1
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Di Cori A, Pistelli L, Parollo M, Zaurino N, Segreti L, Zucchelli G. Approaching Ventricular Tachycardia Ablation in 2024: An Update on Mapping and Ablation Strategies, Timing, and Future Directions. J Clin Med 2024; 13:5017. [PMID: 39274230 PMCID: PMC11396273 DOI: 10.3390/jcm13175017] [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: 06/06/2024] [Revised: 08/01/2024] [Accepted: 08/22/2024] [Indexed: 09/16/2024] Open
Abstract
This review provides insights into mapping and ablation strategies for VT, offering a comprehensive overview of contemporary approaches and future perspectives in the field. The strengths and limitations of classical mapping strategies, namely activation mapping, pace mapping, entrainment mapping, and substrate mapping, are deeply discussed. The increasing pivotal relevance of CMR and MDCT in substrate definition is highlighted, particularly in defining the border zone, tissue channels, and fat. The integration of CMR and MDCT images with EAM is explored, with a special focus on their role in enhancing effectiveness and procedure safety. The abstract concludes by illustrating the Pisa workflow for the VT ablation procedure.
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Affiliation(s)
- Andrea Di Cori
- Second Division of Cardiology, Cardiac-Thoracic and Vascular Department, University Hospital of Pisa, 56124 Pisa, Italy
| | - Lorenzo Pistelli
- Second Division of Cardiology, Cardiac-Thoracic and Vascular Department, University Hospital of Pisa, 56124 Pisa, Italy
| | - Matteo Parollo
- Second Division of Cardiology, Cardiac-Thoracic and Vascular Department, University Hospital of Pisa, 56124 Pisa, Italy
| | - Nicola Zaurino
- Biosense Webster, Johnson & Johnson Medial SpA, 00071 Pomezia, Italy
| | - Luca Segreti
- Second Division of Cardiology, Cardiac-Thoracic and Vascular Department, University Hospital of Pisa, 56124 Pisa, Italy
| | - Giulio Zucchelli
- Second Division of Cardiology, Cardiac-Thoracic and Vascular Department, University Hospital of Pisa, 56124 Pisa, Italy
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2
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Leenknegt L, Panfilov AV, Dierckx H. Impact of electrode orientation, myocardial wall thickness, and myofiber direction on intracardiac electrograms: numerical modeling and analytical solutions. Front Physiol 2023; 14:1213218. [PMID: 37492643 PMCID: PMC10364610 DOI: 10.3389/fphys.2023.1213218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 06/14/2023] [Indexed: 07/27/2023] Open
Abstract
Intracardiac electrograms (iEGMs) are time traces of the electrical potential recorded close to the heart muscle. We calculate unipolar and bipolar iEGMs analytically for a myocardial slab with parallel myofibers and validate them against numerical bidomain simulations. The analytical solution obtained via the method of mirrors is an infinite series of arctangents. It goes beyond the solid angle theory and is in good agreement with the simulations, even though bath loading effects were not accounted for in the analytical calculation. At a large distance from the myocardium, iEGMs decay as 1/R (unipolar), 1/R 2 (bipolar and parallel), and 1/R 3 (bipolar and perpendicular to the endocardium). At the endocardial surface, there is a mathematical branch cut. Here, we show how a thicker myocardium generates iEGMs with larger amplitudes and how anisotropy affects the iEGM width and amplitude. If only the leading-order term of our expansion is retained, it can be determined how the conductivities of the bath, torso, myocardium, and myofiber direction together determine the iEGM amplitude. Our results will be useful in the quantitative interpretation of iEGMs, the selection of thresholds to characterize viable tissues, and for future inferences of tissue parameters.
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Affiliation(s)
- Lore Leenknegt
- Department of Mathematics, KU Leuven Campus KULAK, KU Leuven, Kortrijk, Belgium
- iSi Health–KU Leuven Institute of Physics-based Modeling for In Silico Health, KU Leuven, Leuven, Belgium
| | | | - Hans Dierckx
- Department of Mathematics, KU Leuven Campus KULAK, KU Leuven, Kortrijk, Belgium
- iSi Health–KU Leuven Institute of Physics-based Modeling for In Silico Health, KU Leuven, Leuven, Belgium
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3
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van Schie MS, Starreveld R, Bogers AJJC, de Groot NMS. Sinus rhythm voltage fingerprinting in patients with mitral valve disease using a high-density epicardial mapping approach. Europace 2021; 23:469-478. [PMID: 33432326 PMCID: PMC7947572 DOI: 10.1093/europace/euaa336] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 10/06/2020] [Indexed: 12/03/2022] Open
Abstract
Aims Unipolar voltage (UV) mapping is increasingly used for guiding ablative therapy of atrial fibrillation (AF) as unipolar electrograms (U-EGMs) are independent of electrode orientation and atrial wavefront direction. This study was aimed at constructing individual, high-resolution sinus rhythm (SR) UV fingerprints to identify low-voltage areas and study the effect of AF episodes in patients with mitral valve disease (MVD). Methods and results Intra-operative epicardial mapping (interelectrode distance 2 mm) of the right and left atrium, Bachmann’s bundle (BB), and pulmonary vein area was performed in 67 patients (27 male, 67 ± 11 years) with or without a history of paroxysmal AF (PAF). In all patients, there were considerable regional variations in voltages. UVs at BB were lower in patients with PAF compared with those without [no AF: 4.94 (3.56–5.98) mV, PAF: 3.30 (2.25–4.57) mV, P = 0.006]. A larger number of low-voltage potentials were recorded at BB in the PAF group [no AF: 2.13 (0.52–7.68) %, PAF: 12.86 (3.18–23.59) %, P = 0.001]. In addition, areas with low-voltage potentials were present in all patients, yet we did not find any predilection sites for low-voltage potentials to occur. Conclusion Even in SR, advanced atrial remodelling in MVD patients shows marked inter-individual and regional variation. Low UVs are even present during SR in patients without a history of AF indicating that low UVs should carefully be used as target sites for ablative therapy.
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Affiliation(s)
- Mathijs S van Schie
- Department of Cardiology, Erasmus Medical Center, Dr Molewaterplein 40, 3015GD Rotterdam, The Netherlands
| | - Roeliene Starreveld
- Department of Cardiology, Erasmus Medical Center, Dr Molewaterplein 40, 3015GD Rotterdam, The Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, 3015GD Rotterdam, The Netherlands
| | - Natasja M S de Groot
- Department of Cardiology, Erasmus Medical Center, Dr Molewaterplein 40, 3015GD Rotterdam, The Netherlands
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4
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van Schie MS, Kharbanda RK, Houck CA, Lanters EAH, Taverne YJHJ, Bogers AJJC, de Groot NMS. Identification of Low-Voltage Areas: A Unipolar, Bipolar, and Omnipolar Perspective. Circ Arrhythm Electrophysiol 2021; 14:e009912. [PMID: 34143644 PMCID: PMC8294660 DOI: 10.1161/circep.121.009912] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Low-voltage areas (LVAs) are commonly considered surrogate markers for an arrhythmogenic substrate underlying tachyarrhythmias. It remains challenging to define a proper threshold to classify LVA, and it is unknown whether unipolar, bipolar, and the recently introduced omnipolar voltage mapping techniques are complementary or contradictory in classifying LVAs. Therefore, this study examined similarities and dissimilarities in unipolar, bipolar, and omnipolar voltage mapping and explored the relation between various types of voltages and conduction velocity (CV).
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Affiliation(s)
- Mathijs S van Schie
- Department of Cardiology (M.S.v.S., R.K.K., C.A.H., E.A.H.L., N.M.S.d.G.), Erasmus Medical Center, Rotterdam, the Netherlands
| | - Rohit K Kharbanda
- Department of Cardiology (M.S.v.S., R.K.K., C.A.H., E.A.H.L., N.M.S.d.G.), Erasmus Medical Center, Rotterdam, the Netherlands.,Department of Cardiothoracic Surgery (R.K.K., C.A.H., Y.J.H.J.T., A.J.J.C.B.), Erasmus Medical Center, Rotterdam, the Netherlands
| | - Charlotte A Houck
- Department of Cardiothoracic Surgery (R.K.K., C.A.H., Y.J.H.J.T., A.J.J.C.B.), Erasmus Medical Center, Rotterdam, the Netherlands
| | - Eva A H Lanters
- Department of Cardiology (M.S.v.S., R.K.K., C.A.H., E.A.H.L., N.M.S.d.G.), Erasmus Medical Center, Rotterdam, the Netherlands
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery (R.K.K., C.A.H., Y.J.H.J.T., A.J.J.C.B.), Erasmus Medical Center, Rotterdam, the Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery (R.K.K., C.A.H., Y.J.H.J.T., A.J.J.C.B.), Erasmus Medical Center, Rotterdam, the Netherlands
| | - Natasja M S de Groot
- Department of Cardiology (M.S.v.S., R.K.K., C.A.H., E.A.H.L., N.M.S.d.G.), Erasmus Medical Center, Rotterdam, the Netherlands
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5
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Left atrial voltage mapping: defining and targeting the atrial fibrillation substrate. J Interv Card Electrophysiol 2019; 56:213-227. [PMID: 31076965 PMCID: PMC6900285 DOI: 10.1007/s10840-019-00537-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 03/12/2019] [Indexed: 12/23/2022]
Abstract
Low atrial endocardial bipolar voltage, measured during catheter ablation for atrial fibrillation (AF), is a commonly used surrogate marker for the presence of atrial fibrosis. Low voltage shows many useful associations with clinical outcomes, comorbidities and has links to trigger sites for AF. Several contemporary trials have shown promise in targeting low voltage areas as the substrate for AF ablation; however, the results have been mixed. In order to understand these results, a thorough understanding of voltage mapping techniques, the relationship between low voltage and the pathophysiology of AF, as well as the inherent limitations in voltage measurement are needed. Two key questions must be answered in order to optimally apply voltage mapping as the road map for ablation. First, are the inherent limitations of voltage mapping small enough as to be ignored when targeting specific tissue based on voltage? Second, can conventional criteria, using a binary threshold for voltage amplitude, truly define the extent of the atrial fibrotic substrate? Here, we review the latest clinical evidence with regard to voltage-based ablation procedures before analysing the utility and limitations of voltage mapping. Finally, we discuss omnipole mapping and dynamic voltage attenuation as two possible approaches to resolving these issues.
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6
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Hwang M, Kim J, Lim B, Song JS, Joung B, Shim EB, Pak HN. Multiple factors influence the morphology of the bipolar electrogram: An in silico modeling study. PLoS Comput Biol 2019; 15:e1006765. [PMID: 30951529 PMCID: PMC6469793 DOI: 10.1371/journal.pcbi.1006765] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 04/17/2019] [Accepted: 01/07/2019] [Indexed: 12/04/2022] Open
Abstract
Although bipolar electrograms (Bi-egms) are commonly used for catheter mapping and ablation of cardiac arrhythmias, the accuracy and reproducibility of Bi-egms have not been evaluated. We aimed to clarify the influence of the catheter orientation (CO), catheter contact angle (CA), local conduction velocity (CV), scar size, and catheter type on the Bi-egm morphology using an in silico 3-dimensional realistic model of atrial fibrillation. We constructed a 3-dimensional, realistic, in silico left atrial model with activation wave propagation including bipolar catheter models. Bi-egms were obtained by computing the extracellular potentials from the distal and proximal electrodes. The amplitude and width were measured on virtual Bi-egms obtained under different conditions created by changing the CO according to the wave direction, catheter-atrial wall CA, local CV, size of the non-conductive area, and catheter type. Bipolar voltages were also compared between virtual and clinically acquired Bi-egms. Bi-egm amplitudes were lower for a perpendicular than parallel CO relative to the wave direction (p<0.001), lower for a 90° than 0° CA (p<0.001), and lower for a CV of 0.13m/s than 0.48m/s (p<0.001). Larger sized non-conductive areas were associated with a decreased bipolar amplitude (p<0.001) and increased bipolar width (p<0.001). Among three commercially available catheters (Orion, Pentaray, and Thermocool), those with more narrowly spaced and smaller electrodes produced higher voltages on the virtual Bi-egms (p<0.001). Multiple factors including the CO, CA, CV, and catheter design significantly influence the Bi-egm morphology. Universal voltage cut-off values may not be appropriate for bipolar voltage-guided substrate mapping. Cardiac arrhythmias are rhythm disorders of the heart leading to abnormal heart function. For the diagnosis and treatment of the arrhythmias, clinicians insert catheters into the heart and examine the electrical signal propagation in the heart. Among different type of catheters, bipolar catheters have two electrodes at the tip of the catheter with the signal being the difference between the two electrodes, which provides sharper signal than unipolar catheter. However, bipolar electrogram is dependent on many factors including catheter design and orientation, and consequently, knowledge of the determinants of the bipolar electrogram is needed for proper interpretation of the signal. In this study, we examined the effects of many factors on bipolar electrogram using computer simulation. Computer simulation is very useful in this type of study because, in clinical settings, it is not feasible to control each factor precisely. We quantitatively demonstrated the effects of catheter design and orientation, and cardiac wave propagation speed on bipolar electrogram.
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Affiliation(s)
- Minki Hwang
- Division of Cardiology, Yonsei University Health System, Seoul, Republic of Korea
| | - Jaehyuk Kim
- Division of Cardiology, Yonsei University Health System, Seoul, Republic of Korea
| | - Byounghyun Lim
- Division of Cardiology, Yonsei University Health System, Seoul, Republic of Korea
| | - Jun-Seop Song
- Division of Cardiology, Yonsei University Health System, Seoul, Republic of Korea
| | - Boyoung Joung
- Division of Cardiology, Yonsei University Health System, Seoul, Republic of Korea
| | - Eun Bo Shim
- Department of Mechanical and Biomedical Engineering, Kangwon National University, Chuncheon, Kangwon-do, Republic of Korea
| | - Hui-Nam Pak
- Division of Cardiology, Yonsei University Health System, Seoul, Republic of Korea
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7
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Kitamura T, Martin CA, Vlachos K, Martin R, Frontera A, Takigawa M, Thompson N, Cheniti G, Massouille G, Lam A, Bourier F, Duchateau J, Pambrun T, Denis A, Derval N, Hocini M, HaÏssaguerre M, Cochet H, JaÏs P, Sacher F. Substrate Mapping and Ablation for Ventricular Tachycardia in Patients with Structural Heart Disease: How to Identify Ventricular Tachycardia Substrate. J Innov Card Rhythm Manag 2019; 10:3565-3580. [PMID: 32477720 PMCID: PMC7252795 DOI: 10.19102/icrm.2019.100302] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 08/20/2018] [Indexed: 01/02/2023] Open
Abstract
Catheter ablation for ventricular tachycardia (VT) has been increasingly used over the past two decades in patients with structural heart disease (SHD). In these individuals, a substrate mapping strategy is being more commonly applied to identify targets for VT ablation, which has been shown to be more effective versus targeting mappable VTs alone. There are a number of substrate mapping methods in existence that aim to explore potential VT isthmuses, although their success rates vary. Most of the reported electrogram-based mapping studies have been performed with ablation catheters; meanwhile, the use of multipolar mapping catheters with smaller electrodes and closer interelectrode spacing has emerged, which allows for an assessment of detailed near-field abnormal electrograms at a higher resolution. Another recent advancement has occurred in the use of imaging techniques in VT ablation, particularly in refining the substrate. The goal of this paper is to review the key developments and limitations of current mapping strategies of substrate-based VT ablation and their outcomes. In addition, we briefly summarize the role of cardiac imaging in delineating VT substrate.
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Affiliation(s)
- Takeshi Kitamura
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France.,Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Claire A Martin
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France.,Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Konstantinos Vlachos
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Ruairidh Martin
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France.,Newcastle University, Newcastle-upon-Tyne, UK
| | - Antonio Frontera
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France.,San Raffaele Hospital, Milan, Italy
| | - Masateru Takigawa
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Nathaniel Thompson
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Ghassen Cheniti
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Gregoire Massouille
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Anna Lam
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Felix Bourier
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Josselin Duchateau
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Thomas Pambrun
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Arnaud Denis
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Nicolas Derval
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Meleze Hocini
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Michel HaÏssaguerre
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Hubert Cochet
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Pierre JaÏs
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Frédéric Sacher
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
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8
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Nguyên UC, Potse M, Vernooy K, Mafi-Rad M, Heijman J, Caputo ML, Conte G, Regoli F, Krause R, Moccetti T, Auricchio A, Prinzen FW, Maffessanti F. A left bundle branch block activation sequence and ventricular pacing influence voltage amplitudes: anin vivoandin silicostudy. Europace 2018; 20:iii77-iii86. [DOI: 10.1093/europace/euy233] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 10/31/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Uyên Châu Nguyên
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), PO Box 616, Maastricht MD, the Netherlands
- Department of Cardiology, CARIM, MUMC+, Maastricht, the Netherlands
| | - Mark Potse
- CARMEN Research Team, Inria Bordeaux Sud-Ouest, Talence F-33400, France
- Université de Bordeaux, IMB, UMR 5251, Talence F-33400, France
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Foundation Bordeaux Université, Pessac, Bordeaux F-33600, France
| | - Kevin Vernooy
- Department of Cardiology, CARIM, MUMC+, Maastricht, the Netherlands
- Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Masih Mafi-Rad
- Department of Cardiology, CARIM, MUMC+, Maastricht, the Netherlands
| | - Jordi Heijman
- Department of Cardiology, CARIM, MUMC+, Maastricht, the Netherlands
| | - Maria Luce Caputo
- Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Giulio Conte
- Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - François Regoli
- Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Rolf Krause
- Center for Computational Medicine in Cardiology (CCMC), Institute of Computational Science, Università della Svizzera italiana, Lugano, Switzerland
| | - Tiziano Moccetti
- Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Angelo Auricchio
- Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland
- Center for Computational Medicine in Cardiology (CCMC), Institute of Computational Science, Università della Svizzera italiana, Lugano, Switzerland
| | - Frits W Prinzen
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center (MUMC+), PO Box 616, Maastricht MD, the Netherlands
| | - Francesco Maffessanti
- Center for Computational Medicine in Cardiology (CCMC), Institute of Computational Science, Università della Svizzera italiana, Lugano, Switzerland
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9
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Determinants of atrial bipolar voltage: Inter electrode distance and wavefront angle. Comput Biol Med 2018; 102:449-457. [DOI: 10.1016/j.compbiomed.2018.07.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 07/16/2018] [Accepted: 07/16/2018] [Indexed: 11/18/2022]
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10
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Nuñez-Garcia M, Camara O, O'Neill MD, Razavi R, Chubb H, Butakoff C. Mind the gap: Quantification of incomplete ablation patterns after pulmonary vein isolation using minimum path search. Med Image Anal 2018; 51:1-12. [PMID: 30347332 DOI: 10.1016/j.media.2018.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 10/02/2018] [Accepted: 10/05/2018] [Indexed: 10/28/2022]
Abstract
Pulmonary vein isolation (PVI) is a common procedure for the treatment of atrial fibrillation (AF) since the initial trigger for AF frequently originates in the pulmonary veins. A successful isolation produces a continuous lesion (scar) completely encircling the veins that stops activation waves from propagating to the atrial body. Unfortunately, the encircling lesion is often incomplete, becoming a combination of scar and gaps of healthy tissue. These gaps are potential causes of AF recurrence, which requires a redo of the isolation procedure. Late-gadolinium enhanced cardiac magnetic resonance (LGE-CMR) is a non-invasive method that may also be used to detect gaps, but it is currently a time-consuming process, prone to high inter-observer variability. In this paper, we present a method to semi-automatically identify and quantify ablation gaps. Gap quantification is performed through minimum path search in a graph where every node is a scar patch and the edges are the geodesic distances between patches. We propose the Relative Gap Measure (RGM) to estimate the percentage of gap around a vein, which is defined as the ratio of the overall gap length and the total length of the path that encircles the vein. Additionally, an advanced version of the RGM has been developed to integrate gap quantification estimates from different scar segmentation techniques into a single figure-of-merit. Population-based statistical and regional analysis of gap distribution was performed using a standardised parcellation of the left atrium. We have evaluated our method on synthetic and clinical data from 50 AF patients who underwent PVI with radiofrequency ablation. The population-based analysis concluded that the left superior PV is more prone to lesion gaps while the left inferior PV tends to have less gaps (p < .05 in both cases), in the processed data. This type of information can be very useful for the optimization and objective assessment of PVI interventions.
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Affiliation(s)
- Marta Nuñez-Garcia
- Physense, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain.
| | - Oscar Camara
- Physense, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain
| | - Mark D O'Neill
- Division of Imaging Sciences and Biomedical Engineering, King's College London, UK
| | - Reza Razavi
- Division of Imaging Sciences and Biomedical Engineering, King's College London, UK
| | - Henry Chubb
- Division of Imaging Sciences and Biomedical Engineering, King's College London, UK
| | - Constantine Butakoff
- Physense, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain
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11
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Kik C, Mouws EMJP, Bogers AJJC, de Groot NMS. Intra-operative mapping of the atria: the first step towards individualization of atrial fibrillation therapy? Expert Rev Cardiovasc Ther 2017; 15:537-545. [PMID: 28591518 DOI: 10.1080/14779072.2017.1340156] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Atrial fibrillation (AF), an age-related progressive disease, is becoming a worldwide epidemic with a prevalence rate of 33 million. Areas covered: In this expert review, an overview of important results obtained from previous intra-operative mapping studies is provided. In addition, our novel intra-operative high resolution mapping studies, its surgical considerations and data analyses are discussed. Furthermore, the importance of high resolution mapping studies of both sinus rhythm and AF for the development of future AF therapy is underlined by our most recent results. Expert commentary: Progression of AF is determined by the extensiveness of electropathology which is defined as conduction disorders caused by structural damage of atrial tissue. The severity of electropathology is a major determinant of therapy failure. At present, we do not have any diagnostic tool to determine the degree of electropathology in the individual patient and we can thus not select the most optimal treatment modality for the individual patient. An intra-operative, high resolution scale, epicardial mapping approach combined with quantification of electrical parameters may serve as a diagnostic tool to stage AF in the individual patient and to provide patient tailored therapy.
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Affiliation(s)
- Charles Kik
- b Department of Cardiothoracic Surgery , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Elisabeth M J P Mouws
- a Department of Cardiology , Erasmus Medical Center , Rotterdam , The Netherlands.,b Department of Cardiothoracic Surgery , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Ad J J C Bogers
- b Department of Cardiothoracic Surgery , Erasmus Medical Center , Rotterdam , The Netherlands
| | - Natasja M S de Groot
- a Department of Cardiology , Erasmus Medical Center , Rotterdam , The Netherlands
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12
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Graham AJ, Orini M, Lambiase PD. Limitations and Challenges in Mapping Ventricular Tachycardia: New Technologies and Future Directions. Arrhythm Electrophysiol Rev 2017; 6:118-124. [PMID: 29018519 DOI: 10.15420/aer.2017.20.1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Recurrent episodes of ventricular tachycardia in patients with structural heart disease are associated with increased mortality and morbidity, despite the life-saving benefits of implantable cardiac defibrillators. Reducing implantable cardiac defibrillator therapies is important, as recurrent shocks can cause increased myocardial damage and stunning, despite the conversion of ventricular tachycardia/ventricular fibrillation. Catheter ablation has emerged as a potential therapeutic option either for primary or secondary prevention of these arrhythmias, particularly in post-myocardial infarction cases where the substrate is well defined. However, the outcomes of catheter ablation of ventricular tachycardia in structural heart disease remain unsatisfactory in comparison with other electrophysiological procedures. The disappointing efficacy of ventricular tachycardia ablation in structural heart disease is multifactorial. In this review, we discuss the issues surrounding this and examine the limitations of current mapping approaches, as well as newer technologies that might help address them.
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Affiliation(s)
| | - Michele Orini
- Barts Heart Centre, London.,Institute of Cardiovascular Science, UCL, London, United Kingdom
| | - Pier D Lambiase
- Barts Heart Centre, London.,Institute of Cardiovascular Science, UCL, London, United Kingdom
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13
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Song JS, Lee YS, Hwang M, Lee JK, Li C, Joung B, Lee MH, Shim EB, Pak HN. Spatial reproducibility of complex fractionated atrial electrogram depending on the direction and configuration of bipolar electrodes: an in-silico modeling study. THE KOREAN JOURNAL OF PHYSIOLOGY & PHARMACOLOGY : OFFICIAL JOURNAL OF THE KOREAN PHYSIOLOGICAL SOCIETY AND THE KOREAN SOCIETY OF PHARMACOLOGY 2016; 20:507-14. [PMID: 27610037 PMCID: PMC5014997 DOI: 10.4196/kjpp.2016.20.5.507] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/08/2016] [Accepted: 07/11/2016] [Indexed: 12/02/2022]
Abstract
Although 3D-complex fractionated atrial electrogram (CFAE) mapping is useful in radiofrequency catheter ablation for persistent atrial fibrillation (AF), the directions and configuration of the bipolar electrodes may affect the electrogram. This study aimed to compare the spatial reproducibility of CFAE by changing the catheter orientations and electrode distance in an in-silico left atrium (LA). We conducted this study by importing the heart CT image of a patient with AF into a 3D-homogeneous human LA model. Electrogram morphology, CFAE-cycle lengths (CLs) were compared for 16 different orientations of a virtual bipolar conventional catheter (conv-cath: size 3.5 mm, inter-electrode distance 4.75 mm). Additionally, the spatial correlations of CFAE-CLs and the percentage of consistent sites with CFAE-CL<120 ms were analyzed. The results from the conv-cath were compared with that obtained using a mini catheter (mini-cath: size 1 mm, inter-electrode distance 2.5 mm). Depending on the catheter orientation, the electrogram morphology and CFAE-CLs varied (conv-cath: 11.5±0.7% variation, mini-cath: 7.1±1.2% variation), however the mini-cath produced less variation of CFAE-CL than conv-cath (p<0.001). There were moderate spatial correlations among CFAE-CL measured at 16 orientations (conv-cath: r=0.3055±0.2194 vs. mini-cath: 0.6074±0.0733, p<0.001). Additionally, the ratio of consistent CFAE sites was higher for mini catheter than conventional one (38.3±4.6% vs. 22.3±1.4%, p<0.05). Electrograms and CFAE distribution are affected by catheter orientation and electrode configuration in the in-silico LA model. However, there was moderate spatial consistency of CFAE areas, and narrowly spaced bipolar catheters were less influenced by catheter direction than conventional catheters.
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Affiliation(s)
- Jun-Seop Song
- Division of Cardiology, Yonsei University Health System, Seoul 03722, Korea
| | - Young-Seon Lee
- Division of Cardiology, Yonsei University Health System, Seoul 03722, Korea
| | - Minki Hwang
- Division of Cardiology, Yonsei University Health System, Seoul 03722, Korea
| | - Jung-Kee Lee
- Division of Cardiology, Yonsei University Health System, Seoul 03722, Korea
| | - Changyong Li
- Division of Cardiology, Yonsei University Health System, Seoul 03722, Korea
| | - Boyoung Joung
- Division of Cardiology, Yonsei University Health System, Seoul 03722, Korea
| | - Moon-Hyoung Lee
- Division of Cardiology, Yonsei University Health System, Seoul 03722, Korea
| | - Eun Bo Shim
- Department of Mechanical and Biomedical Engineering, Kangwon National University, Chuncheon 24341, Korea
| | - Hui-Nam Pak
- Division of Cardiology, Yonsei University Health System, Seoul 03722, Korea
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14
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Josephson ME, Anter E. Substrate Mapping for Ventricular Tachycardia: Assumptions and Misconceptions. JACC Clin Electrophysiol 2015; 1:341-352. [PMID: 29759461 DOI: 10.1016/j.jacep.2015.09.001] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 08/31/2015] [Accepted: 09/04/2015] [Indexed: 11/30/2022]
Abstract
Substrate mapping was developed to treat poorly tolerated infarct-related ventricular tachycardias (VTs). This concept was based on 30-year-old data derived from surgical and percutaneous mapping during sinus rhythm and VT that demonstrated specific electrograms (EGMs) that characterized the "arrhythmogenic substrate" of VT. Electrogram characteristics of the arrhythmogenic VT substrate during sinus rhythm included low-voltage, fractionation, long duration, split signals, and isolated late potentials as well as EGMs demonstrating adjacent early and late activation. Introduction of electroanatomical mapping (EAM) systems during the mid-1990s has allowed investigators to record electrograms in 3 dimensions and to identify sites assumed to represent the central common pathway ("isthmus") during re-entrant VTs. However, several important assumptions and misconceptions make currently used "substrate mapping" techniques inaccurate. These include: 1) re-entrant circuits are produced by fixed barriers of immutable "inexcitable" scar; 2) low voltage amplitude (≤0.5 mV) implies dense "inexcitable" scar; 3) isthmuses identified in patients with tolerated VTs using entrainment mapping are both valid and provide an accurate depiction of isthmuses in less hemodynamically tolerated VTs; and 4) current mapping tools and methods can delineate specific electrophysiologic features that will determine the barriers forming channels during re-entrant VTs. None of these assumptions has been validated and recent experimental and human data using higher resolution mapping with very small electrodes cast doubt on their validity. These data call for re-evaluation of substrate-mapping techniques to characterize the arrhythmogenic substrate of post-infarction VT. Standardization of recording techniques including electrode size, interelectrode spacing, tissue contact, catheter orientation, and wavefront activation must be taken into consideration.
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Affiliation(s)
- Mark E Josephson
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Elad Anter
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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