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Odland HH, Holm T, Cornelussen R, Kongsgård E. Determinants of the time-to-peak left ventricular dP/dt (Td) and QRS duration with different fusion strategies in cardiac resynchronization therapy. Front Cardiovasc Med 2022; 9:979581. [PMID: 36186985 PMCID: PMC9520326 DOI: 10.3389/fcvm.2022.979581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 08/23/2022] [Indexed: 12/03/2022] Open
Abstract
Background Cardiac resynchronization therapy (CRT) is helpful in selected patients; however, responder rates rarely exceed 70%. Optimization of CRT may therefore benefit a large number of patients. Time-to-peak dP/dt (Td) is a novel marker of myocardial synergy that reflects the degree of myocardial dyssynchrony with the potential to guide and optimize treatment with CRT. Optimal electrical activation is a prerequisite for CRT to be effective. Electrical activation can be altered by changing the electrical wave-front fusion resulting from pacing to optimize resynchronization. We designed this study to understand the acute effects of different electrical wave-front fusion strategies and LV pre-/postexcitation on Td and QRS duration (QRSd). A better understanding of measuring and optimizing resynchronization can help improve the benefits of CRT. Methods Td and QRSd were measured in 19 patients undergoing a CRT implantation. Two biventricular pacing groups were compared: pacing the left ventricle (LV) with fusion with intrinsic right ventricular activation (FUSION group) and pacing the LV and right ventricle (RV) at short atrioventricular delay (STANDARD group) to avoid fusion with intrinsic RV activation. A quadripolar LV lead enabled pacing from widely separated electrodes; distal (DIST), proximal (PROX) and both electrodes combined (multipoint pacing, MPP). The LV was stimulated relative in time to RV activation (either RV pace-onset or QRS-onset), with the LV stimulated prior to (PRE), simultaneous with (SIM) or after (POST) RV activation. In addition, we analyzed the interactions of the two groups (FUSION/STANDARD) with three different electrode configurations (DIST, PROX, MPP), each paced with three different degrees of LV pre-/postexcitation (PRE, SIM, POST) in a statistical model. Results We found that FUSION provided shorter Td and QRSd than STANDARD, MPP provided shorter Td and QRSd than DIST and PROX, and SIM provided both the shortest QRSd and Td compared to PRE and POST. The interaction analysis revealed that pacing MPP with fusion with intrinsic RV activation simultaneous with the onset of the QRS complex (MPP*FUSION*SIM) shortened QRSd and Td the most compared to all other modes and configurations. The difference in QRSd and Td from their respective references were significantly correlated (β = 1, R = 0.9, p < 0.01). Conclusion Pacing modes and electrode configurations designed to optimize electrical wave-front fusion (intrinsic RV activation, LV multipoint pacing and simultaneous RV and LV activation) shorten QRSd and Td the most. As demonstrated in this study, electrical and mechanical measures of resynchronization are highly correlated. Therefore, Td can potentially serve as a marker for CRT optimization.
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Affiliation(s)
- Hans Henrik Odland
- Department of Cardiology and Pediatric Cardiology, Section for Arrhythmias, Oslo University Hospital, Oslo, Norway
- *Correspondence: Hans Henrik Odland
| | - Torbjørn Holm
- Department of Cardiology, Section for Arrhythmias, Oslo University Hospital, Oslo, Norway
| | | | - Erik Kongsgård
- Department of Cardiology, Section for Arrhythmias, Oslo University Hospital, Oslo, Norway
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Programming Algorithms for Cardiac Resynchronization Therapy. Card Electrophysiol Clin 2022; 14:243-252. [PMID: 35715082 DOI: 10.1016/j.ccep.2021.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Current cardiac resynchronization therapy (CRT) implant guidelines emphasize the presence of electrical dyssynchrony (left bundle branch block (LBBB) and QRS > 150 ms) yet have modest predictive value for response and have not reduced the 30% nonresponse rate. Optimized programming to optimize CRT delivery has promised much but to date has largely been ineffective. What is missing is the understanding of LV paced effects (which are unpredictable) and optimal paced AV interval (that can be conserved during physiologic variations) that then can be incorporated into an individualized programming prescription. Automatic device-based algorithms that deliver electrical optimization and maintain this during ambulatory fluctuations in AV interval are discussed.
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Sedova K, Repin K, Donin G, Dam PV, Kautzner J. Clinical Utility of Body Surface Potential Mapping in CRT Patients. Arrhythm Electrophysiol Rev 2021; 10:113-119. [PMID: 34401184 PMCID: PMC8335851 DOI: 10.15420/aer.2021.14] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/12/2021] [Indexed: 12/15/2022] Open
Abstract
This paper reviews the current status of the knowledge on body surface potential mapping (BSPM) and ECG imaging (ECGI) methods for patient selection, left ventricular (LV) lead positioning, and optimisation of CRT programming, to indicate the major trends and future perspectives for the application of these methods in CRT patients. A systematic literature review using PubMed, Scopus, and Web of Science was conducted to evaluate the available clinical evidence regarding the usage of BSPM and ECGI methods in CRT patients. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement was used as a basis for this review. BSPM and ECGI methods applied in CRT patients were assessed, and quantitative parameters of ventricular depolarisation delivered from BSPM and ECGI were extracted and summarised. BSPM and ECGI methods can be used in CRT in several ways, namely in predicting CRT outcome, in individualised optimisation of CRT device programming, and the guiding of LV electrode placement, however, further prospective or randomised trials are necessary to verify the utility of BSPM for routine clinical practice.
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Affiliation(s)
- Ksenia Sedova
- Department of Biomedical Technology, Faculty of Biomedical Engineering, Czech Technical University in Prague, Kladno, Czech Republic
| | - Kirill Repin
- Department of Biomedical Technology, Faculty of Biomedical Engineering, Czech Technical University in Prague, Kladno, Czech Republic
| | - Gleb Donin
- Department of Biomedical Technology, Faculty of Biomedical Engineering, Czech Technical University in Prague, Kladno, Czech Republic
| | - Peter Van Dam
- Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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Varma N, Baker J, Tomassoni G, Love CJ, Martin D, Sheppard R, Niazi I, Cranke G, Lee K, Corbisiero R. Left Ventricular Enlargement, Cardiac Resynchronization Therapy Efficacy, and Impact of MultiPoint Pacing. Circ Arrhythm Electrophysiol 2020; 13:e008680. [DOI: 10.1161/circep.120.008680] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Background:
Left ventricular (LV) epicardial pacing results in slowly propagating paced wavefronts. We postulated that this effect might limit cardiac resynchronization therapy efficacy in patients with LV enlargement using conventional biventricular pacing with single-site LV pacing, but be mitigated by LV stimulation from 2 widely spaced sites using MultiPoint pacing with wide anatomic separation (MPP-AS: ≥30 mm). We tested this hypothesis in the multicenter randomized MPP investigational device exemption trial.
Methods:
Following implant, quadripolar biventricular single-site pacing was activated in all patients (n=506). From 3 to 9 months postimplant, among patients with available baseline LV end-diastolic volume (LVEDV) measures, 188 received biventricular single-site pacing and 43 received MPP-AS. Patients were dichotomized by median baseline LVEDV indexed to height (LVEDVI
Median
). Outcomes were measured by the clinical composite score (primary efficacy end point), quality of life, LV structural remodeling (↑EF >5% and ↓ESV 10%) and heart failure event/cardiovascular death.
Results:
LVEDVI
Median
was 1.1 mL/cm. Baseline characteristics differed in patients with LVEDVI
>Median
versus LVEDVI
≤Median
. Among patients with LVEDVI
>Median
, biventricular single-site pacing was less efficacious compared to patients with LVEDVI
≤Median
(clinical composite score, 65% versus 79%). In contrast, MPP-AS programming generated greater clinical composite score response (92% versus 65%,
P
=0.023) and improved quality of life (−31.0±29.7 versus −15.7±22.1,
P
=0.038) versus biventricular single-site pacing in patients with LVEDVI
>Median
. Reverse remodeling trended better with MPP-AS programming. In patients with LVEDVI
>Median
, heart failure event rate increased following the 3-month randomization point with biventricular single-site pacing (0.0150±0.1725 in LVEDVI
>Median versus
−0.0190±0.0808 in LVEDVI
≤Median
,
P
=0.012), but no heart failure event occurred in patients with MPP-AS programming between 3 and 9 months in LVEDVI
>Median
. All measured outcomes did not differ in patients receiving MPP-AS and biventricular single-site pacing with LVEDVI
≤Median
.
Conclusions:
Conventional biventricular single-site pacing, even with a quadripolar lead, has reduced efficacy in patients with LV enlargement. However, the greatest response rate in patients with larger hearts was observed when programmed to MPP-AS pacing.
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Affiliation(s)
- Niraj Varma
- Cleveland Clinic Foundation, Cleveland, OH (N.V.)
| | - James Baker
- Saint Thomas Research Institute, Nashville, TN (J.B.)
| | | | | | | | | | - Imran Niazi
- Aurora Cardiovascular Services, Milwaukee, WI (I.N.)
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Moubarak G, Sebag FA, Socie P, Villejoubert O, Louembe J, Ferchaud V. Interrelationships between interventricular electrical delays in cardiac resynchronization therapy. J Cardiovasc Electrophysiol 2020; 31:2405-2414. [PMID: 32562444 DOI: 10.1111/jce.14629] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/07/2020] [Accepted: 06/14/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION In cardiac resynchronization therapy, pacing the left ventricle (LV) at sites of prolonged electrical delay is associated with better outcomes. We sought to characterize the interrelationships between intrinsic, right-ventricular (RV)-paced, and LV-paced interventricular delays. METHODS AND RESULTS The following electrical timings were measured at implantation for all electrodes of the LV quadripolar leads: QLV, interventricular delay in intrinsic rhythm (RVs-LVs), in RV-paced rhythm (RVp-LVs), and in LV-paced rhythm (LVp-RVs). We included 32 patients (78% men, age 72 years, LV ejection fraction 29%, left bundle branch block 84%). QLV and RVs-LVs were correlated (R2 = .72, p < .0001), as were RVs-LVs and RVp-LVs (R2 = .27, p = .002) and RVp-LVs and LVp-RVs (R2 = .60, p < .001). Direction of activation along the four LV lead electrodes was concordant between RVs-LVs and RVp-LVs in only 17 (53%) patients. The latest-activated electrodes in RVs-LVs and RVp-LVs were concordant in 26 (81%) patients, adjacent in 3 (9%) patients, and remote in 3 (9%) patients. Biventricular-paced QRS duration varied by more than 10 ms between the two electrodes in half of the patients with dissimilar latest electrodes. Among the seven echocardiographic nonresponders at 6 months, the programmed electrode was remote from the latest electrode in RVs-LVs in five patients and in RVp-LVs in three patients. CONCLUSION Intrinsic and RV-paced interventricular electrical delays are correlated, but there is substantial heterogeneity between patients. The latest-activated electrode may be different between RVs-LVs and RVp-LVs, and this might have important implications in selecting the optimal LV vector.
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Affiliation(s)
- Ghassan Moubarak
- Department of Electrophysiology and Pacing, Centre Médico-Chirurgical Ambroise Paré, Neuilly-sur-Seine, France
| | - Frédéric A Sebag
- Département de Cardiologie Médicale, Institut Mutualiste Montsouris, Paris, France
| | - Pierre Socie
- Department of Cardiology, Centre Hospitalier de Chartres, Chartres, France
| | - Olivier Villejoubert
- Département de Cardiologie Médicale, Institut Mutualiste Montsouris, Paris, France
| | - Jules Louembe
- Department of Cardiology, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Virginie Ferchaud
- Department of Electrophysiology and Pacing, Centre Médico-Chirurgical Ambroise Paré, Neuilly-sur-Seine, France.,Department of Cardiology, Centre Hospitalier Universitaire de Caen Normandie, Caen, France
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Bear LR, Huntjens PR, Walton RD, Bernus O, Coronel R, Dubois R. Cardiac electrical dyssynchrony is accurately detected by noninvasive electrocardiographic imaging. Heart Rhythm 2018; 15:1058-1069. [PMID: 29477975 DOI: 10.1016/j.hrthm.2018.02.024] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Poor identification of electrical dyssynchrony is postulated to be a major factor contributing to the low success rate for cardiac resynchronization therapy. OBJECTIVE The purpose of this study was to evaluate the sensitivity of body surface mapping and electrocardiographic imaging (ECGi) to detect electrical dyssynchrony noninvasively. METHODS Langendorff-perfused pig hearts (n = 11) were suspended in a human torso-shaped tank, with left bundle branch block (LBBB) induced through ablation. Recordings were taken simultaneously from a 108-electrode epicardial sock and 128 electrodes embedded in the tank surface during sinus rhythm and ventricular pacing. Computed tomography provided electrode and heart positions in the tank. Epicardial unipolar electrograms were reconstructed from torso potentials using ECGi. Dyssynchrony markers from torso potentials (eg, QRS duration) or ECGi (total activation time, interventricular delay [D-LR], and intraventricular markers) were correlated with those recorded from the sock. RESULTS LBBB was induced (n = 8), and sock-derived activation maps demonstrated interventricular dyssynchrony (D-LR and total activation time) in all cases (P < .05) and intraventricular dyssynchrony for complete LBBB (P < .05) compared to normal sinus rhythm. Only D-LR returned to normal with biventricular pacing (P = .1). Torso markers increased with large degrees of dyssynchrony, and no reduction was seen during biventricular pacing (P > .05). Although ECGi-derived markers were significantly lower than recorded (P < .05), there was a significant strong linear relationship between ECGi and recorded values. ECGi correctly diagnosed electrical dyssynchrony and interventricular resynchronization in all cases. The latest site of activation was identified to 9.1 ± 0.6 mm by ECGi. CONCLUSION ECGi reliably and accurately detects electrical dyssynchrony, resynchronization by biventricular pacing, and the site of latest activation, providing more information than do body surface potentials.
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Affiliation(s)
- Laura R Bear
- Electrophysiology and Heart Modelling Institute (IHU-LIRYC), Fondation Bordeaux Université, Pessac, France; Université de Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux U1045, France; Inserm, U1045, Centre de Recherche Cardio-Thoracique de Bordeaux, France.
| | - Peter R Huntjens
- Electrophysiology and Heart Modelling Institute (IHU-LIRYC), Fondation Bordeaux Université, Pessac, France; Université de Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux U1045, France; Inserm, U1045, Centre de Recherche Cardio-Thoracique de Bordeaux, France; CARIM School for Cardiovascular Diseases, Maastricht University MedicalCentre, Maastricht, The Netherlands
| | - Richard D Walton
- Electrophysiology and Heart Modelling Institute (IHU-LIRYC), Fondation Bordeaux Université, Pessac, France; Université de Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux U1045, France; Inserm, U1045, Centre de Recherche Cardio-Thoracique de Bordeaux, France
| | - Olivier Bernus
- Electrophysiology and Heart Modelling Institute (IHU-LIRYC), Fondation Bordeaux Université, Pessac, France; Université de Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux U1045, France; Inserm, U1045, Centre de Recherche Cardio-Thoracique de Bordeaux, France
| | - Ruben Coronel
- Electrophysiology and Heart Modelling Institute (IHU-LIRYC), Fondation Bordeaux Université, Pessac, France; Department of Experimental Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Rémi Dubois
- Electrophysiology and Heart Modelling Institute (IHU-LIRYC), Fondation Bordeaux Université, Pessac, France; Université de Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux U1045, France; Inserm, U1045, Centre de Recherche Cardio-Thoracique de Bordeaux, France
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Varma N, O'Donnell D, Bassiouny M, Ritter P, Pappone C, Mangual J, Cantillon D, Badie N, Thibault B, Wisnoskey B. Programming Cardiac Resynchronization Therapy for Electrical Synchrony: Reaching Beyond Left Bundle Branch Block and Left Ventricular Activation Delay. J Am Heart Assoc 2018; 7:e007489. [PMID: 29432133 PMCID: PMC5850248 DOI: 10.1161/jaha.117.007489] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 11/30/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND QRS narrowing following cardiac resynchronization therapy with biventricular (BiV) or left ventricular (LV) pacing is likely affected by patient-specific conduction characteristics (PR, qLV, LV-paced propagation interval), making a universal programming strategy likely ineffective. We tested these factors using a novel, device-based algorithm (SyncAV) that automatically adjusts paced atrioventricular delay (default or programmable offset) according to intrinsic atrioventricular conduction. METHODS AND RESULTS Seventy-five patients undergoing cardiac resynchronization therapy (age 66±11 years; 65% male; 32% with ischemic cardiomyopathy; LV ejection fraction 28±8%; QRS duration 162±16 ms) with intact atrioventricular conduction (PR interval 194±34, range 128-300 ms), left bundle branch block, and optimized LV lead position were studied at implant. QRS duration (QRSd) reduction was compared for the following pacing configurations: nominal simultaneous BiV (Mode I: paced/sensed atrioventricular delay=140/110 ms), BiV+SyncAV with 50 ms offset (Mode II), BiV+SyncAV with offset that minimized QRSd (Mode III), or LV-only pacing+SyncAV with 50 ms offset (Mode IV). The intrinsic QRSd (162±16 ms) was reduced to 142±17 ms (-11.8%) by Mode I, 136±14 ms (-15.6%) by Mode IV, and 132±13 ms (-17.8%) by Mode II. Mode III yielded the shortest overall QRSd (123±12 ms, -23.9% [P<0.001 versus all modes]) and was the only configuration without QRSd prolongation in any patient. QRS narrowing occurred regardless of QRSd, PR, or LV-paced intervals, or underlying ischemic disease. CONCLUSIONS Post-implant electrical optimization in already well-selected patients with left bundle branch block and optimized LV lead position is facilitated by patient-tailored BiV pacing adjusted to intrinsic atrioventricular timing using an automatic device-based algorithm.
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Affiliation(s)
| | | | | | | | - Carlo Pappone
- Department of Electrophysiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | | | | | | | - Bernard Thibault
- Electrophysiology Service, Montreal Heart Institute, Montreal, Canada
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Varma N. Left ventricular electrical activation during right ventricular pacing in heart failure patients with LBBB: Visualization by electrocardiographic imaging and implications for cardiac resynchronization therapy. J Electrocardiol 2015; 48:53-61. [DOI: 10.1016/j.jelectrocard.2014.09.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Indexed: 11/16/2022]
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Rinaldi CA, Burri H, Thibault B, Curnis A, Rao A, Gras D, Sperzel J, Singh JP, Biffi M, Bordachar P, Leclercq C. A review of multisite pacing to achieve cardiac resynchronization therapy. Europace 2014; 17:7-17. [DOI: 10.1093/europace/euu197] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Periprocedural Management of Cardiac Resynchronization Therapy. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2014; 16:298. [DOI: 10.1007/s11936-014-0298-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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van der Graaf AM, Bhagirath P, Ramanna H, van Driel VJ, de Hooge J, de Groot NM, Götte MJ. Noninvasive imaging of cardiac excitation: current status and future perspective. Ann Noninvasive Electrocardiol 2014; 19:105-13. [PMID: 24620843 PMCID: PMC6932091 DOI: 10.1111/anec.12140] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Noninvasive imaging of cardiac excitation using body surface potential mapping (BSPM) data and inverse procedures is an emerging technique that enables estimation of myocardial depolarization and repolarization. Despite numerous reports on the possible advantages of this imaging technique, it has not yet advanced into daily clinical practice. This is mainly due to the time consuming nature of data acquisition and the complexity of the mathematics underlying the used inverse procedures. However, the popularity of this field of research has increased and noninvasive imaging of cardiac electrophysiology is considered a promising tool to complement conventional invasive electrophysiological studies. Furthermore, the use of appropriately designed electrode vests and more advanced computers has greatly reduced the procedural time. This review provides descriptive overview of the research performed thus far and the possible future directions. The general challenges in routine application of BSPM and inverse procedures are discussed. In addition, individual properties of the biophysical models underlying the inverse procedures are illustrated.
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Affiliation(s)
| | - Pranav Bhagirath
- Department of CardiologyHaga Teaching HospitalThe HagueThe Netherlands
| | - Hemanth Ramanna
- Department of CardiologyHaga Teaching HospitalThe HagueThe Netherlands
| | | | - Jacques de Hooge
- Department of CardiologyHaga Teaching HospitalThe HagueThe Netherlands
| | | | - Marco J.W. Götte
- Department of CardiologyHaga Teaching HospitalThe HagueThe Netherlands
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