electrograms were marked for activation time, and activation maps were constructed. The activation signal, or signature, is defined as the cumulative number of recording sites that have activated per millisecond, and it was utilized to segment each circuit into inner and outer circuit pathways, and as an estimate of best ablation lesion location to prevent VT. RESULTS VT circuit components were differentiable by activation signals as: inner pathway (mean: 0.30 sites activating/ms) and outer pathway (mean: 2.68 sites activating/ms). These variables were linearly related (p < .001). Activation signal characteristics were dependent in part upon the isthmus exit site. The inner circuit pathway determined by the activation signal overlapped and often extended beyond the activation map isthmus location for each circuit. The best lesion location estimated by the activation signal would likely block an electrical impulse traveling through the isthmus, to prevent VT in all circuits. CONCLUSIONS The activation signal algorithm, simple to implement for real-time computer display, approximates the VT isthmus location and shape as determined from activation marking, and best ablation lesion location to prevent reinduction.
Collapse
Affiliation(s)
- Edward J Ciaccio
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, Columbia University, New York, New York, USA
- ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Deepak S Saluja
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Nicholas S Peters
- ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Hirad Yarmohammadi
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, Columbia University, New York, New York, USA
| |
Collapse
|
11
|
Bhagirath P. Post-ablation cardiac magnetic resonance in ventricular tachycardia ablation: shining light on dark cores and corridors. Eur Heart J Cardiovasc Imaging 2024; 25:199-200. [PMID: 37861369 PMCID: PMC10824471 DOI: 10.1093/ehjci/jead275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/21/2023] Open
Affiliation(s)
- Pranav Bhagirath
- School of Biomedical Engineering and Imaging Sciences, King’s College London, Westminster Bridge Rd, London SE1 7EH, UK
- Department of Cardiology, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ Amsterdam,The Netherlands
| |
Collapse
|
12
|
Dhakal BP, Patel NA, Garg L, Frankel DS, Hyman MC, Guandalini GS, Supple GE, Nazarian S, Kumareswaran R, Riley MP, Santangeli P, Lin D, Callans DJ, Arkles J, Schaller RD, Tschabrunn CM, Zado ES, Marchlinski FE, Dixit S. Utility of Very High-Output Pacing to Identify VT Circuits in Patients Manifesting Traditionally Inexcitable Scar. JACC Clin Electrophysiol 2023; 9:2523-2533. [PMID: 37715743 DOI: 10.1016/j.jacep.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 08/11/2023] [Accepted: 08/13/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Entrainment and pace mapping are used to identify critical components (CCs) of ventricular tachycardia (VT) circuits. In patients with dense myocardial scarring, VT circuits may elude capture at standard high pacing outputs (up to 10 mA at a 2-millisecond pulse width). OBJECTIVES The purpose of this study was to assess the utility of very high-output pacing (V-HOP, 50 mA at 2 milliseconds) for identifying CCs of VT circuits after standard high pacing output failed to elicit capture in densely scarred myocardial tissue. METHODS Our standard VT ablation approach included electroanatomic mapping for substrate characterization and entrainment and/or pace mapping to identify CCs of VT circuits. Patients that required V-HOP to capture sites of interest comprised the study cohort. Ablation endpoints were VT termination and noninducibility. RESULTS Twenty-five patients (71 ± 10 years of age, all males) undergoing 26 VT ablations met the inclusion criteria. The mean left ventricular ejection fraction was 30% ± 14%, and 85% had ischemic cardiomyopathy. V-HOP was used to successfully entrain VT in 17 patients, yielding central isthmus sites in 10 and entrance/exit sites in 4. VT terminated with radiofrequency ablation at these sites in 15 patients. In 9 patients, V-HOP identified scar locations with a delayed exit. Acute procedural success was achieved in 24 patients without any adverse events. Over a follow-up period of 16 ± 21 months, 2 patients experienced VT recurrence requiring repeat ablation during which the same location was targeted successfully in 1 patient. CONCLUSIONS In VT patients with a dense scar that is traditionally inexcitable, V-HOP can identify CCs of the re-entrant circuit and guide successful ablation.
Collapse
Affiliation(s)
- Bishnu P Dhakal
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Neel A Patel
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lohit Garg
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Frankel
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew C Hyman
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gustavo S Guandalini
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory E Supple
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Saman Nazarian
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ramanan Kumareswaran
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael P Riley
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pasquale Santangeli
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Lin
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J Callans
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey Arkles
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert D Schaller
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cory M Tschabrunn
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erica S Zado
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sanjay Dixit
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
13
|
Okada M, Tanaka K, Ikada Y, Tanaka N. Annotating far-field diastolic electrograms delineates the midmyocardial isthmus in 3-dimensional ventricular tachycardia. HeartRhythm Case Rep 2023; 9:893-897. [PMID: 38204841 PMCID: PMC10774533 DOI: 10.1016/j.hrcr.2023.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Affiliation(s)
- Masato Okada
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Koji Tanaka
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Yusuke Ikada
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| | - Nobuaki Tanaka
- Cardiovascular Center, Sakurabashi Watanabe Hospital, Osaka, Japan
| |
Collapse
|
14
|
Mills MT, Luther V. Five scar patterns to reclassify the ventricular tachycardia substrate. J Cardiovasc Electrophysiol 2023; 34:2283-2285. [PMID: 37752727 DOI: 10.1111/jce.16088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 09/17/2023] [Indexed: 09/28/2023]
Affiliation(s)
- Mark T Mills
- Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, UK
| | - Vishal Luther
- Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool, UK
- Department of Cardiology, Liverpool Heart & Chest Hospital NHS Foundation Trust, Liverpool, UK
| |
Collapse
|
15
|
Ciaccio EJ, Coromilas J, Wan EY, Yarmohammadi H, Saluja DS, Peters NS, Garan H, Biviano AB. Correlation relationships of the reentrant ventricular tachycardia circuit. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 241:107764. [PMID: 37597351 DOI: 10.1016/j.cmpb.2023.107764] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 07/01/2023] [Accepted: 08/12/2023] [Indexed: 08/21/2023]
Abstract
INTRODUCTION A quantitative analysis of the components of reentrant ventricular tachycardia (VT) circuitry could improve understanding of its onset and perpetuation. METHOD In 19 canine experiments, the left anterior descending coronary artery was ligated to generate a subepicardial infarct. The border zone resided at the epicardial surface of the anterior left ventricle and was mapped 3-5 days postinfarction with a 196-312 bipolar multielectrode array. Monomorphic VT was inducible by extrastimulation. Activation maps revealed an epicardial double-loop reentrant circuit and isthmus, causing VT. Several circuit parameters were analyzed: the coupling interval for VT induction, VT cycle length, the lateral isthmus boundary (LIB) lengths, and isthmus width and angle. RESULTS The extrastimulus interval for VT induction and the VT cycle length were strongly correlated (p < 0.001). Both the extrastimulus interval and VT cycle length were correlated to the shortest LIB (p < 0.005). A derivation was developed to suggest that when conduction block at the shorter LIB is functional, the VT cycle length may depend on the local refractory period and the delay from wavefront pivot around the LIB. Isthmus width and angle were uncorrelated to other parameters. CONCLUSIONS The shorter LIB is correlated to VT cycle length, hence its circuit loop may drive reentrant VT. The extrastimulation interval, VT cycle length, and shorter LIB are intertwined, and may depend upon the local refractory period. Isthmus width and angle are less correlated, perhaps being more related to electrical discontinuity caused by alterations in infarct shape at depth.
Collapse
Affiliation(s)
- Edward J Ciaccio
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY, USA; ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.
| | - James Coromilas
- Department of Medicine - Division of Cardiovascular Disease and Hypertension, Rutgers University, New Brunswick, NJ, USA
| | - Elaine Y Wan
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Hirad Yarmohammadi
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Deepak S Saluja
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Nicholas S Peters
- ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Hasan Garan
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Angelo B Biviano
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| |
Collapse
|
16
|
Stevenson WG, Tandri H, Roden DM. The Shape of Ventricular Tachycardia. Circulation 2023; 148:1368-1370. [PMID: 37903185 DOI: 10.1161/circulationaha.123.066574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2023]
Affiliation(s)
- William G Stevenson
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Harikrishna Tandri
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Dan M Roden
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN
| |
Collapse
|
17
|
Nishimura T, Shatz N, Weiss JP, Zawaneh M, Bai R, Beaser AD, Upadhyay GA, Aziz ZA, Nayak HM, Shatz DY, Miyazaki S, Goya M, Sasano T, Su W, Raiman M, Tung R. Identification of Human Ventricular Tachycardia Demarcated by Fixed Lines of Conduction Block in a 3-Dimensional Hyperboloid Circuit. Circulation 2023; 148:1354-1367. [PMID: 37638389 DOI: 10.1161/circulationaha.123.065525] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/01/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND The circuit boundaries for reentrant ventricular tachycardia (VT) have been historically conceptualized within a 2-dimensional (2D) construct, with their fixed or functional nature unresolved. This study aimed to examine the correlation between localized lines of conduction block (LOB) evident during baseline rhythm with lateral isthmus boundaries that 3-dimensionally constrain the VT isthmus as a hyperboloid structure. METHODS A total of 175 VT activation maps were correlated with isochronal late activation maps during baseline rhythm in 106 patients who underwent catheter ablation for scar-related VT from 3 centers (42% nonischemic cardiomyopathy). An overt LOB was defined by a deceleration zone with split potentials (≥20 ms isoelectric segment) during baseline rhythm. A novel application of pacing within deceleration zone (≥600 ms) was implemented to unmask a concealed LOB not evident during baseline rhythm. LOB identified during baseline rhythm or pacing were correlated with isthmus boundaries during VT. RESULTS Among 202 deceleration zones analyzed during baseline rhythm, an overt LOB was evident in 47%. When differential pacing was performed in 38 deceleration zones without overt LOB, an underlying concealed LOB was exposed in 84%. In 152 VT activation maps (2D=53, 3-dimensional [3D]=99), 69% of lateral boundaries colocalized with an LOB in 2D activation patterns, and the depth boundary during 3D VT colocalized with an LOB in 79%. In VT circuits with isthmus regions that colocalized with a U-shaped LOB (n=28), the boundary invariably served as both lateral boundaries in 2D and 3D. Overall, 74% of isthmus boundaries were identifiable as fixed LOB during baseline rhythm or differential pacing. CONCLUSIONS The majority of VT circuit boundaries can be identified as fixed LOB from intrinsic or paced activation during sinus rhythm. Analysis of activation while pacing within the scar substrate is a novel technique that may unmask concealed LOB, previously interpreted to be functional in nature. An LOB from the perspective of a myocardial surface is frequently associated with intramural conduction, supporting the existence of a 3D hyperboloid VT circuit structure. Catheter ablation may be simplified to targeting both sides around an identified LOB during sinus rhythm.
Collapse
Affiliation(s)
- Takuro Nishimura
- The University of Chicago Medicine, Pritzker School of Medicine, Illinois (T.N., A.D.B., G.A.U., Z.A.A., H.M.N., D.Y.S., R.T.)
- Tokyo Medical and Dental University, Department of Cardiovascular Medicine, Japan (T.N., S.M., M.G., T.S.)
| | - Nathan Shatz
- Abbott Laboratories, Abbott Park, Illinois (N.S., M.R.)
| | - J Peter Weiss
- The University of Arizona College of Medicine - Phoenix, Banner - University Medical Center, Phoenix (J.P.W., M.Z., R.B., D.Y.S., W.S., R.T.)
| | - Michael Zawaneh
- The University of Arizona College of Medicine - Phoenix, Banner - University Medical Center, Phoenix (J.P.W., M.Z., R.B., D.Y.S., W.S., R.T.)
| | - Rong Bai
- The University of Arizona College of Medicine - Phoenix, Banner - University Medical Center, Phoenix (J.P.W., M.Z., R.B., D.Y.S., W.S., R.T.)
| | - Andrew D Beaser
- The University of Chicago Medicine, Pritzker School of Medicine, Illinois (T.N., A.D.B., G.A.U., Z.A.A., H.M.N., D.Y.S., R.T.)
| | - Gaurav A Upadhyay
- The University of Chicago Medicine, Pritzker School of Medicine, Illinois (T.N., A.D.B., G.A.U., Z.A.A., H.M.N., D.Y.S., R.T.)
| | - Zaid A Aziz
- The University of Chicago Medicine, Pritzker School of Medicine, Illinois (T.N., A.D.B., G.A.U., Z.A.A., H.M.N., D.Y.S., R.T.)
| | - Hemal M Nayak
- The University of Chicago Medicine, Pritzker School of Medicine, Illinois (T.N., A.D.B., G.A.U., Z.A.A., H.M.N., D.Y.S., R.T.)
| | - Dalise Y Shatz
- The University of Chicago Medicine, Pritzker School of Medicine, Illinois (T.N., A.D.B., G.A.U., Z.A.A., H.M.N., D.Y.S., R.T.)
- The University of Arizona College of Medicine - Phoenix, Banner - University Medical Center, Phoenix (J.P.W., M.Z., R.B., D.Y.S., W.S., R.T.)
| | - Shinsuke Miyazaki
- Tokyo Medical and Dental University, Department of Cardiovascular Medicine, Japan (T.N., S.M., M.G., T.S.)
| | - Masahiko Goya
- Tokyo Medical and Dental University, Department of Cardiovascular Medicine, Japan (T.N., S.M., M.G., T.S.)
| | - Tetsuo Sasano
- Tokyo Medical and Dental University, Department of Cardiovascular Medicine, Japan (T.N., S.M., M.G., T.S.)
| | - Wilber Su
- The University of Arizona College of Medicine - Phoenix, Banner - University Medical Center, Phoenix (J.P.W., M.Z., R.B., D.Y.S., W.S., R.T.)
| | | | - Roderick Tung
- The University of Chicago Medicine, Pritzker School of Medicine, Illinois (T.N., A.D.B., G.A.U., Z.A.A., H.M.N., D.Y.S., R.T.)
- The University of Arizona College of Medicine - Phoenix, Banner - University Medical Center, Phoenix (J.P.W., M.Z., R.B., D.Y.S., W.S., R.T.)
| |
Collapse
|
18
|
Bhagirath P, Campos FO, Postema PG, Kemme MJB, Wilde AAM, Prassl AJ, Neic A, Rinaldi CA, Götte MJW, Plank G, Bishop MJ. Arrhythmogenic vulnerability of re-entrant pathways in post-infarct ventricular tachycardia assessed by advanced computational modelling. Europace 2023; 25:euad198. [PMID: 37421339 PMCID: PMC10481251 DOI: 10.1093/europace/euad198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/26/2023] [Accepted: 06/21/2023] [Indexed: 07/10/2023] Open
Abstract
AIMS Substrate assessment of scar-mediated ventricular tachycardia (VT) is frequently performed using late gadolinium enhancement (LGE) images. Although this provides structural information about critical pathways through the scar, assessing the vulnerability of these pathways for sustaining VT is not possible with imaging alone.This study evaluated the performance of a novel automated re-entrant pathway finding algorithm to non-invasively predict VT circuit and inducibility. METHODS Twenty post-infarct VT-ablation patients were included for retrospective analysis. Commercially available software (ADAS3D left ventricular) was used to generate scar maps from 2D-LGE images using the default 40-60 pixel-signal-intensity (PSI) threshold. In addition, algorithm sensitivity for altered thresholds was explored using PSI 45-55, 35-65, and 30-70. Simulations were performed on the Virtual Induction and Treatment of Arrhythmias (VITA) framework to identify potential sites of block and assess their vulnerability depending on the automatically computed round-trip-time (RTT). Metrics, indicative of substrate complexity, were correlated with VT-recurrence during follow-up. RESULTS Total VTs (85 ± 43 vs. 42 ± 27) and unique VTs (9 ± 4 vs. 5 ± 4) were significantly higher in patients with- compared to patients without recurrence, and were predictive of recurrence with area under the curve of 0.820 and 0.770, respectively. VITA was robust to scar threshold variations with no significant impact on total and unique VTs, and mean RTT between the four models. Simulation metrics derived from PSI 45-55 model had the highest number of parameters predictive for post-ablation VT-recurrence. CONCLUSION Advanced computational metrics can non-invasively and robustly assess VT substrate complexity, which may aid personalized clinical planning and decision-making in the treatment of post-infarction VT.
Collapse
Affiliation(s)
- Pranav Bhagirath
- School of Biomedical Engineering and Imaging Sciences, King's College London, 4th Floor, Lambeth Wing, St. Thomas' Hospital, London SE1 7EH, UK
- Department of Cardiology, St Thomas' Hospital, London SE1 7EH, UK
| | - Fernando O Campos
- School of Biomedical Engineering and Imaging Sciences, King's College London, 4th Floor, Lambeth Wing, St. Thomas' Hospital, London SE1 7EH, UK
| | - Pieter G Postema
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Michiel J B Kemme
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Arthur A M Wilde
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Anton J Prassl
- Gottfried Schatz Research Center, Division of Biophysics, Medical University of Graz, Graz, Austria
| | - Aurel Neic
- Gottfried Schatz Research Center, Division of Biophysics, Medical University of Graz, Graz, Austria
| | | | - Marco J W Götte
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Gernot Plank
- Gottfried Schatz Research Center, Division of Biophysics, Medical University of Graz, Graz, Austria
| | - Martin J Bishop
- School of Biomedical Engineering and Imaging Sciences, King's College London, 4th Floor, Lambeth Wing, St. Thomas' Hospital, London SE1 7EH, UK
| |
Collapse
|
19
|
Rossi P, Cauti FM, Niscola M, Magnocavallo M, Polselli M, Capone S, Della Rocca DG, Rodriguez-Garrido J, Piccirillo G, Anguera I, Dallaglio P, Bianchi S. Ventricular Electrograms Duration Map to Detect Ventricular Arrhythmia Substrate: the VEDUM Project Study. Circ Arrhythm Electrophysiol 2023; 16:447-455. [PMID: 37485678 PMCID: PMC10786440 DOI: 10.1161/circep.122.011729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 07/16/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND The analysis of the wave-front activation patterns is crucial for the comprehension and treatment of ventricular tachycardia (VT). The ventricular electrograms duration map (VEDUM) is a potential method to identify areas (VEDUM area) with slow and inhomogeneous activation. There is no available data on the characteristics and the arrhythmogenic role of VEDUM areas identified during sinus/paced rhythm. METHODS Patients referred for VT ablation were enrolled at 3 different centers. VEDUM maps during sinus/paced rhythm as well as substrate and functional maps were created; activation mapping was performed for all hemodynamically tolerated VT. RESULTS Thirty-two patients (mean age:70.1±9.4 years; males 93.8%) were enrolled. The VEDUM approach was achieved in all patients and the mean size of the VEDUM area was 12.1±6.9 cm2 (interquartile range, 7.8-14.9 cm2). A significative difference was observed between the electrogram duration in the VEDUM area and the normal tissue (163.7 ms [interquartile range, 142.3-199.2 ms]; versus 65.5 ms [interquartile range, 59.5-76.2 ms]; P<0.001). The VEDUM area was visualized in a dense scar (<0.5 mV) in 19 (59.4%) patients. A deceleration zone and late potentials were recorded inside the VEDUM area in 56.3% and 81.3%, respectively. When a complete VT activation mapping was available, the isthmus projected in the VEDUM area in 93.5% of patients; 8 of them had multiple VTs mapped and in the 87.5% all VT isthmuses were included in the VEDUM area. CONCLUSIONS VEDUM maps allow the identification of discrete areas of inhomogeneous and slow conduction. They represent a potential target for VT ablation, including patients with multiple morphologies.
Collapse
Affiliation(s)
- Pietro Rossi
- Arrhythmology Unit, Ospedale Fatebenefratelli Isola Tiberina-Gemelli Isola, Rome, Italy (P.R., F.M.C., M.M., M.P., S.C., S.B.)
| | - Filippo Maria Cauti
- Arrhythmology Unit, Ospedale Fatebenefratelli Isola Tiberina-Gemelli Isola, Rome, Italy (P.R., F.M.C., M.M., M.P., S.C., S.B.)
| | - Marta Niscola
- Abbott Medical Italy, Sesto San Giovanni, Milan, Italy (M.N.)
| | - Michele Magnocavallo
- Arrhythmology Unit, Ospedale Fatebenefratelli Isola Tiberina-Gemelli Isola, Rome, Italy (P.R., F.M.C., M.M., M.P., S.C., S.B.)
| | - Marco Polselli
- Arrhythmology Unit, Ospedale Fatebenefratelli Isola Tiberina-Gemelli Isola, Rome, Italy (P.R., F.M.C., M.M., M.P., S.C., S.B.)
| | - Silvia Capone
- Arrhythmology Unit, Ospedale Fatebenefratelli Isola Tiberina-Gemelli Isola, Rome, Italy (P.R., F.M.C., M.M., M.P., S.C., S.B.)
| | - Domenico Giovanni Della Rocca
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology & Pacing, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Belgium (D.G.D.R.)
| | | | - Gianfranco Piccirillo
- University of Rome “Sapienza,” Department of Science of Internal Clinics, Anestesiologists & Cardiovasculars, Policlinico Umberto I, Rome, Italy (G.P.)
| | - Ignasi Anguera
- Arrhythmias Unit, Cardiology Department, Bellvitge University Hospital & Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Unstitute (IDIBELL), L’Hospitalet de Llobregat, Barcelona, Spain (I.A., P.D.)
| | - Paolo Dallaglio
- Arrhythmias Unit, Cardiology Department, Bellvitge University Hospital & Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Unstitute (IDIBELL), L’Hospitalet de Llobregat, Barcelona, Spain (I.A., P.D.)
| | - Stefano Bianchi
- Arrhythmology Unit, Ospedale Fatebenefratelli Isola Tiberina-Gemelli Isola, Rome, Italy (P.R., F.M.C., M.M., M.P., S.C., S.B.)
| |
Collapse
|
20
|
Ciaccio EJ, Coromilas J, Wan EY, Yarmohammadi H, Saluja DS, Peters NS, Garan H, Biviano AB. Lateral Boundaries of the Ventricular Tachycardia Circuit Align With Sinus Rhythm Discontinuities. JACC Clin Electrophysiol 2023; 9:851-861. [PMID: 37227361 DOI: 10.1016/j.jacep.2022.11.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/08/2022] [Accepted: 11/20/2022] [Indexed: 05/26/2023]
Abstract
BACKGROUND Sinus rhythm electrical activation mapping can provide information regarding the ischemic re-entrant ventricular tachycardia (VT) circuit. The information gleaned may include the localization of sinus rhythm electrical discontinuities, which can be defined as arcs of disrupted electrical conduction with large activation time differences across the arc. OBJECTIVES This study sought to detect and localize sinus rhythm electrical discontinuities that might be present in activation maps constructed from infarct border zone electrograms. METHODS Monomorphic re-entrant VT with a double-loop circuit and central isthmus was repeatedly inducible by programmed electrical stimulation in the epicardial border zone of 23 postinfarction canine hearts. Sinus rhythm and VT activation maps were constructed from 196 to 312 bipolar electrograms acquired surgically at the epicardial surface and analyzed computationally. A complete re-entrant circuit was mappable from the epicardial electrograms of VT, and isthmus lateral boundary (ILB) locations were ascertained. The difference in sinus rhythm activation time across ILB locations, vs the central isthmus and vs the circuit periphery, was determined. RESULTS Sinus rhythm activation time differences averaged 14.4 milliseconds across the ILB vs 6.5 milliseconds at the central isthmus and 6.4 milliseconds at the periphery (ie, the outer circuit loop) (P ≤ 0.001). Locations with large sinus rhythm activation difference tended to overlap ILB (60.3% ± 23.2%) compared with their overlap with the entire grid (27.5% ± 18.5%) (P < 0.001). CONCLUSIONS Disrupted electrical conduction is evident as discontinuity in sinus rhythm activation maps, particularly at ILB locations. These areas may represent permanent fixtures relating to spatial differences in border zone electrical properties, caused in part by alterations in underlying infarct depth. The tissue properties producing sinus rhythm discontinuity at ILB may contribute to functional conduction block formation at VT onset.
Collapse
Affiliation(s)
- Edward J Ciaccio
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York, USA; ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom.
| | - James Coromilas
- Department of Medicine, Division of Cardiovascular Disease and Hypertension, Rutgers University, New Brunswick, New Jersey, USA
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Hirad Yarmohammadi
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Deepak S Saluja
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Nicholas S Peters
- ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom
| | - Hasan Garan
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Angelo B Biviano
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York, USA
| |
Collapse
|
21
|
Khanra D, Calvert P, Hughes S, Waktare J, Modi S, Hall M, Todd D, Mahida S, Gupta D, Luther V. An approach to help differentiate postinfarct scar from borderzone tissue using Ripple Mapping during ventricular tachycardia ablation. J Cardiovasc Electrophysiol 2023; 34:664-672. [PMID: 36478627 DOI: 10.1111/jce.15766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/15/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ventricular scar is traditionally highlighted on a bipolar voltage (BiVolt) map in areas of myocardium <0.50 mV. We describe an alternative approach using Ripple Mapping (RM) superimposed onto a BiVolt map to differentiate postinfarct scar from conducting borderzone (BZ) during ventricular tachycardia (VT) ablation. METHODS Fifteen consecutive patients (left ventricular ejection fraction 30 ± 7%) underwent endocardial left ventricle pentaray mapping (median 5148 points) and ablation targeting areas of late Ripple activation. BiVolt maps were studied offline at initial voltage of 0.50-0.50 mV to binarize the color display (red and purple). RMs were superimposed, and the BiVolt limits were sequentially reduced until only areas devoid of Ripple bars appeared red, defined as RM-scar. The surrounding area supporting conducting Ripple wavefronts in tissue <0.50 mV defined the RM-BZ. RESULTS RM-scar was significantly smaller than the traditional 0.50 mV cutoff (median 4% vs. 12% shell area, p < .001). 65 ± 16% of tissue <0.50 mV supported Ripple activation within the RM-BZ. The mean BiVolt threshold that differentiated RM-scar from BZ tissue was 0.22 ± 0.07 mV, though this ranged widely (from 0.12 to 0.35 mV). In this study, septal infarcts (7/15) were associated with more rapid VTs (282 vs. 347 ms, p = .001), and had a greater proportion of RM-BZ to RM-scar (median ratio 3.2 vs. 1.2, p = .013) with faster RM-BZ conduction speed (0.72 vs. 0.34 m/s, p = .001). Conversely, scars that supported hemodynamically stable sustained VT (6/15) were slower (367 ± 38 ms), had a smaller proportion of RM-BZ to RM-scar (median ratio 1.2 vs. 3.2, p = .059), and slower RM-BZ conduction speed (0.36 vs. 0.63 m/s, p = .036). RM guided ablation collocated within 66 ± 20% of RM-BZ, most concentrated around the RM-scar perimeter, with significant VT reduction (median 4.0 episodes preablation vs. 0 post, p < .001) at 11 ± 6 months follow-up. CONCLUSION Postinfarct scars appear significantly smaller than traditional 0.50 mV cut-offs suggest, with voltage thresholds unique to each patient.
Collapse
Affiliation(s)
| | - Peter Calvert
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | | | | | - Simon Modi
- Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Mark Hall
- Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Derick Todd
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | - Saagar Mahida
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | - Dhiraj Gupta
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | - Vishal Luther
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| |
Collapse
|
22
|
Monaci S, Qian S, Gillette K, Puyol-Antón E, Mukherjee R, Elliott MK, Whitaker J, Rajani R, O’Neill M, Rinaldi CA, Plank G, King AP, Bishop MJ. Non-invasive localization of post-infarct ventricular tachycardia exit sites to guide ablation planning: a computational deep learning platform utilizing the 12-lead electrocardiogram and intracardiac electrograms from implanted devices. Europace 2023; 25:469-477. [PMID: 36369980 PMCID: PMC9935046 DOI: 10.1093/europace/euac178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 09/08/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS Existing strategies that identify post-infarct ventricular tachycardia (VT) ablation target either employ invasive electrophysiological (EP) mapping or non-invasive modalities utilizing the electrocardiogram (ECG). Their success relies on localizing sites critical to the maintenance of the clinical arrhythmia, not always recorded on the 12-lead ECG. Targeting the clinical VT by utilizing electrograms (EGM) recordings stored in implanted devices may aid ablation planning, enhancing safety and speed and potentially reducing the need of VT induction. In this context, we aim to develop a non-invasive computational-deep learning (DL) platform to localize VT exit sites from surface ECGs and implanted device intracardiac EGMs. METHODS AND RESULTS A library of ECGs and EGMs from simulated paced beats and representative post-infarct VTs was generated across five torso models. Traces were used to train DL algorithms to localize VT sites of earliest systolic activation; first tested on simulated data and then on a clinically induced VT to show applicability of our platform in clinical settings. Localization performance was estimated via localization errors (LEs) against known VT exit sites from simulations or clinical ablation targets. Surface ECGs successfully localized post-infarct VTs from simulated data with mean LE = 9.61 ± 2.61 mm across torsos. VT localization was successfully achieved from implanted device intracardiac EGMs with mean LE = 13.10 ± 2.36 mm. Finally, the clinically induced VT localization was in agreement with the clinical ablation volume. CONCLUSION The proposed framework may be utilized for direct localization of post-infarct VTs from surface ECGs and/or implanted device EGMs, or in conjunction with efficient, patient-specific modelling, enhancing safety and speed of ablation planning.
Collapse
Affiliation(s)
- Sofia Monaci
- Biomedical Engineering & Imaging Sciences, King’s College London, London SE1 7EH, United Kingdom
| | - Shuang Qian
- Biomedical Engineering & Imaging Sciences, King’s College London, London SE1 7EH, United Kingdom
| | | | - Esther Puyol-Antón
- Biomedical Engineering & Imaging Sciences, King’s College London, London SE1 7EH, United Kingdom
| | - Rahul Mukherjee
- Biomedical Engineering & Imaging Sciences, King’s College London, London SE1 7EH, United Kingdom
- Guy’s and St Thomas’ Hospital, London SE1 7EH, United Kingdom
| | - Mark K Elliott
- Biomedical Engineering & Imaging Sciences, King’s College London, London SE1 7EH, United Kingdom
- Guy’s and St Thomas’ Hospital, London SE1 7EH, United Kingdom
| | - John Whitaker
- Biomedical Engineering & Imaging Sciences, King’s College London, London SE1 7EH, United Kingdom
- Guy’s and St Thomas’ Hospital, London SE1 7EH, United Kingdom
| | - Ronak Rajani
- Biomedical Engineering & Imaging Sciences, King’s College London, London SE1 7EH, United Kingdom
- Guy’s and St Thomas’ Hospital, London SE1 7EH, United Kingdom
| | - Mark O’Neill
- Biomedical Engineering & Imaging Sciences, King’s College London, London SE1 7EH, United Kingdom
| | - Christopher A Rinaldi
- Biomedical Engineering & Imaging Sciences, King’s College London, London SE1 7EH, United Kingdom
- Guy’s and St Thomas’ Hospital, London SE1 7EH, United Kingdom
| | | | - Andrew P King
- Biomedical Engineering & Imaging Sciences, King’s College London, London SE1 7EH, United Kingdom
| | - Martin J Bishop
- Biomedical Engineering & Imaging Sciences, King’s College London, London SE1 7EH, United Kingdom
| |
Collapse
|
23
|
Sung E, Prakosa A, Kyranakis S, Berger RD, Chrispin J, Trayanova NA. Wavefront directionality and decremental stimuli synergistically improve identification of ventricular tachycardia substrate: insights from personalized computational heart models. Europace 2023; 25:223-235. [PMID: 36006658 PMCID: PMC10103576 DOI: 10.1093/europace/euac140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/16/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS Multiple wavefront pacing (MWP) and decremental pacing (DP) are two electroanatomic mapping (EAM) strategies that have emerged to better characterize the ventricular tachycardia (VT) substrate. The aim of this study was to assess how well MWP, DP, and their combination improve identification of electrophysiological abnormalities on EAM that reflect infarct remodelling and critical VT sites. METHODS AND RESULTS Forty-eight personalized computational heart models were reconstructed using images from post-infarct patients undergoing VT ablation. Paced rhythms were simulated by delivering an initial (S1) and an extra-stimulus (S2) from one of 100 locations throughout each heart model. For each pacing, unipolar signals were computed along the myocardial surface to simulate substrate EAM. Six EAM features were extracted and compared with the infarct remodelling and critical VT sites. Concordance of S1 EAM features between different maps was lower in hearts with smaller amounts of remodelling. Incorporating S1 EAM features from multiple maps greatly improved the detection of remodelling, especially in hearts with less remodelling. Adding S2 EAM features from multiple maps decreased the number of maps required to achieve the same detection accuracy. S1 EAM features from multiple maps poorly identified critical VT sites. However, combining S1 and S2 EAM features from multiple maps paced near VT circuits greatly improved identification of critical VT sites. CONCLUSION Electroanatomic mapping with MWP is more advantageous for characterization of substrate in hearts with less remodelling. During substrate EAM, MWP and DP should be combined and delivered from locations proximal to a suspected VT circuit to optimize identification of the critical VT site.
Collapse
Affiliation(s)
- Eric Sung
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21287, USA
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218, USA
| | - Adityo Prakosa
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21287, USA
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218, USA
| | - Stephen Kyranakis
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Ronald D Berger
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218, USA
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Jonathan Chrispin
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218, USA
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Natalia A Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21287, USA
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218, USA
| |
Collapse
|
24
|
Vlachos K, Letsas KP, Srinivasan NT, Frontera A, Efremidis M, Dragasis S, Martin CA, Martin R, Nakashima T, Bazoukis G, Kitamura T, Mililis P, Saplaouras A, Georgopoulos S, Sofoulis S, Kariki O, Koskina S, Takigawa M, Sacher F, Jais P, Santangeli P. The value of functional substrate mapping in ventricular tachycardia ablation. Heart Rhythm O2 2023; 4:134-146. [PMID: 36873315 PMCID: PMC9975018 DOI: 10.1016/j.hroo.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
In the setting of structural heart disease, ventricular tachycardia (VT) is typically associated with a re-entrant mechanism. In patients with hemodynamically tolerated VTs, activation and entrainment mapping remain the gold standard for the identification of the critical parts of the circuit. However, this is rarely accomplished, as most VTs are not hemodynamically tolerated to permit mapping during tachycardia. Other limitations include noninducibility of arrhythmia or nonsustained VT. This has led to the development of substrate mapping techniques during sinus rhythm, eliminating the need for prolonged periods of mapping during tachycardia. Recurrence rates following VT ablation are high; therefore, new mapping techniques for substrate characterization are required. Advances in catheter technology and especially multielectrode mapping of abnormal electrograms has increased the ability to identify the mechanism of scar-related VT. Several substrate-guided approaches have been developed to overcome this, including scar homogenization and late potential mapping. Dynamic substrate changes are mainly identified within regions of myocardial scar and can be identified as local abnormal ventricular activities. Furthermore, mapping strategies incorporating ventricular extrastimulation, including from different directions and coupling intervals, have been shown to increase the accuracy of substrate mapping. The implementation of extrastimulus substrate mapping and automated annotation require less extensive ablation and would make VT ablation procedures less cumbersome and accessible to more patients.
Collapse
Affiliation(s)
- Konstantinos Vlachos
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- Electrophysiology Department, Onassis Cardiac Surgery Center, Athens, Greece
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
- Address reprint requests and correspondence: Dr Konstantinos Vlachos, Onassis Cardiac Surgery Center, Electrophysiology Department, Syggrou Avenue 356, PC 176 74, Athens, Greece.
| | | | - Neil T. Srinivasan
- Department of Cardiac Electrophysiology, Essex Cardiothoracic Centre, Basildon, United Kingdom
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Antonio Frontera
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - Michael Efremidis
- Electrophysiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Stelios Dragasis
- Electrophysiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Claire A. Martin
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus
| | - Ruaridh Martin
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - Takashi Nakashima
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - George Bazoukis
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus
- Department of Cardiology, Larnaca General Hospital, Larnaca, Cyprus
| | - Takeshi Kitamura
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - Panagiotis Mililis
- Laboratory of Cardiac Electrophysiology, General Hospital of Athens Evangelismos, Athens, Greece
| | | | - Stamatios Georgopoulos
- Laboratory of Cardiac Electrophysiology, General Hospital of Athens Evangelismos, Athens, Greece
| | - Stamatios Sofoulis
- Electrophysiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Ourania Kariki
- Electrophysiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Stavroula Koskina
- Electrophysiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Masateru Takigawa
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - Frédéric Sacher
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - Pierre Jais
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - Pasquale Santangeli
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
25
|
Campos FO, Shiferaw Y, Whitaker J, Plank G, Bishop MJ. Subthreshold delayed afterdepolarizations provide an important arrhythmogenic substrate in the border zone of infarcted hearts. Heart Rhythm 2023; 20:299-306. [PMID: 36343889 DOI: 10.1016/j.hrthm.2022.10.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Fernando O Campos
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom.
| | - Yohannes Shiferaw
- Department of Physics, University of California, Los Angeles, California
| | - John Whitaker
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Gernot Plank
- Gottfried Schatz Research Center, Division of Biophysics, Medical University of Graz, Graz, Austria
| | - Martin J Bishop
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| |
Collapse
|
26
|
Atreya AR, Yalagudri SD, Subramanian M, Rangaswamy VV, Saggu DK, Narasimhan C. Best Practices for the Catheter Ablation of Ventricular Arrhythmias. Card Electrophysiol Clin 2022; 14:571-607. [PMID: 36396179 DOI: 10.1016/j.ccep.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Techniques for catheter ablation have evolved to effectively treat a range of ventricular arrhythmias. Pre-operative electrocardiographic and cardiac imaging data are very useful in understanding the arrhythmogenic substrate and can guide mapping and ablation. In this review, we focus on best practices for catheter ablation, with emphasis on tailoring ablation strategies, based on the presence or absence of structural heart disease, underlying clinical status, and hemodynamic stability of the ventricular arrhythmia. We discuss steps to make ablation safe and prevent complications, and techniques to improve the efficacy of ablation, including optimal use of electroanatomical mapping algorithms, energy delivery, intracardiac echocardiography, and selective use of mechanical circulatory support.
Collapse
Affiliation(s)
- Auras R Atreya
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India; Division of Cardiovascular Medicine, Electrophysiology Section, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sachin D Yalagudri
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India
| | - Muthiah Subramanian
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India
| | | | - Daljeet Kaur Saggu
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India
| | - Calambur Narasimhan
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India.
| |
Collapse
|
27
|
Ventricular Tachycardia Corridors and Fat. JACC Clin Electrophysiol 2022; 8:1286-1288. [DOI: 10.1016/j.jacep.2022.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/05/2022] [Indexed: 11/06/2022]
|
28
|
Sung E, Prakosa A, Zhou S, Berger RD, Chrispin J, Nazarian S, Trayanova NA. Fat infiltration in the infarcted heart as a paradigm for ventricular arrhythmias. NATURE CARDIOVASCULAR RESEARCH 2022; 1:933-945. [PMID: 36589896 PMCID: PMC9802586 DOI: 10.1038/s44161-022-00133-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Infiltrating adipose tissue (inFAT) has been recently found to co-localize with scar in infarcted hearts and may contribute to ventricular arrhythmias (VAs), a life-threatening heart rhythm disorder. However, the contribution of inFAT to VA has not been well-established. We investigated the role of inFAT versus scar in VA through a combined prospective clinical and mechanistic computational study. Using personalized computational heart models and comparing the results from simulations of VA dynamics with measured electrophysiological abnormalities during the clinical procedure, we demonstrate that inFAT, rather than scar, is a primary driver of arrhythmogenic propensity and is frequently present in critical regions of the VA circuit. We determined that, within the VA circuitry, inFAT, as opposed to scar, is primarily responsible for conduction slowing in critical sites, mechanistically promoting VA. Our findings implicate inFAT as a dominant player in infarct-related VA, challenging existing paradigms and opening the door for unexplored anti-arrhythmic strategies.
Collapse
Affiliation(s)
- Eric Sung
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA
| | - Adityo Prakosa
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA
| | - Shijie Zhou
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA
| | - Ronald D. Berger
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA.,Department of Medicine, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jonathan Chrispin
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA.,Department of Medicine, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, USA.,These authors jointly supervised this work: Jonathan Chrispin, Saman Nazarian, Natalia A. Trayanova
| | - Saman Nazarian
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,These authors jointly supervised this work: Jonathan Chrispin, Saman Nazarian, Natalia A. Trayanova
| | - Natalia A. Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA.,These authors jointly supervised this work: Jonathan Chrispin, Saman Nazarian, Natalia A. Trayanova.,Correspondence and requests for materials should be addressed to Natalia A. Trayanova.
| |
Collapse
|
29
|
Tetreault-Langlois M, Frontera A, Hadjis AE. Incessant ventricular tachycardia with simultaneous recording of separate exits with common isthmus wavefront propagation. Heart Rhythm O2 2022; 3:710-712. [PMID: 36589914 PMCID: PMC9795278 DOI: 10.1016/j.hroo.2022.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Affiliation(s)
- Marianne Tetreault-Langlois
- Division of Cardiology, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Antonio Frontera
- Cardiac Arrhythmia department, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Alexios E. Hadjis
- Division of Cardiology, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, Quebec, Canada
- Address reprint requests and correspondence: Dr Alexios E. Hadjis, Division of Cardiology, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec H4J 1C5, Canada.
| |
Collapse
|
30
|
Elliott MK, Costa CM, Whitaker J, Gemmell P, Mehta VS, Sidhu BS, Gould J, Williams SE, O'Neill M, Razavi R, Niederer S, Bishop MJ, Rinaldi CA. Effect of scar and pacing location on repolarization in a porcine myocardial infarction model. Heart Rhythm O2 2022; 3:186-195. [PMID: 35496454 PMCID: PMC9043407 DOI: 10.1016/j.hroo.2022.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background The effect of chronic ischemic scar on repolarization is unclear, with conflicting results from human and animal studies. An improved understanding of electrical remodeling within scar and border zone tissue may enhance substrate-guided ablation techniques for treatment of ventricular tachycardia. Computational modeling studies have suggested increased dispersion of repolarization during epicardial, but not endocardial, left ventricular pacing, in close proximity to scar. However, the effect of endocardial pacing near scar in vivo is unknown. Objective The purpose of this study was to investigate the effect of scar and pacing location on local repolarization in a porcine myocardial infarction model. Methods Six model pigs underwent late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) imaging followed by electroanatomic mapping of the left ventricular endocardium. LGE-CMR images were registered to the anatomic shell and scar defined by LGE. Activation recovery intervals (ARIs), a surrogate for action potential duration, and local ARI gradients were calculated from unipolar electrograms within areas of late gadolinium enhancement (aLGE) and healthy myocardium. Results There was no significant difference between aLGE and healthy myocardium in mean ARI (304.20 ± 19.44 ms vs 300.59 ± 19.22 ms; P = .43), ARI heterogeneity (23.32 ± 11.43 ms vs 24.85 ± 12.99 ms; P = .54), or ARI gradients (6.18 ± 2.09 vs 5.66 ± 2.32 ms/mm; P = .39). Endocardial pacing distance from scar did not affect ARI gradients. Conclusion Our findings suggest that changes in ARI are not an intrinsic property of surviving myocytes within scar, and endocardial pacing close to scar does not affect local repolarization.
Collapse
Affiliation(s)
- Mark K Elliott
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Caroline Mendonca Costa
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - John Whitaker
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Philip Gemmell
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Vishal S Mehta
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Baldeep S Sidhu
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Justin Gould
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Steven E Williams
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Mark O'Neill
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Reza Razavi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Martin J Bishop
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Christopher A Rinaldi
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
- Department of Cardiology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| |
Collapse
|
31
|
Hawson J, Anderson RD, Al-Kaisey A, Chieng D, Segan L, Watts T, Campbell T, Morton J, McLellan A, Kistler P, Voskoboinik A, Pathik B, Kumar S, Kalman J, Lee G. Functional Assessment of Ventricular Tachycardia Circuits and Their Underlying Substrate Using Automated Conduction Velocity Mapping. JACC Clin Electrophysiol 2022; 8:480-494. [PMID: 35450603 DOI: 10.1016/j.jacep.2021.12.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 11/03/2021] [Accepted: 12/17/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study sought to describe the utility of automated conduction velocity mapping (ACVM) in ventricular tachycardia (VT) ablation. BACKGROUND Identification of areas of slowed conduction velocity (CV) is critical to our understanding of VT circuits and their underlying substrate. Recently, an ACVM called Coherent Mapping (Biosense Webster Inc) has been developed for atrial mapping. However, its utility in VT mapping has not been described. METHODS Patients with paired high-density VT activation and substrate maps were included. ACVM was applied to paired VT activation and substrate maps to assess regional CV and activation patterns. A combination of ACVM, traditional local activation time maps, electrogram analysis, and off-line calculated CV using triangulation were used to characterize zones of slowed conduction during VT and in substrate mapping. RESULTS Fifteen patients were included in the study. In all cases, ACVM identified slow CV within the putative VT isthmus, which colocalized to the VT isthmus identified with entrainment. The dimensions of the VT isthmus with local activation time mapping were 37.8 ± 13.7 mm long and 8.7 ± 4.2 mm wide. In comparison, ACVM produced an isthmus that was shorter (length: 25.1 ± 10.6 mm; mean difference: 12.8; 95% CI: 7.5-18.0; P < 0.01) and wider (width: 18.8 ± 8.1 mm; mean difference: 10.1; 95% CI: 6.1-14.2; P < 0.01). In VT, the CV using triangulation at the entrance (8.0 ± 3.6 cm/s) and midisthmus (8.1 ± 4.3 cm/s) was not significantly different (P = 0.92) but was significantly faster at the exit (16.2 ± 9.7 cm/s; P < 0.01). In the paired substrate analysis, traditional local activation time isochronal mapping identified 6.3 ± 2.0 deceleration zones. In contrast, ACVM identified a median of 0 deceleration zones (IQR: 0-1; P < 0.01). CONCLUSIONS ACVM is a novel complementary tool that can be used to accurately resolve complex VT circuits and identify slow conduction zones in VT but has limited accuracy in identifying slowed conduction during substrate-based mapping.
Collapse
Affiliation(s)
- Joshua Hawson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Robert D Anderson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Ahmed Al-Kaisey
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - David Chieng
- Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Louise Segan
- Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Troy Watts
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Timothy Campbell
- Faculty of Medicine and Health, Western Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Joseph Morton
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Alexander McLellan
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Peter Kistler
- Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Aleksander Voskoboinik
- Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Bhupesh Pathik
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital and Westmead Applied Research Centre, Westmead, New South Wales, Australia; Faculty of Medicine and Health, Western Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia.
| |
Collapse
|
32
|
Rossi P, Cauti FM, Polselli M, Corradetti S, Bianchi S. Local inhomogeneous conduction and non-uniform anisotropism in a normal voltage atrial map. J Interv Card Electrophysiol 2022; 64:759-760. [PMID: 35246770 DOI: 10.1007/s10840-022-01162-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 02/16/2022] [Indexed: 11/25/2022]
Abstract
A patient with symptomatic persistent atrial fibrillation and recurrences after pulmonary vein isolation (PVI) underwent a second ablation procedure. The PVs were found isolated and the left atrial substrate tissue was mapped. During sinus rhythm, the voltage map resulted in a normal range (>0,5mV) while a map of EGMs durations revealed an area presenting prolonged EGMs (>45 ms) in the anterior region. The activation map of this area demonstrated abnormal conduction and a non-uniform anisotropism when compared with areas in which EGM's normal durations were recorded. The EGMs duration map may offer additional clinical information on the areas presenting abnormal conduction predisposing arrhythmias maintenance in patients suffering from persistent atrial fibrillation.
Collapse
Affiliation(s)
- Pietro Rossi
- Cardiology Division, Arrhythmology Unit, S. Giovanni Calibita Hospital, Isola Tiberina, Via Ponte Quattro Capi, 39, 00186, Rome, Italy.
| | - Filippo Maria Cauti
- Cardiology Division, Arrhythmology Unit, S. Giovanni Calibita Hospital, Isola Tiberina, Via Ponte Quattro Capi, 39, 00186, Rome, Italy
| | - Marco Polselli
- Cardiology Division, Arrhythmology Unit, S. Giovanni Calibita Hospital, Isola Tiberina, Via Ponte Quattro Capi, 39, 00186, Rome, Italy
| | - Sara Corradetti
- Cardiology Division, Arrhythmology Unit, S. Giovanni Calibita Hospital, Isola Tiberina, Via Ponte Quattro Capi, 39, 00186, Rome, Italy
| | - Stefano Bianchi
- Cardiology Division, Arrhythmology Unit, S. Giovanni Calibita Hospital, Isola Tiberina, Via Ponte Quattro Capi, 39, 00186, Rome, Italy
| |
Collapse
|