1
|
Deneke T, Kutyifa V, Hindricks G, Sommer P, Zeppenfeld K, Carbucicchio C, Pürerfellner H, Heinzel FR, Traykov VB, De Riva M, Pontone G, Lehmkuhl L, Haugaa K. Pre- and post-procedural cardiac imaging (computed tomography and magnetic resonance imaging) in electrophysiology: a clinical consensus statement of the European Heart Rhythm Association and European Association of Cardiovascular Imaging of the European Society of Cardiology. Europace 2024; 26:euae108. [PMID: 38743765 PMCID: PMC11104536 DOI: 10.1093/europace/euae108] [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: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 05/16/2024] Open
Abstract
Imaging using cardiac computed tomography (CT) or magnetic resonance (MR) imaging has become an important option for anatomic and substrate delineation in complex atrial fibrillation (AF) and ventricular tachycardia (VT) ablation procedures. Computed tomography more common than MR has been used to detect procedure-associated complications such as oesophageal, cerebral, and vascular injury. This clinical consensus statement summarizes the current knowledge of CT and MR to facilitate electrophysiological procedures, the current value of real-time integration of imaging-derived anatomy, and substrate information during the procedure and the current role of CT and MR in diagnosing relevant procedure-related complications. Practical advice on potential advantages of one imaging modality over the other is discussed for patients with implanted cardiac rhythm devices as well as for planning, intraprocedural integration, and post-interventional management in AF and VT ablation patients. Establishing a team of electrophysiologists and cardiac imaging specialists working on specific details of imaging for complex ablation procedures is key. Cardiac magnetic resonance (CMR) can safely be performed in most patients with implanted active cardiac devices. Standard procedures for pre- and post-scanning management of the device and potential CMR-associated device malfunctions need to be in place. In VT patients, imaging-specifically MR-may help to determine scar location and mural distribution in patients with ischaemic and non-ischaemic cardiomyopathy beyond evaluating the underlying structural heart disease. Future directions in imaging may include the ability to register multiple imaging modalities and novel high-resolution modalities, but also refinements of imaging-guided ablation strategies are expected.
Collapse
Affiliation(s)
- Thomas Deneke
- Clinic for Rhythmology at Klinikum Nürnberg Campus Süd, University Hospital of the Paracelsus Medical University, Nuremberg, Germany
| | | | | | | | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | | | - Helmut Pürerfellner
- Department of Clinical Electrophysiology, Ordensklinikum Linz Elisabethinen, Linz, Austria
| | - Frank R Heinzel
- Städtisches Klinikum Dresden, Department of Cardiology, Angiology and Intensive Care Medicine, Dresden, Germany
| | - Vassil B Traykov
- Department of Invasive Electrophysiology and Cardiac Pacing, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Marta De Riva
- Department of Cardiology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Lukas Lehmkuhl
- Department of Radiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Germany
| | | |
Collapse
|
2
|
Lucas P, Sciacca V, Sommer P, Fink T. [Long-term results of catheter ablation of idiopathic and structural ventricular tachycardia]. Herzschrittmacherther Elektrophysiol 2023; 34:298-304. [PMID: 37855890 DOI: 10.1007/s00399-023-00964-1] [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: 07/19/2023] [Accepted: 09/20/2023] [Indexed: 10/20/2023]
Abstract
Catheter ablation of ventricular tachycardia (VTs) has emerged as an effective treatment modality. Ablation procedures for idiopathic VTs depends on the anatomical origin of the arrhythmias, is highly effective in certain cases, and has been implemented as a first-line therapy in recent European guidelines. In contrast, catheter ablation of VTs in patients with structural heart disease has a significant risk of arrhythmia recurrence. Interventional treatment for patients with ischemic cardiomyopathy was studied in multiple randomized multicenter trials and it was shown that catheter ablation was more effective in arrhythmia suppression compared to conservative treatment modalities. Catheter ablation of nonischemic cardiomyopathy suffers from far higher rates of arrhythmia recurrences as documented in several long-term studies and often needs complex procedures with or without epicardial mapping and ablation. There is still no clear proof of a mortality benefit from catheter ablation of VTs in patients with or without structural heart disease. Nevertheless, recent guidelines recommend catheter ablation as an alternative to implantation of cardioverter-defibrillators (ICD) in selected cases.
Collapse
Affiliation(s)
- Philipp Lucas
- Klinik für Elektrophysiologie und Rhythmologie, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Deutschland
| | - Vanessa Sciacca
- Klinik für Elektrophysiologie und Rhythmologie, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Deutschland
| | - Philipp Sommer
- Klinik für Elektrophysiologie und Rhythmologie, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Deutschland.
| | - Thomas Fink
- Klinik für Elektrophysiologie und Rhythmologie, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Georgstr. 11, 32545, Bad Oeynhausen, Deutschland
| |
Collapse
|
3
|
Xu L, Zahid S, Khoshknab M, Moss J, Berger RD, Chrispin J, Callans D, Marchlinski FE, Zimmerman SL, Han Y, Desjardins B, Trayanova N, Nazarian S. Lipomatous Metaplasia Facilitates Slow Conduction in Critical Ventricular Tachycardia Corridors Within Postinfarct Myocardium. JACC Clin Electrophysiol 2023; 9:1235-1245. [PMID: 37227343 PMCID: PMC11168467 DOI: 10.1016/j.jacep.2023.02.014] [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: 11/28/2022] [Revised: 02/10/2023] [Accepted: 02/15/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Myocardial lipomatous metaplasia (LM) has been reported to be associated with post-infarct ventricular tachycardia (VT) circuitry. OBJECTIVES This study examined the association of scar versus LM composition with impulse conduction velocity (CV) in putative VT corridors that traverse the infarct zone in post-infarct patients. METHODS The cohort included 31 post-infarct patients from the prospective INFINITY (Intra-Myocardial Fat Deposition and Ventricular Tachycardia in Cardiomyopathy) study. Myocardial scar, border zone, and potential viable corridors were defined by late gadolinium enhancement cardiac magnetic resonance (LGE-CMR), and LM was defined by computed tomography. Images were registered to electroanatomic maps, and the CV at each electroanatomic map point was calculated as the mean CV between that point and 5 adjacent points along the activation wave front. RESULTS Regions with LM exhibited lower CV than scar (median = 11.9 vs 13.5 cm/s; P < 0.001). Of 94 corridors computed from LGE-CMR and electrophysiologically confirmed to participate in VT circuitry, 93 traversed through or near LM. These critical corridors displayed slower CV (median 8.8 [IQR: 5.9-15.7] cm/s vs 39.2 [IQR: 28.1-58.5]) cm/s; P < 0.001) than 115 noncritical corridors distant from LM. Additionally, critical corridors demonstrated low-peripheral, high-center (mountain shaped, 23.3%) or mean low-level (46.7%) CV patterns compared with 115 noncritical corridors distant from LM that displayed high-peripheral, low-center (valley shaped, 19.1%) or mean high-level (60.9%) CV patterns. CONCLUSIONS The association of myocardial LM with VT circuitry is at least partially mediated by slowing nearby corridor CV thus facilitating an excitable gap that enables circuit re-entry.
Collapse
Affiliation(s)
- Lingyu Xu
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
| | - Sohail Zahid
- Department of Internal Medicine, New York University Langone Medical Center, New York, New York, USA
| | - Mirmilad Khoshknab
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Juwann Moss
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ronald D Berger
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA; Department of Cardiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jonathan Chrispin
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA; Department of Cardiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - David Callans
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Stefan L Zimmerman
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Yuchi Han
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Benoit Desjardins
- Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Natalia Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Saman Nazarian
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA. https://twitter.com/Dr_Nazarian_EP
| |
Collapse
|
4
|
Xu L, Desjardins B, Witschey WR, Nazarian S. Noninvasive Assessment of Lipomatous Metaplasia as a Substrate for Ventricular Tachycardia in Chronic Infarct. Circ Cardiovasc Imaging 2023; 16:e014399. [PMID: 37526027 PMCID: PMC10528518 DOI: 10.1161/circimaging.123.014399] [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: 08/02/2023]
Abstract
Myocardial lipomatous metaplasia (LM) has been increasingly reported in patients with prior myocardial infarction. Cardiac magnetic resonance and cardiac contrast-enhanced computed tomography have been used to noninvasively detect and quantify myocardial LM in postinfarct patients, and may provide useful information for understanding cardiac mechanics, arrhythmia susceptibility, and prognosis. This review aims to summarize the advantages and disadvantages, clinical applications, and imaging features of different cardiac magnetic resonance sequences and cardiac contrast-enhanced computed tomography for LM detection and quantification. We also briefly summarize LM prevalence in different cohorts of postinfarct patients and review the clinical utility of cardiac imaging in exploring myocardial LM as an arrhythmogenic substrate in patients with prior myocardial infarction.
Collapse
Affiliation(s)
- Lingyu Xu
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Benoit Desjardins
- Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Walter R. Witschey
- Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Saman Nazarian
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, PA
| |
Collapse
|
5
|
Xu L, Khoshknab M, Berger RD, Chrispin J, Dixit S, Santangeli P, Callans D, Marchlinski FE, Zimmerman SL, Han Y, Trayanova N, Desjardins B, Nazarian S. Lipomatous Metaplasia Enables Ventricular Tachycardia by Reducing Current Loss Within the Protected Corridor. JACC Clin Electrophysiol 2022; 8:1274-1285. [PMID: 36266004 PMCID: PMC11148646 DOI: 10.1016/j.jacep.2022.07.005] [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: 04/18/2022] [Revised: 06/23/2022] [Accepted: 07/01/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Post-myocardial infarction ventricular tachycardia (VT) is due to re-entry through surviving conductive myocardial corridors across infarcted tissue. However, not all conductive corridors participate in re-entry. OBJECTIVES This study sought to test the hypothesis that critical VT corridors are more likely to traverse near lipomatous metaplasia (LM) and that current loss is reduced during impulse propagation through such corridors. METHODS Among 30 patients in the Prospective 2-center INFINITY (Intra-Myocardial Fat Deposition and Ventricular Tachycardia in Cardiomyopathy) study, potential VT-viable corridors within myocardial scar or LM were computed from late gadolinium enhancement cardiac magnetic resonance images. Because late gadolinium enhancement highlights both scar and LM, LM was distinguished from scar by using computed tomography. The SD of the current along each corridor was measured. RESULTS Scar exhibited lower impedance than LM (median Z-score -0.22 [IQR: -0.84 to 0.35] vs -0.07 [IQR: -0.67 to 0.54]; P < 0.001). Among all 381 corridors, 84 were proven to participate in VT re-entry circuits, 83 (99%) of which traversed or were adjacent to LM. In comparison, only 13 (4%) non-VT corridors were adjacent to LM. Critical corridors adjacent to LM displayed lower SD of current compared with noncritical corridors through scar but distant from LM (2.0 [IQR: 1.0 to 3.4] μA vs 8.4 [IQR: 5.5 to 12.8] μA; P < 0.001). CONCLUSIONS Corridors critical to VT circuitry traverse infarcted tissue through or near LM. This association is likely mediated by increased regional resistance and reduced current loss as impulses traverse corridors adjacent to LM.
Collapse
Affiliation(s)
- Lingyu Xu
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Mirmilad Khoshknab
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ronald D Berger
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA; Department of Cardiology, Johns Hopkins University, Baltimore Maryland, USA
| | - Jonathan Chrispin
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA; Department of Cardiology, Johns Hopkins University, Baltimore Maryland, USA
| | - Sanjay Dixit
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Pasquale Santangeli
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - David Callans
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Stefan L Zimmerman
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore Maryland, USA
| | - Yuchi Han
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Natalia Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Benoit Desjardins
- Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Saman Nazarian
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
| |
Collapse
|
6
|
Hawson J, Al-Kaisey A, Anderson RD, Watts T, Morton J, Kumar S, Kistler P, Kalman J, Lee G. Substrate-based approaches in ventricular tachycardia ablation. Indian Pacing Electrophysiol J 2022; 22:273-285. [PMID: 36007824 PMCID: PMC9649336 DOI: 10.1016/j.ipej.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/23/2022] [Accepted: 08/16/2022] [Indexed: 11/30/2022] Open
Abstract
Catheter ablation for ventricular tachycardia (VT) in patients with structural heart disease is now part of standard care. Mapping and ablation of the clinical VT is often limited when the VT is noninducible, nonsustained or not haemodynamically tolerated. Substrate-based ablation strategies have been developed in an aim to treat VT in this setting and, subsequently, have been shown to improve outcomes in VT ablation when compared to focused ablation of mapped VTs. Since the initial description of linear ablation lines targeting ventricular scar, many different approaches to substrate-based VT ablation have been developed. Strategies can broadly be divided into three categories: 1) targeting abnormal electrograms, 2) anatomical targeting of conduction channels between areas of myocardial scar, and 3) targeting areas of slow and/or decremental conduction, identified with “functional” substrate mapping techniques. This review summarises contemporary substrate-based ablation strategies, along with their strengths and weaknesses.
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
| | - 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
| | - 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
| | - Troy Watts
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Joseph Morton
- 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; Western Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, 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
| | - 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
|
7
|
Trivedi SJ, Campbell T, Stefani LD, Thomas L, Kumar S. Strain by speckle tracking echocardiography correlates with electroanatomic scar location and burden in ischaemic cardiomyopathy. Eur Heart J Cardiovasc Imaging 2021; 22:855-865. [PMID: 33585879 DOI: 10.1093/ehjci/jeab021] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS Ventricular tachycardia (VT) in ischaemic cardiomyopathy (ICM) originates from scar, identified as low-voltage areas with invasive high-density electroanatomic mapping (EAM). Abnormal myocardial deformation on speckle tracking strain echocardiography can non-invasively identify scar. We examined if regional and global longitudinal strain (GLS) can localize and quantify low-voltage scar identified with high-density EAM. METHODS AND RESULTS We recruited 60 patients, 40 ICM patients undergoing VT ablation and 20 patients undergoing ablation for other arrhythmias as controls. All patients underwent an echocardiogram prior to high-density left ventricular (LV) EAM. Endocardial bipolar and unipolar scar location and percentage were correlated with regional and multilayer GLS. Controls had normal GLS and normal bipolar and unipolar voltages. There was a strong correlation between endocardial and mid-myocardial longitudinal strain and endocardial bipolar scar percentage for all 17 LV segments (r = 0.76-0.87, P < 0.001) in ICM patients. Additionally, indices of myocardial contraction heterogeneity, myocardial dispersion (MD), and delta contraction duration (DCD) correlated with bipolar scar percentage. Endocardial and mid-myocardial GLS correlated with total LV bipolar scar percentage (r = 0.83; 0.82, P < 0.001 respectively), whereas epicardial GLS correlated with epicardial bipolar scar percentage (r = 0.78, P < 0.001). Endocardial GLS -9.3% or worse had 93% sensitivity and 82% specificity for predicting endocardial bipolar scar >46% of LV surface area. CONCLUSIONS Multilayer strain analysis demonstrated good linear correlations with low-voltage scar by invasive EAM. Validation studies are needed to establish the utility of strain as a non-invasive tool for quantifying scar location and burden, thereby facilitating mapping and ablation of VT.
Collapse
Affiliation(s)
- Siddharth J Trivedi
- Department of Cardiology, Westmead Hospital, Hawkesbury Road, Westmead, NSW 2145, Australia.,Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Westmead Hospital, Hawkesbury Road, Westmead, NSW 2145, Australia
| | - Timothy Campbell
- Department of Cardiology, Westmead Hospital, Hawkesbury Road, Westmead, NSW 2145, Australia.,Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Luke D Stefani
- Department of Cardiology, Westmead Hospital, Hawkesbury Road, Westmead, NSW 2145, Australia
| | - Liza Thomas
- Department of Cardiology, Westmead Hospital, Hawkesbury Road, Westmead, NSW 2145, Australia.,Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Westmead Hospital, Hawkesbury Road, Westmead, NSW 2145, Australia.,South Western Sydney Clinical School, Faculty of Medicine, University of New South Wales, Liverpool Hospital, Elizabeth Street, Liverpool, NSW 2170, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Hawkesbury Road, Westmead, NSW 2145, Australia.,Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Westmead Hospital, Hawkesbury Road, Westmead, NSW 2145, Australia.,Westmead Applied Research Centre, Faculty of Medicine and Health, The University of Sydney, Westmead Hospital, Westmead, NSW 2145, Australia
| |
Collapse
|
8
|
Giannopoulos AA, Pazhenkottil AP. Innervation imaging to guide ventricular arrhythmia ablation. J Nucl Cardiol 2021; 28:184-186. [PMID: 30719658 DOI: 10.1007/s12350-019-01632-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 01/24/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Andreas A Giannopoulos
- Cardiac Imaging, Department of Cardiology and Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Cardiac Imaging, Department of Cardiology and Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
| |
Collapse
|
9
|
Campos FO, Orini M, Arnold R, Whitaker J, O'Neill M, Razavi R, Plank G, Hanson B, Porter B, Rinaldi CA, Gill J, Lambiase PD, Taggart P, Bishop MJ. Assessing the ability of substrate mapping techniques to guide ventricular tachycardia ablation using computational modelling. Comput Biol Med 2021; 130:104214. [PMID: 33476992 DOI: 10.1016/j.compbiomed.2021.104214] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 01/05/2021] [Accepted: 01/05/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Identification of targets for ablation of post-infarction ventricular tachycardias (VTs) remains challenging, often requiring arrhythmia induction to delineate the reentrant circuit. This carries a risk for the patient and may not be feasible. Substrate mapping has emerged as a safer strategy to uncover arrhythmogenic regions. However, VT recurrence remains common. GOAL To use computer simulations to assess the ability of different substrate mapping approaches to identify VT exit sites. METHODS A 3D computational model of the porcine post-infarction heart was constructed to simulate VT and paced rhythm. Electroanatomical maps were constructed based on endocardial electrogram features and the reentry vulnerability index (RVI - a metric combining activation (AT) and repolarization timings to identify tissue susceptibility to reentry). Since scar transmurality in our model was not homogeneous, parameters derived from all signals (including dense scar regions) were used in the analysis. Potential ablation targets obtained from each electroanatomical map during pacing were compared to the exit site detected during VT mapping. RESULTS Simulation data showed that voltage cut-offs applied to bipolar electrograms could delineate the scar, but not the VT circuit. Electrogram fractionation had the highest correlation with scar transmurality. The RVI identified regions closest to VT exit site but was outperformed by AT gradients combined with voltage cut-offs. The performance of all metrics was affected by pacing location. CONCLUSIONS Substrate mapping could provide information about the infarct, but the directional dependency on activation should be considered. Activation-repolarization metrics have utility in safely identifying VT targets, even with non-transmural scars.
Collapse
Affiliation(s)
- Fernando O Campos
- School of Biomedical Engineering and Imaging Sciences, Rayne Institute, 4th Floor, Lambeth Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom.
| | - Michele Orini
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Electrophysiology Department, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Robert Arnold
- Gottfried Schatz Research Center (for Cell Signaling, Metabolism and Aging), Division of Biophysics, Graz, Austria
| | - John Whitaker
- School of Biomedical Engineering and Imaging Sciences, Rayne Institute, 4th Floor, Lambeth Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom
| | - Mark O'Neill
- School of Biomedical Engineering and Imaging Sciences, Rayne Institute, 4th Floor, Lambeth Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom
| | - Reza Razavi
- School of Biomedical Engineering and Imaging Sciences, Rayne Institute, 4th Floor, Lambeth Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom
| | - Gernot Plank
- Gottfried Schatz Research Center (for Cell Signaling, Metabolism and Aging), Division of Biophysics, Graz, Austria
| | - Ben Hanson
- Department of Mechanical Engineering, University College London, London, United Kingdom
| | - Bradley Porter
- School of Biomedical Engineering and Imaging Sciences, Rayne Institute, 4th Floor, Lambeth Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom; Department of Cardiology, Guys and St Thomas' NHS Trust, London, United Kingdom
| | | | - Jaswinder Gill
- School of Biomedical Engineering and Imaging Sciences, Rayne Institute, 4th Floor, Lambeth Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom; Department of Cardiology, Guys and St Thomas' NHS Trust, London, United Kingdom
| | - Pier D Lambiase
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Electrophysiology Department, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Peter Taggart
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Electrophysiology Department, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Martin J Bishop
- School of Biomedical Engineering and Imaging Sciences, Rayne Institute, 4th Floor, Lambeth Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom
| |
Collapse
|
10
|
Paola AAVD. Translational Approach for Percutaneous Interventions for the Treatment of Cardiac Arrhythmias. INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2020. [DOI: 10.36660/ijcs.20200152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
11
|
Lee P, Quintanilla JG, Alfonso-Almazán JM, Galán-Arriola C, Yan P, Sánchez-González J, Pérez-Castellano N, Pérez-Villacastín J, Ibañez B, Loew LM, Filgueiras-Rama D. In vivo ratiometric optical mapping enables high-resolution cardiac electrophysiology in pig models. Cardiovasc Res 2020; 115:1659-1671. [PMID: 30753358 PMCID: PMC6704389 DOI: 10.1093/cvr/cvz039] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 01/31/2019] [Accepted: 02/06/2019] [Indexed: 11/28/2022] Open
Abstract
Aims Cardiac optical mapping is the gold standard for measuring complex electrophysiology in ex vivo heart preparations. However, new methods for optical mapping in vivo have been elusive. We aimed at developing and validating an experimental method for performing in vivo cardiac optical mapping in pig models. Methods and results First, we characterized ex vivo the excitation-ratiometric properties during pacing and ventricular fibrillation (VF) of two near-infrared voltage-sensitive dyes (di-4-ANBDQBS/di-4-ANEQ(F)PTEA) optimized for imaging blood-perfused tissue (n = 7). Then, optical-fibre recordings in Langendorff-perfused hearts demonstrated that ratiometry permits the recording of optical action potentials (APs) with minimal motion artefacts during contraction (n = 7). Ratiometric optical mapping ex vivo also showed that optical AP duration (APD) and conduction velocity (CV) measurements can be accurately obtained to test drug effects. Secondly, we developed a percutaneous dye-loading protocol in vivo to perform high-resolution ratiometric optical mapping of VF dynamics (motion minimal) using a high-speed camera system positioned above the epicardial surface of the exposed heart (n = 11). During pacing (motion substantial) we recorded ratiometric optical signals and activation via a 2D fibre array in contact with the epicardial surface (n = 7). Optical APs in vivo under general anaesthesia showed significantly faster CV [120 (63–138) cm/s vs. 51 (41–64) cm/s; P = 0.032] and a statistical trend to longer APD90 [242 (217–254) ms vs. 192 (182–233) ms; P = 0.095] compared with ex vivo measurements in the contracting heart. The average rate of signal-to-noise ratio (SNR) decay of di-4-ANEQ(F)PTEA in vivo was 0.0671 ± 0.0090 min−1. However, reloading with di-4-ANEQ(F)PTEA fully recovered the initial SNR. Finally, toxicity studies (n = 12) showed that coronary dye injection did not generate systemic nor cardiac damage, although di-4-ANBDQBS injection induced transient hypotension, which was not observed with di-4-ANEQ(F)PTEA. Conclusions In vivo optical mapping using voltage ratiometry of near-infrared dyes enables high-resolution cardiac electrophysiology in translational pig models.
Collapse
Affiliation(s)
- Peter Lee
- Essel Research and Development Inc., Toronto, 337 Sheppard Ave East, Toronto, Ontario M2N 3B3, Canada
| | - Jorge G Quintanilla
- Spanish National Cardiovascular Research Center, Carlos III (CNIC), Myocardial Pathophysiology Area, Melchor Fernández Almagro, 3, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Av. Monforte de Lemos 3-5, Madrid, Spain.,Arrhythmia Unit, Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Prof. Martín Lagos s/n, Madrid, Spain
| | - José M Alfonso-Almazán
- Spanish National Cardiovascular Research Center, Carlos III (CNIC), Myocardial Pathophysiology Area, Melchor Fernández Almagro, 3, Madrid, Spain
| | - Carlos Galán-Arriola
- Spanish National Cardiovascular Research Center, Carlos III (CNIC), Myocardial Pathophysiology Area, Melchor Fernández Almagro, 3, Madrid, Spain
| | - Ping Yan
- Richard D. Berlin Center for Cell Analysis and Modeling, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT, USA
| | | | - Nicasio Pérez-Castellano
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Av. Monforte de Lemos 3-5, Madrid, Spain.,Arrhythmia Unit, Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Prof. Martín Lagos s/n, Madrid, Spain
| | - Julián Pérez-Villacastín
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Av. Monforte de Lemos 3-5, Madrid, Spain.,Arrhythmia Unit, Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Prof. Martín Lagos s/n, Madrid, Spain.,Fundación Interhospitalaria para la Investigación Cardiovascular (FIC), Paseo de San Francisco de Sales 3, Madrid, Spain
| | - Borja Ibañez
- Spanish National Cardiovascular Research Center, Carlos III (CNIC), Myocardial Pathophysiology Area, Melchor Fernández Almagro, 3, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Av. Monforte de Lemos 3-5, Madrid, Spain.,IIS-University Hospital Fundación Jiménez Díaz, Department of Cardiology, Av. Reyes Católicos 2, Madrid, Spain
| | - Leslie M Loew
- Richard D. Berlin Center for Cell Analysis and Modeling, University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, CT, USA
| | - David Filgueiras-Rama
- Spanish National Cardiovascular Research Center, Carlos III (CNIC), Myocardial Pathophysiology Area, Melchor Fernández Almagro, 3, Madrid, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Av. Monforte de Lemos 3-5, Madrid, Spain.,Arrhythmia Unit, Cardiovascular Institute, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Prof. Martín Lagos s/n, Madrid, Spain
| |
Collapse
|
12
|
Malaczynska-Rajpold K, Blaszyk K, Kociemba A, Pyda M, Posadzy-Malaczynska A, Grajek S. Islets of heterogeneous myocardium within the scar in cardiac magnetic resonance predict ventricular tachycardia after myocardial infarction. J Cardiovasc Electrophysiol 2020; 31:1452-1461. [PMID: 32227520 DOI: 10.1111/jce.14461] [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: 09/19/2019] [Revised: 03/06/2020] [Accepted: 03/24/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We assessed findings in cardiac magnetic resonance (CMR) as predictors of ventricular tachycardia (VT) after myocardial infarction (MI), which could allow for more precise identification of patients at risk of sudden cardiac death. METHODS Forty-eight patients after prior MI were enrolled and divided into two groups: with (n = 24) and without (n = 24) VT. VT was confirmed by electrophysiological study and exit site was estimated based on 12-lead electrocardiogram. All patients underwent CMR with late gadolinium enhancement. RESULTS The examined groups did not differ significantly in clinical and demographical parameters (including LV ejection fraction). There was a significant difference in the infarct age between the VT and non-VT group (15.8 ± 8.4 vs 7.1 ± 6.7 years, respectively; P = .002), with the cut-off point at the level of 12 years. In the scar core, islets of heterogeneous myocardium were revealed. They were defined as areas of potentially viable myocardium within or adjacent to the core scar. The number of islets was the strongest independent predictor of VT (odds ratio [OR], 1.42; confidence interval [CI], 1.17-1.73), but total islet size and the largest islet area were also significantly higher in the VT group (OR, 1.04; CI, 1.02-1.07 and OR, 1.16; CI, 1.01-1.27, respectively). Myocardial segments with fibrosis forming 25%-75% of the ventricular wall were associated with a higher incidence of VT (7.5 ± 2.1 vs 5.7 ± 2.6; P = .014). Three-dimension CMR reconstruction confirmed good correlation of the location of the islets/channels with VT exit site during electroanatomical mapping in five cases. CONCLUSIONS The identification and quantification of islets of heterogeneous myocardium within the scar might be useful for predicting VT in patients after MI.
Collapse
Affiliation(s)
- Katarzyna Malaczynska-Rajpold
- Heart Division, Royal Brompton & Harefield NHS Foundation Trust, London, UK.,1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Krzysztof Blaszyk
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Anna Kociemba
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland.,Heart Division, Affidea International Oncology Centre, Poznan, Poland
| | - Malgorzata Pyda
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Stefan Grajek
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| |
Collapse
|
13
|
Aronis KN, Ali RL, Prakosa A, Ashikaga H, Berger RD, Hakim JB, Liang J, Tandri H, Teng F, Chrispin J, Trayanova NA. Accurate Conduction Velocity Maps and Their Association With Scar Distribution on Magnetic Resonance Imaging in Patients With Postinfarction Ventricular Tachycardias. Circ Arrhythm Electrophysiol 2020; 13:e007792. [PMID: 32191131 DOI: 10.1161/circep.119.007792] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Characterizing myocardial conduction velocity (CV) in patients with ischemic cardiomyopathy (ICM) and ventricular tachycardia (VT) is important for understanding the patient-specific proarrhythmic substrate of VTs and therapeutic planning. The objective of this study is to accurately assess the relation between CV and myocardial fibrosis density on late gadolinium-enhanced cardiac magnetic resonance imaging (LGE-CMR) in patients with ICM. METHODS We enrolled 6 patients with ICM undergoing VT ablation and 5 with structurally normal left ventricles (controls) undergoing premature ventricular contraction or VT ablation. All patients underwent LGE-CMR and electroanatomic mapping (EAM) in sinus rhythm (2960 electroanatomic mapping points analyzed). We estimated CV from electroanatomic mapping local activation time using the triangulation method that provides an accurate estimate of CV as it accounts for the direction of wavefront propagation. We evaluated the association between LGE-CMR intensity and CV with multilevel linear mixed models. RESULTS Median CV in patients with ICM and controls was 0.41 m/s and 0.65 m/s, respectively. In patients with ICM, CV in areas with no visible fibrosis was 0.81 m/s (95% CI, 0.59-1.12 m/s). For each 25% increase in normalized LGE intensity, CV decreased by 1.34-fold (95% CI, 1.25-1.43). Dense scar areas have, on average, 1.97- to 2.66-fold slower CV compared with areas without dense scar. Ablation lesions that terminated VTs were localized in areas of slow conduction on CV maps. CONCLUSIONS CV is inversely associated with LGE-CMR fibrosis density in patients with ICM. Noninvasive derivation of CV maps from LGE-CMR is feasible. Integration of noninvasive CV maps with electroanatomic mapping during substrate mapping has the potential to improve procedural planning and outcomes. Visual Overview: A visual overview is available for this article.
Collapse
Affiliation(s)
- Konstantinos N Aronis
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University (K.N.A., R.L.A., A.P., J.B.H., J.L., F.T., N.A.T.).,Section of Electrophysiology, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD (K.N.A., H.A., R.D.B., H.T., J.C.)
| | - Rheeda L Ali
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University (K.N.A., R.L.A., A.P., J.B.H., J.L., F.T., N.A.T.)
| | - Adityo Prakosa
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University (K.N.A., R.L.A., A.P., J.B.H., J.L., F.T., N.A.T.)
| | - Hiroshi Ashikaga
- Section of Electrophysiology, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD (K.N.A., H.A., R.D.B., H.T., J.C.)
| | - Ronald D Berger
- Section of Electrophysiology, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD (K.N.A., H.A., R.D.B., H.T., J.C.)
| | - Joe B Hakim
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University (K.N.A., R.L.A., A.P., J.B.H., J.L., F.T., N.A.T.)
| | - Jialiu Liang
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University (K.N.A., R.L.A., A.P., J.B.H., J.L., F.T., N.A.T.)
| | - Harikrishna Tandri
- Section of Electrophysiology, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD (K.N.A., H.A., R.D.B., H.T., J.C.)
| | - Fei Teng
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University (K.N.A., R.L.A., A.P., J.B.H., J.L., F.T., N.A.T.)
| | - Jonathan Chrispin
- Section of Electrophysiology, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD (K.N.A., H.A., R.D.B., H.T., J.C.)
| | - Natalia A Trayanova
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University (K.N.A., R.L.A., A.P., J.B.H., J.L., F.T., N.A.T.)
| |
Collapse
|
14
|
Bhaskaran A, Nayyar S, Porta-Sánchez A, Jons C, Massé S, Magtibay K, Aukhojee P, Ha A, Bokhari M, Tung R, Downar E, Nanthakumar K. Direct and indirect mapping of intramural space in ventricular tachycardia. Heart Rhythm 2020; 17:439-446. [DOI: 10.1016/j.hrthm.2019.10.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Indexed: 12/01/2022]
|
15
|
Jang J, Whitaker J, Leshem E, Ngo LH, Neisius U, Nakamori S, Pashakhanloo F, Menze B, Manning WJ, Anter E, Nezafat R. Local Conduction Velocity in the Presence of Late Gadolinium Enhancement and Myocardial Wall Thinning: A Cardiac Magnetic Resonance Study in a Swine Model of Healed Left Ventricular Infarction. Circ Arrhythm Electrophysiol 2020; 12:e007175. [PMID: 31006313 DOI: 10.1161/circep.119.007175] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Conduction velocity (CV) is an important property that contributes to the arrhythmogenicity of the tissue substrate. The aim of this study was to investigate the association between local CV versus late gadolinium enhancement (LGE) and myocardial wall thickness in a swine model of healed left ventricular infarction. METHODS Six swine with healed myocardial infarction underwent cardiovascular magnetic resonance imaging and electroanatomic mapping. Two healthy controls (one treated with amiodarone and one unmedicated) underwent electroanatomic mapping with identical protocols to establish the baseline CV. CV was estimated using a triangulation technique. LGE+ regions were defined as signal intensity >2 SD than the mean of remote regions, wall thinning+ as those with wall thickness <2 SD than the mean of remote regions. LGE heterogeneity was defined as SD of LGE in the local neighborhood of 5 mm and wall thickness gradient as SD within 5 mm. Cardiovascular magnetic resonance and electroanatomic mapping data were registered, and hierarchical modeling was performed to estimate the mean difference of CV (LGE+/-, wall thinning+/-), or the change of the mean of CV per unit change (LGE heterogeneity, wall thickness gradient). RESULTS Significantly slower CV was observed in LGE+ (0.33±0.25 versus 0.54±0.36 m/s; P<0.001) and wall thinning+ regions (0.38±0.28 versus 0.55±0.37 m/s; P<0.001). Areas with greater LGE heterogeneity ( P<0.001) and wall thickness gradient ( P<0.001) exhibited slower CV. CONCLUSIONS Slower CV is observed in the presence of LGE, myocardial wall thinning, high LGE heterogeneity, and a high wall thickness gradient. Cardiovascular magnetic resonance may offer a valuable imaging surrogate for estimating CV, which may support noninvasive identification of the arrhythmogenic substrate.
Collapse
Affiliation(s)
- Jihye Jang
- Cardiovascular Division, Department of Medicine (J.J., E.L., L.H.N., U.N., S.N., F.P., W.J.M., E.A., R.N.), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.,Department of Computer Science, Technical University of Munich, Germany (J.J., B.M.)
| | - John Whitaker
- Division of Imaging Sciences and Biomedical Engineering, King's College London, United Kingdom (J.W.)
| | - Eran Leshem
- Cardiovascular Division, Department of Medicine (J.J., E.L., L.H.N., U.N., S.N., F.P., W.J.M., E.A., R.N.), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Long H Ngo
- Cardiovascular Division, Department of Medicine (J.J., E.L., L.H.N., U.N., S.N., F.P., W.J.M., E.A., R.N.), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Ulf Neisius
- Cardiovascular Division, Department of Medicine (J.J., E.L., L.H.N., U.N., S.N., F.P., W.J.M., E.A., R.N.), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Shiro Nakamori
- Cardiovascular Division, Department of Medicine (J.J., E.L., L.H.N., U.N., S.N., F.P., W.J.M., E.A., R.N.), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Farhad Pashakhanloo
- Cardiovascular Division, Department of Medicine (J.J., E.L., L.H.N., U.N., S.N., F.P., W.J.M., E.A., R.N.), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Bjoern Menze
- Department of Computer Science, Technical University of Munich, Germany (J.J., B.M.)
| | - Warren J Manning
- Cardiovascular Division, Department of Medicine (J.J., E.L., L.H.N., U.N., S.N., F.P., W.J.M., E.A., R.N.), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA.,Department of Radiology (W.J.M.), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Elad Anter
- Cardiovascular Division, Department of Medicine (J.J., E.L., L.H.N., U.N., S.N., F.P., W.J.M., E.A., R.N.), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Reza Nezafat
- Cardiovascular Division, Department of Medicine (J.J., E.L., L.H.N., U.N., S.N., F.P., W.J.M., E.A., R.N.), Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| |
Collapse
|
16
|
Markman TM, Nazarian S. Treatment of ventricular arrhythmias: What's New? Trends Cardiovasc Med 2019; 29:249-261. [DOI: 10.1016/j.tcm.2018.09.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 09/19/2018] [Accepted: 09/19/2018] [Indexed: 12/17/2022]
|
17
|
Mukherjee RK, Whitaker J, Williams SE, Razavi R, O'Neill MD. Magnetic resonance imaging guidance for the optimization of ventricular tachycardia ablation. Europace 2019; 20:1721-1732. [PMID: 29584897 PMCID: PMC6212773 DOI: 10.1093/europace/euy040] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/19/2018] [Indexed: 01/02/2023] Open
Abstract
Catheter ablation has an important role in the management of patients with ventricular tachycardia (VT) but is limited by modest long-term success rates. Magnetic resonance imaging (MRI) can provide valuable anatomic and functional information as well as potentially improve identification of target sites for ablation. A major limitation of current MRI protocols is the spatial resolution required to identify the areas of tissue responsible for VT but recent developments have led to new strategies which may improve substrate assessment. Potential ways in which detailed information gained from MRI may be utilized during electrophysiology procedures include image integration or performing a procedure under real-time MRI guidance. Image integration allows pre-procedural magnetic resonance (MR) images to be registered with electroanatomical maps to help guide VT ablation and has shown promise in preliminary studies. However, multiple errors can arise during this process due to the registration technique used, changes in ventricular geometry between the time of MRI and the ablation procedure, respiratory and cardiac motion. As isthmus sites may only be a few millimetres wide, reducing these errors may be critical to improve outcomes in VT ablation. Real-time MR-guided intervention has emerged as an alternative solution to address the limitations of pre-acquired imaging to guide ablation. There is now a growing body of literature describing the feasibility, techniques, and potential applications of real-time MR-guided electrophysiology. We review whether real-time MR-guided intervention could be applied in the setting of VT ablation and the potential challenges that need to be overcome.
Collapse
Affiliation(s)
- Rahul K Mukherjee
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK
| | - John Whitaker
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK
| | - Steven E Williams
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK.,Department of Cardiology, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| | - Reza Razavi
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK
| | - Mark D O'Neill
- School of Biomedical Engineering and Imaging Sciences, 4th Floor, North Wing, St Thomas' Hospital, King's College London, London, UK.,Department of Cardiology, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
| |
Collapse
|
18
|
Entropy as a Novel Measure of Myocardial Tissue Heterogeneity for Prediction of Ventricular Arrhythmias and Mortality in Post-Infarct Patients. JACC Clin Electrophysiol 2019; 5:480-489. [DOI: 10.1016/j.jacep.2018.12.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 12/12/2018] [Accepted: 12/12/2018] [Indexed: 11/24/2022]
|
19
|
Xie S, Kubala M, Liang JJ, Yang J, Desjardins B, Santangeli P, van der Geest RJ, Schaller R, Riley M, Supple G, Frankel DS, Callans D, Pac EZ, Marchlinski F, Nazarian S. Utility of ripple mapping for identification of slow conduction channels during ventricular tachycardia ablation in the setting of arrhythmogenic right ventricular cardiomyopathy. J Cardiovasc Electrophysiol 2019; 30:366-373. [PMID: 30575168 DOI: 10.1111/jce.13819] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 11/01/2018] [Accepted: 11/21/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Ripple mapping displays every deflection of a bipolar electrogram and enables the visualization of conduction channels (RMCC) within postinfarction ventricular scar to guide ventricular tachycardia (VT) ablation. The utility of RMCC identification for facilitation of VT ablation in the setting of arrhythmogenic right ventricular cardiomyopathy (ARVC) has not been described. OBJECTIVE We sought to (a) identify the slow conduction channels in the endocardial/epicardial scar by ripple mapping and (b) retrospectively analyze whether the elimination of RMCC is associated with improved VT-free survival, in ARVC patients. METHODS High-density right ventricular endocardial and epicardial electrograms were collected using the CARTO 3 system in sinus rhythm or ventricular pacing and reviewed for RMCC. Low-voltage zones and abnormal myocardium in the epicardium were identified by using standardized late-gadolinium-enhanced (LGE) magnetic resonance imaging (MRI) signal intensity (SI) z-scores. RESULTS A cohort of 20 ARVC patients that had undergone simultaneous high-density right ventricular endocardial and epicardial electrogram mapping was identified (age 44 ± 13 years). Epicardial scar, defined as bipolar voltage less than 1.0 mV, occupied 47.6% (interquartile range [IQR], 30.9-63.7) of the total epicardial surface area and was larger than endocardial scar, defined as bipolar voltage less than 1.5 mV, which occupied 11.2% (IQR, 4.2 ± 17.8) of the endocardium (P < 0.01). A median 1.5 RMCC, defined as continuous corridors of sequential late activation within scar, were identified per patient (IQR, 1-3), most of which were epicardial. The median ratio of RMCC ablated was 1 (IQR, 0.6-1). During a median follow-up of 44 months (IQR, 11-49), the ratio of RMCC ablated was associated with freedom from recurrent VT (hazard ratio, 0.01; P = 0.049). Among nine patients with adequate MRI, 73% of RMCC were localized in LGE regions, 24% were adjacent to an area with LGE, and 3% were in regions without LGE. CONCLUSION Slow conduction channels within endocardial or epicardial ARVC scar were delineated clearly by ripple mapping and corresponded to critical isthmus sites during entrainment. Complete elimination of RMCC was associated with freedom from VT.
Collapse
Affiliation(s)
- Shuanglun Xie
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Cardiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Maciej Kubala
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jackson J Liang
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jiandu Yang
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benoit Desjardins
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pasquale Santangeli
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rob J van der Geest
- Division of Image Processing, Leiden University Medical Centre, Leiden, The Netherlands
| | - Robert Schaller
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Riley
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory Supple
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David S Frankel
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Callans
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erica Zado Pac
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis Marchlinski
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Saman Nazarian
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
20
|
Association of regional myocardial conduction velocity with the distribution of hypoattenuation on contrast-enhanced perfusion computed tomography in patients with postinfarct ventricular tachycardia. Heart Rhythm 2018; 16:588-594. [PMID: 30935494 DOI: 10.1016/j.hrthm.2018.10.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Cardiac magnetic resonance imaging has been shown to be beneficial for identification of the ventricular tachycardia (VT) substrate before catheter ablation. Contrast-enhanced perfusion multidetector computed tomography (CEP-MDCT) is more generalizable to clinical practice, and wall thickness and regional hypoenhancement on CEP-MDCT can identify potential substrate sites, albeit with decreased specificity. OBJECTIVE The purpose of this study was to evaluate the association between wall thickness and attenuation on CEP-MDCT with local conduction velocity (CV) and electrogram abnormalities in patients with postinfarct VT. METHODS Fourteen patients with postinfarct VT underwent preprocedural CEP-MDCT followed by endocardial electroanatomic mapping (EAM) and ablation. Myocardial attenuation and wall thickness were calculated from 3-dimensional MDCT images using ADAS-VT software (Galgo Medical). EAM was registered with 3-dimensional MDCT images using the CartoMERGE module of CARTO3 software (Biosense Webster). Local CV was calculated by averaging the velocity between each point and 5 adjacent points with concordant wavefront direction. RESULTS A total of 3689 points were included. In multivariable regression analysis clustered by patient, local CV was positively associated with myocardial attenuation, bipolar voltage, unipolar voltage, and wall thickness. Each 10-HU drop in full-thickness attenuation correlated to 2.6% decrease in CV (P <.001) and 5.5% decrease in bipolar voltage amplitude (P <.001), after adjusting for wall thickness. CONCLUSION Myocardial attenuation distribution on CEP-MDCT is associated with regional CV and electrogram amplitude. Regions with low CV identified with low attenuation on CEP-MDCT may serve as important VT substrates in postinfarct patients.
Collapse
|
21
|
Catheter Ablation of Post-Infarct VT: Mechanisms, Strategies and Outcomes. Heart Lung Circ 2018; 28:76-83. [PMID: 30482686 DOI: 10.1016/j.hlc.2018.10.003] [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: 07/24/2018] [Revised: 10/02/2018] [Accepted: 10/03/2018] [Indexed: 12/29/2022]
Abstract
Ventricular arrhythmias are one of the leading causes of death in patients with a prior myocardial infarction. Implantable cardioverter-defibrillators (ICDs) are very effective in the prevention of sudden cardiac death but the risk of recurrence remains an issue since defibrillation does not alter the underlying substrate. Recurrent ICD shocks are distressing and are associated with an increase in mortality. Catheter ablation is an effective treatment for recurrent ventricular tachycardia in these patients, particularly when antiarrhythmic therapy produces side effects or is ineffective. This paper reviews the underlying mechanisms of VT in patients with a prior myocardial infarction, and the indications, strategies and outcomes of catheter ablation.
Collapse
|
22
|
Morellato J, Chik W, Barry MA, Lu J, Thiagalingam A, Kovoor P, Pouliopoulos J. Quantitative spectral assessment of intracardiac electrogram characteristics associated with post infarct fibrosis and ventricular tachycardia. PLoS One 2018; 13:e0204997. [PMID: 30289934 PMCID: PMC6173422 DOI: 10.1371/journal.pone.0204997] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 09/18/2018] [Indexed: 12/15/2022] Open
Abstract
Background Post-myocardial infarction (MI) remodeling contributes to increased electrophysiological and structural heterogeneity and arrhythmogenesis. Utilising the post-infarct ovine model our aim was to determine unipolar electrogram frequency characteristics consequent to this remodeling and the development of Ventricular Tachycardia (VT). Methods and results Mapping studies were performed on 14 sheep at >1 month post-MI induction. Sheep were divided into VT inducible (n = 7) and non-inducible (n = 7) groups. Multielectrode needles (n = 20) were deployed within and surrounding ventricular scar for electrophysiological assessment of electrogram amplitude and width. Spectral analysis of electrograms was undertaken using wavelet and fast fourier transformations (WFFT) to calculate root mean square (RMS) power intervals spanning 0-300Hz in 20Hz intervals. Quantitative assessment between electrophysiological and histological parameters including collagen density, and structural organization of the myocardium was performed. Increasing myocardial scar density resulted in attenuation of electrogram amplitude and RMS values. (all p<0.01). Between groups there were no differences in electrogram amplitude (p = 0.37), however WFFT analysis revealed significantly higher RMS values in the VT group (p<0.05) in association with high frequency fractional components of the electrogram. As scar density increased, greater between-group differences in RMS were observed spanning this high frequency (200-280Hz) spectrum and which were proportionally dependent on the degree of structural disorganisation of the myocardium (p<0.001) and number of extrastimuli required to induce VT (p<0.05). Conclusion High frequency unipolar electrogram spectral characteristics were quantitatively co-influenced by the presence of fibrosis and degree of myocardial structural dissorganisation and were associated with the propensity for development of VT.
Collapse
Affiliation(s)
| | - William Chik
- University of Sydney, Sydney, Australia
- Department of Cardiology, Westmead Hospital, Sydney, Australia
| | - M. A. Barry
- Department of Cardiology, Westmead Hospital, Sydney, Australia
| | - Juntang Lu
- Department of Cardiology, Westmead Hospital, Sydney, Australia
| | - Aravinda Thiagalingam
- University of Sydney, Sydney, Australia
- Department of Cardiology, Westmead Hospital, Sydney, Australia
| | - Pramesh Kovoor
- University of Sydney, Sydney, Australia
- Department of Cardiology, Westmead Hospital, Sydney, Australia
| | - Jim Pouliopoulos
- University of Sydney, Sydney, Australia
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- * E-mail: ,
| |
Collapse
|
23
|
Dinov B, Oebel S, Hilbert S, Loebe S, Arya A, Bollmann A, Sommer P, Jahnke C, Paetsch I, Hindricks G. Characteristics of the ablation lesions in cardiac magnetic resonance imaging after radiofrequency ablation of ventricular arrhythmias in relation to the procedural success. Am Heart J 2018; 204:68-75. [PMID: 30077835 DOI: 10.1016/j.ahj.2018.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 06/21/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND In human patients, studies about the cardiac magnetic resonance (CMR) appearance of the acute radiofrequency (RF) lesions in relation to the procedural outcomes after catheter ablation (CA) of ventricular arrhythmias (VA) are scarce. We aimed to investigate the RF lesions characteristics in relation to the procedural success. METHODS Patients referred for ablation of VA received CMR (1.5 T) using gadolinium contrast before and after ablation. CA in left ventricle was performed using a 3.5-mm irrigated catheter. The volume and transmurality of the RF-induced lesions were measured in early gadolinium-enhanced postablation CMRs. Acute failure was defined as persistently inducible VA at the end of the CA. RESULTS Twenty-five patients (60.7 ± 9.8 years, 19 with sustained ventricular tachycardia) were studied. All RF lesions had nonenhanced core. The volume of the nonenhanced lesions showed positive correlation with the maximal RF power (r = 0.598, P = .002) and the impedance drop (r = 0.416, P = .038). Patients with transmural (≥75%) lesions had significantly larger impedance drop as compared to those with nontransmural lesions (<75%): 20.3 ± 9.4 versus 13.5 ± 4.3, P = .037. In the failures, the lesions volume was nonsignificantly larger: 3.86 ± 3.3% versus 2.6 ± 1.7%, P = .197; however, it was considerably deeper: 86 ± 13% versus 62 ± 26%, P = .03. CONCLUSIONS CMR after VA ablation showed nonenhanced lesions resembling the no-reflow phenomenon in myocardial infarction. Although the size and the depth of the RF injury correlated with the ablation energy and impedance drop, they were not associated with acute ablation success.
Collapse
|
24
|
Misra S, Zahid S, Prakosa A, Saju N, Tandri H, Berger RD, Marine JE, Calkins H, Zipunnikov V, Trayanova N, Zimmerman SL, Nazarian S. Field of view of mapping catheters quantified by electrogram associations with radius of myocardial attenuation on contrast-enhanced cardiac computed tomography. Heart Rhythm 2018; 15:1617-1625. [PMID: 29870783 DOI: 10.1016/j.hrthm.2018.05.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Contrast-enhanced cardiac computed tomography (CE-CT) provides useful substrate characterization in patients with ventricular tachycardia (VT). OBJECTIVE The purpose of this study was to describe the association between endocardial electrogram measurements and myocardial characteristics on CE-CT, in particular the field of view of electrogram features. METHODS Fifteen patients with postinfarct VT who underwent catheter ablation with preprocedural CE-CT were included. Electroanatomic maps were registered to CE-CT, and myocardial attenuation surrounding each endocardial point was measured at a radius of 5, 10, and 15 mm. The association between endocardial voltage and attenuation was assessed using a multilevel random effects linear regression model, clustered by patient, with best model fit defined by highest log likelihood. RESULTS A total of 4698 points were included. There was a significant association of bipolar and unipolar voltage with myocardial attenuation at all radii. For unipolar voltage, the best model fit was at an analysis radius of 15 mm regardless of the mapping catheter used. For bipolar voltage, the best model fit was at an analysis radius of 15 mm for points acquired with a conventional ablation catheter. In contrast, the best model fit for points acquired with a multipolar mapping catheter was at an analysis radius of 5 mm. CONCLUSION Myocardial attenuation on CE-CT indicates a smaller myocardial field of view of bipolar electrograms using multipolar catheters with smaller electrodes in comparison to standard ablation catheters despite similar interelectrode spacing. Smaller electrodes may provide improved spatial resolution for the definition of myocardial substrate for VT ablation.
Collapse
Affiliation(s)
- Satish Misra
- Department of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Sohail Zahid
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adityo Prakosa
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nissi Saju
- Department of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Harikrishna Tandri
- Department of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ronald D Berger
- Department of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph E Marine
- Department of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hugh Calkins
- Department of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vadim Zipunnikov
- Department of Epidemiology, Johns Hopkins University School of Public Heatlh, Baltimore, Maryland
| | - Natalia Trayanova
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stefan L Zimmerman
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Saman Nazarian
- Department of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
25
|
Andreu D, Penela D, Acosta J, Fernández-Armenta J, Perea RJ, Soto-Iglesias D, de Caralt TM, Ortiz-Perez JT, Prat-González S, Borràs R, Guasch E, Tolosana JM, Mont L, Berruezo A. Cardiac magnetic resonance-aided scar dechanneling: Influence on acute and long-term outcomes. Heart Rhythm 2018; 14:1121-1128. [PMID: 28760258 DOI: 10.1016/j.hrthm.2017.05.018] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Indexed: 10/19/2022]
Abstract
BACKGROUND Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) provides tissue characterization of ventricular myocardium and scar that can be depicted as pixel signal intensity (PSI) maps. OBJECTIVE To assess the possible benefit of guiding the ventricular tachycardia (VT) substrate mapping by integrating these PSI maps into the navigation system. METHODS In total, 159 consecutive patients (66 ± 11 years old, 151 men [95%]) with scar-related left ventricular (LV) VT were included. VT substrate ablation used the scar dechanneling technique. A CMR-aided ablation using the PSI maps was performed in 54 patients (34%). Procedural data as well as acute and long-term outcomes were compared with those of the remaining 105 patients (66%). RESULTS Mean procedure duration and fluoroscopy time were 229 ± 67 minutes and 20 ± 9 minutes, respectively, without significant differences between groups. Both the number of radiofrequency (RF) applications and RF delivery time were lower in the CMR-aided group (28 ± 18 applications vs 36 ± 18 applications, P = .037, and 19 ± 12 minutes vs 27 ± 16 minutes, P = .009, respectively). After substrate ablation, monomorphic VT inducibility was lower in the CMR-aided than in the control group (17 [32%] vs 53 [51%] patients, P = .022). After a mean follow-up period of 20 ± 19 months, patients from the CMR-aided group had a lower recurrence rate than those in the control group (10 patients [18.5%] vs 46 patients [43.8%], respectively, P = .002; log-rank P = .017). Multivariate analysis found that CMR-aided ablation (hazard ratio, 0.48 [95% Confirdence Interval (CI) 0.24-0.96], P = .037) was an independent predictor of recurrences. CONCLUSION CMR-aided scar dechanneling is associated with a lower need for RF delivery, higher noninducibility rates after substrate ablation, and a higher VT-recurrence-free survival.
Collapse
Affiliation(s)
- David Andreu
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - Diego Penela
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - Juan Acosta
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | | | - Rosario J Perea
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - David Soto-Iglesias
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - Teresa M de Caralt
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - Jose T Ortiz-Perez
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - Susana Prat-González
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - Roger Borràs
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - Eduard Guasch
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - Jose María Tolosana
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - Lluis Mont
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain
| | - Antonio Berruezo
- Hospital Clínic and Institut d'Investigació August Pi i Sunyer, Barcelona, Spain.
| |
Collapse
|
26
|
Zghaib T, Ipek EG, Hansford R, Ashikaga H, Berger RD, Marine JE, Spragg DD, Tandri H, Zimmerman SL, Halperin H, Brancato S, Calkins H, Henrikson C, Nazarian S. Response by Zghaib et al to Letter Regarding Article, “Standard Ablation Versus Magnetic Resonance Imaging–Guided Ablation in the Treatment of Ventricular Tachycardia”. Circ Arrhythm Electrophysiol 2018; 11:e006413. [DOI: 10.1161/circep.118.006413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Tarek Zghaib
- Division of Cardiology, Johns Hopkins University School of Medicine (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.), Department of Radiology and Radiological Sciences, Johns Hopkins Medicine (S.L.Z., H.H.), and Department of Biomedical Engineering (H.H), Johns Hopkins University, Baltimore, MD. Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.). Division of Cardiology, Oregon Health Sciences University, Portland (C.H.). Division of
| | - Esra G. Ipek
- Division of Cardiology, Johns Hopkins University School of Medicine (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.), Department of Radiology and Radiological Sciences, Johns Hopkins Medicine (S.L.Z., H.H.), and Department of Biomedical Engineering (H.H), Johns Hopkins University, Baltimore, MD. Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.). Division of Cardiology, Oregon Health Sciences University, Portland (C.H.). Division of
| | - Rozann Hansford
- Division of Cardiology, Johns Hopkins University School of Medicine (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.), Department of Radiology and Radiological Sciences, Johns Hopkins Medicine (S.L.Z., H.H.), and Department of Biomedical Engineering (H.H), Johns Hopkins University, Baltimore, MD. Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.). Division of Cardiology, Oregon Health Sciences University, Portland (C.H.). Division of
| | - Hiroshi Ashikaga
- Division of Cardiology, Johns Hopkins University School of Medicine (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.), Department of Radiology and Radiological Sciences, Johns Hopkins Medicine (S.L.Z., H.H.), and Department of Biomedical Engineering (H.H), Johns Hopkins University, Baltimore, MD. Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.). Division of Cardiology, Oregon Health Sciences University, Portland (C.H.). Division of
| | - Ronald D. Berger
- Division of Cardiology, Johns Hopkins University School of Medicine (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.), Department of Radiology and Radiological Sciences, Johns Hopkins Medicine (S.L.Z., H.H.), and Department of Biomedical Engineering (H.H), Johns Hopkins University, Baltimore, MD. Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.). Division of Cardiology, Oregon Health Sciences University, Portland (C.H.). Division of
| | - Joseph E. Marine
- Division of Cardiology, Johns Hopkins University School of Medicine (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.), Department of Radiology and Radiological Sciences, Johns Hopkins Medicine (S.L.Z., H.H.), and Department of Biomedical Engineering (H.H), Johns Hopkins University, Baltimore, MD. Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.). Division of Cardiology, Oregon Health Sciences University, Portland (C.H.). Division of
| | - David D. Spragg
- Division of Cardiology, Johns Hopkins University School of Medicine (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.), Department of Radiology and Radiological Sciences, Johns Hopkins Medicine (S.L.Z., H.H.), and Department of Biomedical Engineering (H.H), Johns Hopkins University, Baltimore, MD. Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.). Division of Cardiology, Oregon Health Sciences University, Portland (C.H.). Division of
| | - Harikrishna Tandri
- Division of Cardiology, Johns Hopkins University School of Medicine (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.), Department of Radiology and Radiological Sciences, Johns Hopkins Medicine (S.L.Z., H.H.), and Department of Biomedical Engineering (H.H), Johns Hopkins University, Baltimore, MD. Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.). Division of Cardiology, Oregon Health Sciences University, Portland (C.H.). Division of
| | - Stefan L. Zimmerman
- Division of Cardiology, Johns Hopkins University School of Medicine (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.), Department of Radiology and Radiological Sciences, Johns Hopkins Medicine (S.L.Z., H.H.), and Department of Biomedical Engineering (H.H), Johns Hopkins University, Baltimore, MD. Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.). Division of Cardiology, Oregon Health Sciences University, Portland (C.H.). Division of
| | - Henry Halperin
- Division of Cardiology, Johns Hopkins University School of Medicine (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.), Department of Radiology and Radiological Sciences, Johns Hopkins Medicine (S.L.Z., H.H.), and Department of Biomedical Engineering (H.H), Johns Hopkins University, Baltimore, MD. Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.). Division of Cardiology, Oregon Health Sciences University, Portland (C.H.). Division of
| | - Scott Brancato
- Division of Cardiology, Johns Hopkins University School of Medicine (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.), Department of Radiology and Radiological Sciences, Johns Hopkins Medicine (S.L.Z., H.H.), and Department of Biomedical Engineering (H.H), Johns Hopkins University, Baltimore, MD. Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.). Division of Cardiology, Oregon Health Sciences University, Portland (C.H.). Division of
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins University School of Medicine (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.), Department of Radiology and Radiological Sciences, Johns Hopkins Medicine (S.L.Z., H.H.), and Department of Biomedical Engineering (H.H), Johns Hopkins University, Baltimore, MD. Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.). Division of Cardiology, Oregon Health Sciences University, Portland (C.H.). Division of
| | - Charles Henrikson
- Division of Cardiology, Johns Hopkins University School of Medicine (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.), Department of Radiology and Radiological Sciences, Johns Hopkins Medicine (S.L.Z., H.H.), and Department of Biomedical Engineering (H.H), Johns Hopkins University, Baltimore, MD. Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.). Division of Cardiology, Oregon Health Sciences University, Portland (C.H.). Division of
| | - Saman Nazarian
- Division of Cardiology, Johns Hopkins University School of Medicine (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.), Department of Radiology and Radiological Sciences, Johns Hopkins Medicine (S.L.Z., H.H.), and Department of Biomedical Engineering (H.H), Johns Hopkins University, Baltimore, MD. Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.). Division of Cardiology, Oregon Health Sciences University, Portland (C.H.). Division of
| |
Collapse
|
27
|
Kuroki K, Nogami A, Igarashi M, Masuda K, Kowase S, Kurosaki K, Komatsu Y, Naruse Y, Machino T, Yamasaki H, Xu D, Murakoshi N, Sekiguchi Y, Aonuma K. New Substrate-Guided Method of Predicting Slow Conducting Isthmuses of Ventricular Tachycardia. Circ Arrhythm Electrophysiol 2018; 11:e005705. [DOI: 10.1161/circep.117.005705] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 01/24/2018] [Indexed: 11/16/2022]
Abstract
Background:
Several conducting channels of ventricular tachycardia (VT) can be identified using voltage limit adjustment (VLA) of substrate mapping. However, the sensitivity or specificity to predict a VT isthmus is not high by using VLA alone. This study aimed to evaluate the efficacy of the combined use of VLA and fast-Fourier transform analysis to predict VT isthmuses.
Methods and Results:
VLA and fast-Fourier transform analyses of local ventricular bipolar electrograms during sinus rhythm were performed in 9 postinfarction patients who underwent catheter ablation for a total of 13 monomorphic VTs. Relatively higher voltage areas on an electroanatomical map were defined as high voltage channels (HVCs), and relatively higher fast-Fourier transform areas were defined as high-frequency channels (HFCs). HVCs were classified into full or partial HVCs (the entire or >30% of HVC can be detectable, respectively). Twelve full HVCs were identified in 7 of 9 patients. HFCs were located on 7 of 12 full HVCs. Five VT isthmuses (71%) were included in the 7 full HVC+/HFC+ sites, whereas no VT isthmus was found in the 5 full HVC+/HFC− sites. HFCs were identical to 9 of 16 partial HVCs. Eight VT isthmuses (89%) were included in the 9 partial HVC+/HFC+ sites, whereas no VT isthmus was found in the 7 partial HVC+/HFC− sites. All HVC+/HFC+ sites predicted VT isthmus with a sensitivity of 100% and a specificity of 80%.
Conclusions:
Combined use of VLA and fast-Fourier transform analysis may be a useful method to detect VT isthmuses.
Collapse
Affiliation(s)
- Kenji Kuroki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan (K.K., A.N., M.I., Y.K., Y.N., T.M., H.Y, D.X., N.M., Y.S., K.A.). Department of Heart Rhythm Management, Yokohama Rosai Hospital, Japan (K.M., S.K., K.K.)
| | - Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan (K.K., A.N., M.I., Y.K., Y.N., T.M., H.Y, D.X., N.M., Y.S., K.A.). Department of Heart Rhythm Management, Yokohama Rosai Hospital, Japan (K.M., S.K., K.K.)
| | - Miyako Igarashi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan (K.K., A.N., M.I., Y.K., Y.N., T.M., H.Y, D.X., N.M., Y.S., K.A.). Department of Heart Rhythm Management, Yokohama Rosai Hospital, Japan (K.M., S.K., K.K.)
| | - Keita Masuda
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan (K.K., A.N., M.I., Y.K., Y.N., T.M., H.Y, D.X., N.M., Y.S., K.A.). Department of Heart Rhythm Management, Yokohama Rosai Hospital, Japan (K.M., S.K., K.K.)
| | - Shinya Kowase
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan (K.K., A.N., M.I., Y.K., Y.N., T.M., H.Y, D.X., N.M., Y.S., K.A.). Department of Heart Rhythm Management, Yokohama Rosai Hospital, Japan (K.M., S.K., K.K.)
| | - Kenji Kurosaki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan (K.K., A.N., M.I., Y.K., Y.N., T.M., H.Y, D.X., N.M., Y.S., K.A.). Department of Heart Rhythm Management, Yokohama Rosai Hospital, Japan (K.M., S.K., K.K.)
| | - Yuki Komatsu
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan (K.K., A.N., M.I., Y.K., Y.N., T.M., H.Y, D.X., N.M., Y.S., K.A.). Department of Heart Rhythm Management, Yokohama Rosai Hospital, Japan (K.M., S.K., K.K.)
| | - Yoshihisa Naruse
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan (K.K., A.N., M.I., Y.K., Y.N., T.M., H.Y, D.X., N.M., Y.S., K.A.). Department of Heart Rhythm Management, Yokohama Rosai Hospital, Japan (K.M., S.K., K.K.)
| | - Takeshi Machino
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan (K.K., A.N., M.I., Y.K., Y.N., T.M., H.Y, D.X., N.M., Y.S., K.A.). Department of Heart Rhythm Management, Yokohama Rosai Hospital, Japan (K.M., S.K., K.K.)
| | - Hiro Yamasaki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan (K.K., A.N., M.I., Y.K., Y.N., T.M., H.Y, D.X., N.M., Y.S., K.A.). Department of Heart Rhythm Management, Yokohama Rosai Hospital, Japan (K.M., S.K., K.K.)
| | - Dongzhu Xu
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan (K.K., A.N., M.I., Y.K., Y.N., T.M., H.Y, D.X., N.M., Y.S., K.A.). Department of Heart Rhythm Management, Yokohama Rosai Hospital, Japan (K.M., S.K., K.K.)
| | - Nobuyuki Murakoshi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan (K.K., A.N., M.I., Y.K., Y.N., T.M., H.Y, D.X., N.M., Y.S., K.A.). Department of Heart Rhythm Management, Yokohama Rosai Hospital, Japan (K.M., S.K., K.K.)
| | - Yukio Sekiguchi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan (K.K., A.N., M.I., Y.K., Y.N., T.M., H.Y, D.X., N.M., Y.S., K.A.). Department of Heart Rhythm Management, Yokohama Rosai Hospital, Japan (K.M., S.K., K.K.)
| | - Kazutaka Aonuma
- Department of Cardiology, Faculty of Medicine, University of Tsukuba, Japan (K.K., A.N., M.I., Y.K., Y.N., T.M., H.Y, D.X., N.M., Y.S., K.A.). Department of Heart Rhythm Management, Yokohama Rosai Hospital, Japan (K.M., S.K., K.K.)
| |
Collapse
|
28
|
Markman TM, McBride DA, Liang JJ. Catheter Ablation for Ventricular Tachycardia in Patients with Structural Heart Disease. US CARDIOLOGY REVIEW 2018. [DOI: 10.15420/usc.2017:28:3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Ventricular tachycardia is a potentially fatal arrhythmia that occurs most frequently in patients with structural heart disease. Acute and long- term management can be complex, requiring an integrated approach with multiple therapeutic modalities including antiarrhythmic drugs, implantable cardioverter defibrillators, and catheter ablation. Each of these options has a role in management of ventricular tachycardia and are generally used in combination. It is essential to be aware that each approach has potential deleterious consequences that must be balanced while establishing a treatment strategy. Catheter ablation for ventricular tachycardia is performed with increasing frequency with rapidly evolving techniques. In this review, we discuss the acute and long-term management of ventricular tachycardia with a focus on techniques and evidence for catheter ablation.
Collapse
|
29
|
Xie S, Desjardins B, Kubala M, Liang J, Yang J, van der Geest RJ, Schaller R, Riley M, Callans D, Zado E, Marchlinski F, Nazarian S. Association of regional epicardial right ventricular electrogram voltage amplitude and late gadolinium enhancement distribution on cardiac magnetic resonance in patients with arrhythmogenic right ventricular cardiomyopathy: Implications for ventricular tachycardia ablation. Heart Rhythm 2018; 15:987-993. [PMID: 29501666 DOI: 10.1016/j.hrthm.2018.02.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Indexed: 01/06/2023]
Abstract
BACKGROUND Criteria for identification of anatomic ventricular tachycardia substrates in arrhythmogenic right ventricular cardiomyopathy (ARVC) on late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) are unclear. OBJECTIVE The purpose of this study was to define (1) the association of regional right ventricular (RV) epicardial voltage amplitude with the distribution of LGE; and (2) appropriate image signal intensity (SI) thresholds for ventricular tachycardia substrate identification in ARVC. METHODS Preprocedural LGE-CMR and epicardial electrogram mapping were performed in 10 ARVC patients. The locations of epicardial electrogram map points, obtained during sinus rhythm with intrinsic conduction or RV pacing, were retrospectively registered to the corresponding LGE image regions. Standardized SI z-scores (standard deviation distance from the mean) were calculated for each 10-mm region surrounding map points. RESULTS In patient-clustered, generalized estimating equations models that included 3205 epicardial electroanatomic points and corresponding SI measures, bipolar (-1.43 mV/z-score; P <.001) and unipolar voltage amplitude (-1.22 mV/z-score; P <.001) were associated with regional SI z-scores. In contrast to the QRS-late potential (LP) interval (P = .362), the LP activation index, defined as electrogram duration divided by QRS-LP, was associated with regional SI z-scores (P <.001). SI z-score thresholds >0.05 (95% confidence interval -0.05 to 0.15) and <-0.16 (95% confidence interval -0.26 to 0.06) corresponded to bipolar voltage measures <0.5 and >1.0 mV, respectively. CONCLUSION Increased RV gadolinium uptake is associated with lower epicardial bipolar and unipolar electrogram voltage amplitude. Standardized LGE-CMR SI z-scores may augment preprocedural planning for identification of low-voltage zones and abnormal myocardium in ARVC.
Collapse
Affiliation(s)
- Shuanglun Xie
- Section of Cardiac Electrophysiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Cardiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Benoit Desjardins
- Section of Cardiac Electrophysiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania; Department of Radiology, Hospital of the University of Pennsylvania, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Maciej Kubala
- Section of Cardiac Electrophysiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jackson Liang
- Section of Cardiac Electrophysiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Jiandu Yang
- Section of Cardiac Electrophysiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Rob J van der Geest
- Division of Image Processing, Leiden University Medical Centre, Leiden, The Netherlands
| | - Robert Schaller
- Section of Cardiac Electrophysiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Michael Riley
- Section of Cardiac Electrophysiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - David Callans
- Section of Cardiac Electrophysiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Erica Zado
- Section of Cardiac Electrophysiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Francis Marchlinski
- Section of Cardiac Electrophysiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Saman Nazarian
- Section of Cardiac Electrophysiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.
| |
Collapse
|
30
|
Zghaib T, Ipek EG, Hansford R, Ashikaga H, Berger RD, Marine JE, Spragg DD, Tandri H, Zimmerman SL, Halperin H, Brancato S, Calkins H, Henrikson C, Nazarian S. Standard Ablation Versus Magnetic Resonance Imaging-Guided Ablation in the Treatment of Ventricular Tachycardia. Circ Arrhythm Electrophysiol 2018; 11:e005973. [PMID: 29330333 PMCID: PMC5776749 DOI: 10.1161/circep.117.005973] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 11/30/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Tarek Zghaib
- From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.)
| | - Esra G Ipek
- From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.)
| | - Rozann Hansford
- From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.)
| | - Hiroshi Ashikaga
- From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.)
| | - Ronald D Berger
- From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.)
| | - Joseph E Marine
- From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.)
| | - David D Spragg
- From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.)
| | - Harikrishna Tandri
- From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.)
| | - Stefan L Zimmerman
- From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.)
| | - Henry Halperin
- From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.)
| | - Scott Brancato
- From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.)
| | - Hugh Calkins
- From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.)
| | - Charles Henrikson
- From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.)
| | - Saman Nazarian
- From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.).
| |
Collapse
|
31
|
Mahida S, Sacher F, Dubois R, Sermesant M, Bogun F, Haïssaguerre M, Jaïs P, Cochet H. Cardiac Imaging in Patients With Ventricular Tachycardia. Circulation 2017; 136:2491-2507. [DOI: 10.1161/circulationaha.117.029349] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Ventricular tachycardia (VT) is a major cause of sudden cardiac death. The majority of malignant VTs occur in patients with structural heart disease. Multimodality imaging techniques play an integral role in determining the underlying etiology and prognostic significance of VT. In recent years, advances in imaging technology have enabled characterization of the structural arrhythmogenic substrate in patients with VT with increasing precision. In parallel with these advances, the role of cardiac imaging has expanded from a largely diagnostic tool to an adjunctive tool to guide interventional approaches for treatment of VT. Invasive and noninvasive imaging techniques, often used in combination, have made it possible to integrate structural and electrophysiological information during VT ablation procedures. An important area of current development is the use of noninvasive imaging techniques based on body surface electrocardiographic mapping to elucidate the mechanisms of VT. In the future, these techniques may provide a priori information on mechanisms of VT in patients undergoing interventional procedures. This review provides an overview of the role of cardiac imaging in patients with VT.
Collapse
Affiliation(s)
- Saagar Mahida
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, UK (S.M.)
| | - Frédéric Sacher
- L’Institut de Rythmologie et Modélisation Cardiaque (LIRYC), Centre Hospitalier Universitaire (CHU) de Bordeaux, France (F.S., R.D., M.H., P.J., H.C.)
| | - Rémi Dubois
- L’Institut de Rythmologie et Modélisation Cardiaque (LIRYC), Centre Hospitalier Universitaire (CHU) de Bordeaux, France (F.S., R.D., M.H., P.J., H.C.)
| | - Maxime Sermesant
- Inria Sophia Antipolis, Sophia Antipolis-Méditerranée, France (M.S.)
| | - Frank Bogun
- Division of Cardiology, University of Michigan, Ann Arbor (F.B.)
| | - Michel Haïssaguerre
- L’Institut de Rythmologie et Modélisation Cardiaque (LIRYC), Centre Hospitalier Universitaire (CHU) de Bordeaux, France (F.S., R.D., M.H., P.J., H.C.)
| | - Pierre Jaïs
- L’Institut de Rythmologie et Modélisation Cardiaque (LIRYC), Centre Hospitalier Universitaire (CHU) de Bordeaux, France (F.S., R.D., M.H., P.J., H.C.)
| | - Hubert Cochet
- L’Institut de Rythmologie et Modélisation Cardiaque (LIRYC), Centre Hospitalier Universitaire (CHU) de Bordeaux, France (F.S., R.D., M.H., P.J., H.C.)
| |
Collapse
|
32
|
Samanta R, Kumar S, Chik W, Qian P, Barry MA, Al Raisi S, Bhaskaran A, Farraha M, Nadri F, Kizana E, Thiagalingam A, Kovoor P, Pouliopoulos J. Influence of Intramyocardial Adipose Tissue on the Accuracy of Endocardial Contact Mapping of the Chronic Myocardial Infarction Substrate. Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.116.004998. [PMID: 29038101 DOI: 10.1161/circep.116.004998] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 08/17/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recent studies have demonstrated that intramyocardial adipose tissue (IMAT) may contribute to ventricular electrophysiological remodeling in patients with chronic myocardial infarction. Using an ovine model of myocardial infarction, we aimed to determine the influence of IMAT on scar tissue identification during endocardial contact mapping and optimal voltage-based mapping criteria for defining IMAT dense regions. METHOD AND RESULTS In 7 sheep, left ventricular endocardial and transmural mapping was performed 84 weeks (15-111 weeks) post-myocardial infarction. Spearman rank correlation coefficient was used to assess the relationship between endocardial contact electrogram amplitude and histological composition of myocardium. Receiver operator characteristic curves were used to derive optimal electrogram thresholds for IMAT delineation during endocardial mapping and to describe the use of endocardial mapping for delineation of IMAT dense regions within scar. Endocardial electrogram amplitude correlated significantly with IMAT (unipolar r=-0.48±0.12, P<0.001; bipolar r=-0.45±0.22, P=0.04) but not collagen (unipolar r=-0.36±0.24, P=0.13; bipolar r=-0.43±0.31, P=0.16). IMAT dense regions of myocardium reliably identified using endocardial mapping with thresholds of <3.7 and <0.6 mV, respectively, for unipolar, bipolar, and combined modalities (single modality area under the curve=0.80, P<0.001; combined modality area under the curve=0.84, P<0.001). Unipolar mapping using optimal thresholding remained significantly reliable (area under the curve=0.76, P<0.001) during mapping of IMAT, confined to putative scar border zones (bipolar amplitude, 0.5-1.5 mV). CONCLUSIONS These novel findings enhance our understanding of the confounding influence of IMAT on endocardial scar mapping. Combined bipolar and unipolar voltage mapping using optimal thresholds may be useful for delineating IMAT dense regions of myocardium, in postinfarct cardiomyopathy.
Collapse
Affiliation(s)
- Rahul Samanta
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Saurabh Kumar
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - William Chik
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Pierre Qian
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Michael A Barry
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Sara Al Raisi
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Abhishek Bhaskaran
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Melad Farraha
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Fazlur Nadri
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Eddy Kizana
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Aravinda Thiagalingam
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Pramesh Kovoor
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Jim Pouliopoulos
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.).
| |
Collapse
|
33
|
Venlet J, Piers SRD, Kapel GFL, de Riva M, Pauli PFG, van der Geest RJ, Zeppenfeld K. Unipolar Endocardial Voltage Mapping in the Right Ventricle: Optimal Cutoff Values Correcting for Computed Tomography-Derived Epicardial Fat Thickness and Their Clinical Value for Substrate Delineation. Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.117.005175. [PMID: 28798020 DOI: 10.1161/circep.117.005175] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 07/07/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Low endocardial unipolar voltage (UV) at sites with normal bipolar voltage (BV) may indicate epicardial scar. Currently applied UV cutoff values are based on studies that lacked epicardial fat information. This study aimed to define endocardial UV cutoff values using computed tomography-derived fat information and to analyze their clinical value for right ventricular substrate delineation. METHODS AND RESULTS Thirty-three patients (50±14 years; 79% men) underwent combined endocardial-epicardial right ventricular electroanatomical mapping and ablation of right ventricular scar-related ventricular tachycardia with computed tomographic image integration, including computed tomography-derived fat thickness. Of 6889 endocardial-epicardial mapping point pairs, 547 (8%) pairs with distance <10 mm and fat thickness <1.0 mm were analyzed for voltage and abnormal (fragmented/late potential) electrogram characteristics. At sites with endocardial BV >1.50 mV, the optimal endocardial UV cutoff for identification of epicardial BV <1.50 mV was 3.9 mV (area under the curve, 0.75; sensitivity, 60%; specificity, 79%) and cutoff for identification of abnormal epicardial electrogram was 3.7 mV (area under the curve, 0.88; sensitivity, 100%; specificity, 67%). The majority of abnormal electrograms (130 of 151) were associated with transmural scar. Eighty-six percent of abnormal epicardial electrograms had corresponding endocardial sites with BV <1.50 mV, and the remaining could be identified by corresponding low endocardial UV <3.7 mV. CONCLUSIONS For identification of epicardial right ventricular scar, an endocardial UV cutoff value of 3.9 mV is more accurate than previously reported cutoff values. Although the majority of epicardial abnormal electrograms are associated with transmural scar with low endocardial BV, the additional use of endocardial UV at normal BV sites improves the diagnostic accuracy resulting in identification of all epicardial abnormal electrograms at sites with <1.0 mm fat.
Collapse
Affiliation(s)
- Jeroen Venlet
- From the Departments of Cardiology (J.V., S.R.D.P., G.F.L.K., M.d.R., P.F.G.P., K.Z.) and Image Processing (R.J.v.d.G.), Leiden University Medical Center, The Netherlands
| | - Sebastiaan R D Piers
- From the Departments of Cardiology (J.V., S.R.D.P., G.F.L.K., M.d.R., P.F.G.P., K.Z.) and Image Processing (R.J.v.d.G.), Leiden University Medical Center, The Netherlands
| | - Gijsbert F L Kapel
- From the Departments of Cardiology (J.V., S.R.D.P., G.F.L.K., M.d.R., P.F.G.P., K.Z.) and Image Processing (R.J.v.d.G.), Leiden University Medical Center, The Netherlands
| | - Marta de Riva
- From the Departments of Cardiology (J.V., S.R.D.P., G.F.L.K., M.d.R., P.F.G.P., K.Z.) and Image Processing (R.J.v.d.G.), Leiden University Medical Center, The Netherlands
| | - Philippe F G Pauli
- From the Departments of Cardiology (J.V., S.R.D.P., G.F.L.K., M.d.R., P.F.G.P., K.Z.) and Image Processing (R.J.v.d.G.), Leiden University Medical Center, The Netherlands
| | - Rob J van der Geest
- From the Departments of Cardiology (J.V., S.R.D.P., G.F.L.K., M.d.R., P.F.G.P., K.Z.) and Image Processing (R.J.v.d.G.), Leiden University Medical Center, The Netherlands
| | - Katja Zeppenfeld
- From the Departments of Cardiology (J.V., S.R.D.P., G.F.L.K., M.d.R., P.F.G.P., K.Z.) and Image Processing (R.J.v.d.G.), Leiden University Medical Center, The Netherlands.
| |
Collapse
|
34
|
Oebel S, Dinov B, Arya A, Hilbert S, Sommer P, Bollmann A, Hindricks G, Paetsch I, Jahnke C. ECG morphology of premature ventricular contractions predicts the presence of myocardial fibrotic substrate on cardiac magnetic resonance imaging in patients undergoing ablation. J Cardiovasc Electrophysiol 2017; 28:1316-1323. [PMID: 28791747 DOI: 10.1111/jce.13309] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Revised: 07/26/2017] [Accepted: 08/01/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND The most likely origin of premature ventricular contractions (PVCs) may be deduced from surface electrocardiogram (ECG) analysis while planning an electrophysiological study (EPS). Apart from purely benign forms of increased ventricular ectopy, myocardial substrate (e.g., regional fibrosis) may be present in certain cases, which will significantly impact the ablation approach. Cardiac magnetic resonance (CMR) imaging can reliably identify fibrotic target lesions and, hence, may assist in adequate patient selection and procedural planning. METHODS AND RESULTS We analyzed 101 patients (59% males, mean age 57.15 ± 15.5 years, mean PVC count 19,801 ± 14,021 per 24 hours) referred for ablation of PVCs. The CMR (1.5T, Philips Ingenia, Best, The Netherlands) protocol included cine and three-dimensional-delayed enhancement imaging using standard cardiac geometries. On surface, ECG right bundle branch block (RBBB) morphology was present in 43% of patients. Twenty-one patients showed the fibrotic substrate on CMR. On univariate analysis, both RBBB morphology (P < 0.001) and presence of multiple PVC morphologies (≥2) significantly predicted the presence of fibrotic substrate (P = 0.01), which various baseline characteristics including left ventricular ejection fraction (45.7 ± 12.6% vs. 50.6 ± 11.0%, P = 0.08) failed to do. CMR-identified fibrosis was associated with the site of origin of the clinical PVCs during EPS and was successfully treated by radiofrequency ablation in 93% (PVC reduction >95%). CONCLUSION In patients with RBBB morphology and/or multiple PVC patterns, CMR imaging before ablation may be helpful due to the increased prevalence of fibrotic lesions with regard to patient stratification and periprocedural management.
Collapse
Affiliation(s)
- Sabrina Oebel
- Department of Rhythmology, HELIOS Heart Center - University of Leipzig, Leipzig, Germany
| | - Borislav Dinov
- Department of Rhythmology, HELIOS Heart Center - University of Leipzig, Leipzig, Germany
| | - Arash Arya
- Department of Rhythmology, HELIOS Heart Center - University of Leipzig, Leipzig, Germany
| | - Sebastian Hilbert
- Department of Rhythmology, HELIOS Heart Center - University of Leipzig, Leipzig, Germany
| | - Philipp Sommer
- Department of Rhythmology, HELIOS Heart Center - University of Leipzig, Leipzig, Germany
| | - Andreas Bollmann
- Department of Rhythmology, HELIOS Heart Center - University of Leipzig, Leipzig, Germany
| | - Gerhard Hindricks
- Department of Rhythmology, HELIOS Heart Center - University of Leipzig, Leipzig, Germany
| | - Ingo Paetsch
- Department of Rhythmology, HELIOS Heart Center - University of Leipzig, Leipzig, Germany
| | - Cosima Jahnke
- Department of Rhythmology, HELIOS Heart Center - University of Leipzig, Leipzig, Germany
| |
Collapse
|
35
|
Nazarian S. Cardiac Electrophysiology Procedures, Known Unknowns, and Unknown Unknowns. JACC Clin Electrophysiol 2017; 3:104-106. [DOI: 10.1016/j.jacep.2016.09.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 09/15/2016] [Indexed: 11/28/2022]
|
36
|
Using wall thickness to understand both sides of the substrate story: Can we predict electrograms with imaging? Heart Rhythm 2017; 14:164-165. [DOI: 10.1016/j.hrthm.2016.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Indexed: 11/19/2022]
|
37
|
Hibernating substrate of ventricular tachycardia: a three-dimensional metabolic and electro-anatomic assessment. J Interv Card Electrophysiol 2017; 48:247-254. [DOI: 10.1007/s10840-016-0219-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 12/14/2016] [Indexed: 10/20/2022]
|
38
|
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.
Collapse
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
| |
Collapse
|
39
|
Fukumoto K, Habibi M, Ipek EG, Zahid S, Khurram IM, Zimmerman SL, Zipunnikov V, Spragg D, Ashikaga H, Trayanova N, Tomaselli GF, Rickard J, Marine JE, Berger RD, Calkins H, Nazarian S. Association of Left Atrial Local Conduction Velocity With Late Gadolinium Enhancement on Cardiac Magnetic Resonance in Patients With Atrial Fibrillation. Circ Arrhythm Electrophysiol 2016; 9:e002897. [PMID: 26917814 DOI: 10.1161/circep.115.002897] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Prior studies have demonstrated regional left atrial late gadolinium enhancement (LGE) heterogeneity on magnetic resonance imaging. Heterogeneity in regional conduction velocities is a critical substrate for functional reentry. We sought to examine the association between left atrial conduction velocity and LGE in patients with atrial fibrillation. METHODS AND RESULTS LGE imaging and left atrial activation mapping were performed during sinus rhythm in 22 patients before pulmonary vein isolation. The locations of 1468 electroanatomic map points were registered to the corresponding anatomic sites on 469 axial LGE image planes. The local conduction velocity at each point was calculated using previously established methods. The myocardial wall thickness and image intensity ratio defined as left atrial myocardial LGE signal intensity divided by the mean left atrial blood pool intensity was calculated for each mapping site. The local conduction velocity and image intensity ratio in the left atrium (mean ± SD) were 0.98 ± 0.46 and 0.95 ± 0.26 m/s, respectively. In multivariable regression analysis, clustered by patient, and adjusting for left atrial wall thickness, conduction velocity was associated with the local image intensity ratio (0.20 m/s decrease in conduction velocity per increase in unit image intensity ratio, P<0.001). CONCLUSIONS In this clinical in vivo study, we demonstrate that left atrial myocardium with increased gadolinium uptake has lower local conduction velocity. Identification of such regions may facilitate the targeting of the substrate for reentrant arrhythmias.
Collapse
Affiliation(s)
- Kotaro Fukumoto
- From the Section of Cardiac Electrophsyiology (K.F., M.H., E.G.I., I.M.K., D.S., H.A., N.T., G.F.T., J.R., J.E.M., R.D.B., H.C., S.N.), Department of Biomedical Engineering (S.Z., H.A., N.T., R.D.B.), Department of Radiology (S.L.Z.), Department of Biostatistics (V.Z.), and Department of Epidemiology (S.N.), Johns Hopkins University, Baltimore, MD
| | - Mohammadali Habibi
- From the Section of Cardiac Electrophsyiology (K.F., M.H., E.G.I., I.M.K., D.S., H.A., N.T., G.F.T., J.R., J.E.M., R.D.B., H.C., S.N.), Department of Biomedical Engineering (S.Z., H.A., N.T., R.D.B.), Department of Radiology (S.L.Z.), Department of Biostatistics (V.Z.), and Department of Epidemiology (S.N.), Johns Hopkins University, Baltimore, MD
| | - Esra Gucuk Ipek
- From the Section of Cardiac Electrophsyiology (K.F., M.H., E.G.I., I.M.K., D.S., H.A., N.T., G.F.T., J.R., J.E.M., R.D.B., H.C., S.N.), Department of Biomedical Engineering (S.Z., H.A., N.T., R.D.B.), Department of Radiology (S.L.Z.), Department of Biostatistics (V.Z.), and Department of Epidemiology (S.N.), Johns Hopkins University, Baltimore, MD
| | - Sohail Zahid
- From the Section of Cardiac Electrophsyiology (K.F., M.H., E.G.I., I.M.K., D.S., H.A., N.T., G.F.T., J.R., J.E.M., R.D.B., H.C., S.N.), Department of Biomedical Engineering (S.Z., H.A., N.T., R.D.B.), Department of Radiology (S.L.Z.), Department of Biostatistics (V.Z.), and Department of Epidemiology (S.N.), Johns Hopkins University, Baltimore, MD
| | - Irfan M Khurram
- From the Section of Cardiac Electrophsyiology (K.F., M.H., E.G.I., I.M.K., D.S., H.A., N.T., G.F.T., J.R., J.E.M., R.D.B., H.C., S.N.), Department of Biomedical Engineering (S.Z., H.A., N.T., R.D.B.), Department of Radiology (S.L.Z.), Department of Biostatistics (V.Z.), and Department of Epidemiology (S.N.), Johns Hopkins University, Baltimore, MD
| | - Stefan L Zimmerman
- From the Section of Cardiac Electrophsyiology (K.F., M.H., E.G.I., I.M.K., D.S., H.A., N.T., G.F.T., J.R., J.E.M., R.D.B., H.C., S.N.), Department of Biomedical Engineering (S.Z., H.A., N.T., R.D.B.), Department of Radiology (S.L.Z.), Department of Biostatistics (V.Z.), and Department of Epidemiology (S.N.), Johns Hopkins University, Baltimore, MD
| | - Vadim Zipunnikov
- From the Section of Cardiac Electrophsyiology (K.F., M.H., E.G.I., I.M.K., D.S., H.A., N.T., G.F.T., J.R., J.E.M., R.D.B., H.C., S.N.), Department of Biomedical Engineering (S.Z., H.A., N.T., R.D.B.), Department of Radiology (S.L.Z.), Department of Biostatistics (V.Z.), and Department of Epidemiology (S.N.), Johns Hopkins University, Baltimore, MD
| | - David Spragg
- From the Section of Cardiac Electrophsyiology (K.F., M.H., E.G.I., I.M.K., D.S., H.A., N.T., G.F.T., J.R., J.E.M., R.D.B., H.C., S.N.), Department of Biomedical Engineering (S.Z., H.A., N.T., R.D.B.), Department of Radiology (S.L.Z.), Department of Biostatistics (V.Z.), and Department of Epidemiology (S.N.), Johns Hopkins University, Baltimore, MD
| | - Hiroshi Ashikaga
- From the Section of Cardiac Electrophsyiology (K.F., M.H., E.G.I., I.M.K., D.S., H.A., N.T., G.F.T., J.R., J.E.M., R.D.B., H.C., S.N.), Department of Biomedical Engineering (S.Z., H.A., N.T., R.D.B.), Department of Radiology (S.L.Z.), Department of Biostatistics (V.Z.), and Department of Epidemiology (S.N.), Johns Hopkins University, Baltimore, MD
| | - Natalia Trayanova
- From the Section of Cardiac Electrophsyiology (K.F., M.H., E.G.I., I.M.K., D.S., H.A., N.T., G.F.T., J.R., J.E.M., R.D.B., H.C., S.N.), Department of Biomedical Engineering (S.Z., H.A., N.T., R.D.B.), Department of Radiology (S.L.Z.), Department of Biostatistics (V.Z.), and Department of Epidemiology (S.N.), Johns Hopkins University, Baltimore, MD
| | - Gordon F Tomaselli
- From the Section of Cardiac Electrophsyiology (K.F., M.H., E.G.I., I.M.K., D.S., H.A., N.T., G.F.T., J.R., J.E.M., R.D.B., H.C., S.N.), Department of Biomedical Engineering (S.Z., H.A., N.T., R.D.B.), Department of Radiology (S.L.Z.), Department of Biostatistics (V.Z.), and Department of Epidemiology (S.N.), Johns Hopkins University, Baltimore, MD
| | - John Rickard
- From the Section of Cardiac Electrophsyiology (K.F., M.H., E.G.I., I.M.K., D.S., H.A., N.T., G.F.T., J.R., J.E.M., R.D.B., H.C., S.N.), Department of Biomedical Engineering (S.Z., H.A., N.T., R.D.B.), Department of Radiology (S.L.Z.), Department of Biostatistics (V.Z.), and Department of Epidemiology (S.N.), Johns Hopkins University, Baltimore, MD
| | - Joseph E Marine
- From the Section of Cardiac Electrophsyiology (K.F., M.H., E.G.I., I.M.K., D.S., H.A., N.T., G.F.T., J.R., J.E.M., R.D.B., H.C., S.N.), Department of Biomedical Engineering (S.Z., H.A., N.T., R.D.B.), Department of Radiology (S.L.Z.), Department of Biostatistics (V.Z.), and Department of Epidemiology (S.N.), Johns Hopkins University, Baltimore, MD
| | - Ronald D Berger
- From the Section of Cardiac Electrophsyiology (K.F., M.H., E.G.I., I.M.K., D.S., H.A., N.T., G.F.T., J.R., J.E.M., R.D.B., H.C., S.N.), Department of Biomedical Engineering (S.Z., H.A., N.T., R.D.B.), Department of Radiology (S.L.Z.), Department of Biostatistics (V.Z.), and Department of Epidemiology (S.N.), Johns Hopkins University, Baltimore, MD
| | - Hugh Calkins
- From the Section of Cardiac Electrophsyiology (K.F., M.H., E.G.I., I.M.K., D.S., H.A., N.T., G.F.T., J.R., J.E.M., R.D.B., H.C., S.N.), Department of Biomedical Engineering (S.Z., H.A., N.T., R.D.B.), Department of Radiology (S.L.Z.), Department of Biostatistics (V.Z.), and Department of Epidemiology (S.N.), Johns Hopkins University, Baltimore, MD
| | - Saman Nazarian
- From the Section of Cardiac Electrophsyiology (K.F., M.H., E.G.I., I.M.K., D.S., H.A., N.T., G.F.T., J.R., J.E.M., R.D.B., H.C., S.N.), Department of Biomedical Engineering (S.Z., H.A., N.T., R.D.B.), Department of Radiology (S.L.Z.), Department of Biostatistics (V.Z.), and Department of Epidemiology (S.N.), Johns Hopkins University, Baltimore, MD.
| |
Collapse
|
40
|
Rijnierse MT, Allaart CP, Knaapen P. Principles and techniques of imaging in identifying the substrate of ventricular arrhythmia. J Nucl Cardiol 2016; 23:218-34. [PMID: 26667814 PMCID: PMC4785206 DOI: 10.1007/s12350-015-0344-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 11/10/2015] [Indexed: 01/26/2023]
Abstract
Life-threatening ventricular arrhythmias (VA) are a major cause of death in patients with cardiomyopathy. To date, impaired left ventricular ejection fraction remains the primary criterion for implantable cardioverter-defibrillator therapy to prevent sudden cardiac death. In recent years, however, advanced imaging techniques such as nuclear imaging, cardiac magnetic resonance imaging, and computed tomography have allowed for a more detailed evaluation of the underlying substrate of VA. These imaging modalities have emerged as a promising approach to assess the risk of sudden cardiac death. In addition, non-invasive identification of the critical sites of arrhythmias may guide ablation therapy. Typical anatomical substrates that can be evaluated by multiple advanced imaging techniques include perfusion abnormalities, scar and its border zone, and sympathetic denervation. Understanding the principles and techniques of different imaging modalities is essential to gain more insight in their role in identifying the arrhythmic substrate. The current review describes the principles of currently available imaging techniques to identify the substrate of VA.
Collapse
Affiliation(s)
- Mischa T Rijnierse
- Department of Cardiology and Institute for Cardiovascular Research (IcaR-VU), VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Cornelis P Allaart
- Department of Cardiology and Institute for Cardiovascular Research (IcaR-VU), VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Paul Knaapen
- Department of Cardiology and Institute for Cardiovascular Research (IcaR-VU), VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
| |
Collapse
|
41
|
Schmidt EJ. Magnetic Resonance Imaging-Guided Cardiac Interventions. Magn Reson Imaging Clin N Am 2015; 23:563-77. [PMID: 26499275 DOI: 10.1016/j.mric.2015.05.011] [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: 11/26/2022]
Abstract
Performing intraoperative cardiovascular procedures inside an MR imaging scanner can potentially provide substantial advantage in clinical outcomes by reducing the risk and increasing the success rate relative to the way such procedures are performed today, in which the primary surgical guidance is provided by X-ray fluoroscopy, by electromagnetically tracked intraoperative devices, and by ultrasound. Both noninvasive and invasive cardiologists are becoming increasingly familiar with the capabilities of MR imaging for providing anatomic and physiologic information that is unequaled by other modalities. As a result, researchers began performing animal (preclinical) interventions in the cardiovascular system in the early 1990s.
Collapse
Affiliation(s)
- Ehud J Schmidt
- Radiology Department, Brigham and Women's Hospital, 221 Longwood Avenue, Room BRB 34C, Boston, MA 02115, USA.
| |
Collapse
|
42
|
Ipek EG, Nazarian S. Cardiac magnetic resonance for prediction of arrhythmogenic areas. Trends Cardiovasc Med 2015; 25:635-42. [PMID: 25937045 PMCID: PMC4559491 DOI: 10.1016/j.tcm.2015.02.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Revised: 02/23/2015] [Accepted: 02/23/2015] [Indexed: 12/20/2022]
Abstract
Catheter ablation has been widely used to manage recurrent atrial and ventricular arrhythmias. It has been established that contrast-enhanced magnetic resonance can accurately characterize the myocardium. In this review, we summarize the role of cardiac magnetic resonance in identification of arrhythmogenic substrates, and the potential utility of cardiac magnetic resonance for catheter ablation of complex atrial and ventricular arrhythmias.
Collapse
Affiliation(s)
- Esra Gucuk Ipek
- Department of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Saman Nazarian
- Department of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| |
Collapse
|
43
|
Abstract
The primary goal of catheter ablation of scar-related ventricular tachycardia (VT) is the interruption of critical areas of slow conduction responsible for the development and maintenance of the reentrant VT circuit. Most patients with scar-related VT present with unstable arrhythmias that are not amenable to interrogation from multiple sites to define the VT circuit based on the intracardiac activation sequence and the response to entrainment mapping. In order to effectively target unstable VTs, a number of ablation approaches have been described with the aim of targeting the abnormal substrate defined with mapping in sinus or paced rhythm. Some of these strategies (eg, late potential and local abnormal ventricular activity ablation or scar homogenization) target the entire abnormal substrate harboring abnormal electrograms, defined with a variety of different criteria. Scar dechanneling, linear ablation through sites matching VT with pacing, and the core isolation approach focus on more discrete regions within the abnormal substrate that have been proven relevant to the clinical and/or inducible arrhythmias by means of physiologic maneuvers, although this does not necessarily translate to fewer radiofrequency lesions to achieve the procedural end-point. Observational studies evaluating different substrate-based ablation techniques have reported fairly uniform arrhythmia-free survivals at short- and mid-term follow-up, although direct comparisons between different techniques are lacking. In this article, we summarize the different state-of-the-art substrate mapping and ablation approaches for targeting unstable VT, with a particular focus on the relative merits and limitations of the described techniques.
Collapse
|
44
|
Left atrial electrophysiologic feature specific for the genesis of complex fractionated atrial electrogram during atrial fibrillation. Heart Vessels 2015; 31:773-82. [PMID: 25854621 DOI: 10.1007/s00380-015-0672-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 04/01/2015] [Indexed: 10/23/2022]
Abstract
Complex fractionated atrial electrogram (CFAE) has been suggested to contribute to the maintenance of atrial fibrillation (AF). However, electrophysiologic characteristics of the left atrial myocardium responsible for genesis of CFAE have not been clarified. Non-contact mapping of the left atrium was performed at 37 AF onset episodes in 24 AF patients. Electrogram amplitude, width, and conduction velocity were measured during sinus rhythm, premature atrial contraction (PAC) with long- (L-PAC), short- (S-PAC) and very short-coupling intervals (VS-PAC). These parameters were compared between CFAE and non-CFAE regions. Unipolar electrogram amplitude was higher in CFAE than non-CFAE during sinus rhythm, L-, S- and VS-PAC (1.82 ± 0.73 vs. 1.13 ± 0.38, p < 0.001; 1.44 ± 0.54 vs. 0.92 ± 0.35, p < 0.001; 1.09 ± 0.40 vs. 0.70 ± 0.27, p < 0.001; 0.76 ± 0.30 vs. 0.53 ± 0.25 mV, p < 0.001). Laplacian bipolar electrogram amplitude was also higher in CFAE than non-CFAE during sinus rhythm, L-, S- and VS-PAC. Unipolar electrogram width was similar in CFAE and non-CFAE. Laplacian bipolar electrogram width was wider in CFAE than non-CFAE during L-, S- and VS-PAC (85.5 ± 6.8 vs. 79.6 ± 4.5, p < 0.001; 96.1 ± 9.7 vs. 84.5 ± 5.9, p < 0.001; 122.4 ± 16.0 vs. 99.6 ± 9.6 ms, p < 0.001), but not during sinus rhythm. The conduction velocity was slower in CFAE during sinus rhythm, L-, S- and VS-PAC than non-CFAE (1.7 ± 0.3 vs. 2.4 ± 0.4, p < 0.001; 1.4 ± 0.3 vs. 2.0 ± 0.5, p < 0.001; 1.2 ± 0.3 vs. 1.7 ± 0.5, p < 0.001; and 0.9 ± 0.3 vs. 1.4 ± 0.4 m/s, p < 0.001). CFAE was generated in the high amplitude atrial myocardium with slow and non-uniform conduction properties which were pronounced associated with premature activation, suggesting that heterogeneous conduction produced in high amplitude region contributes to the genesis of CFAE.
Collapse
|
45
|
Sasaki T, Calkins H, Miller CF, Zviman MM, Zipunnikov V, Arai T, Sawabe M, Terashima M, Marine JE, Berger RD, Nazarian S, Zimmerman SL. New insight into scar-related ventricular tachycardia circuits in ischemic cardiomyopathy: Fat deposition after myocardial infarction on computed tomography--A pilot study. Heart Rhythm 2015; 12:1508-18. [PMID: 25814415 DOI: 10.1016/j.hrthm.2015.03.041] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Indexed: 10/23/2022]
Abstract
BACKGROUND Myocardial fat deposition (FAT-DEP) has been frequently observed in regions of chronic myocardial infarction in patients with ischemic cardiomyopathy. The role of FAT-DEP within scar-related ventricular tachycardia (VT) circuits has not been investigated. OBJECTIVE This pilot study aimed to assess the impact of myocardial FAT-DEP on local electrograms and VT circuits in patients with ischemic cardiomyopathy. METHODS Contrast-enhanced computed tomography was performed in 22 patients with ischemic VT. Electroanatomic map points were registered to the corresponding contrast-enhanced computed tomography images. Myocardial FAT-DEP was identified and characterized using a postprocessing image overlay that highlighted areas below 0 Hounsfield units (HU). The mean attenuation of local myocardial regions corresponding to sampled electrograms was measured on short-axis images. The associations of mean attenuation with bipolar and unipolar amplitudes, left ventricular wall thickness, and VT circuit sites were investigated. RESULTS Of 1801 electroanatomic map points, 519 (28.8%) were located in regions with FAT-DEP. Significant differences were observed in mean intensity (23.2 ± 35.6 HU vs 81.7 ± 21.9 HU; P < .001), bipolar (0.75 ± 0.83 mV vs 2.9 ± 2.4 mV; P < .001) and unipolar (3.1 ± 1.7 mV vs 7.4 ± 4.3 mV; P < .001) amplitudes, and left ventricular wall thickness (5.2 ± 1.7 mm vs 8.2 ± 2.5 mm; P < .001) between regions with and without FAT-DEP. Lower HU was strongly associated with lower bipolar and unipolar amplitudes (P < .0001, respectively). Importantly, FAT-DEP was associated with critical VT circuit sites with fractionated or isolated potentials. CONCLUSION FAT-DEP was associated with electrogram characteristics and VT circuit sites. Further work will be needed to determine whether FAT-DEP plays a causal role in the generation of ischemic scar-related VT circuits.
Collapse
Affiliation(s)
| | | | | | | | | | - Tomio Arai
- Department of Pathology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan
| | - Motoji Sawabe
- Department of Molecular Pathology, Tokyo Medical and Dental University, Tokyo, Japan
| | | | | | | | | | - Stefan L Zimmerman
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, Maryland
| |
Collapse
|
46
|
Gücük İpek E. The usefulness of cardiac magnetic resonance in prevention of sudden cardiac death after myocardial infarction. Anatol J Cardiol 2015; 15:77. [PMID: 25550254 PMCID: PMC5336908 DOI: 10.5152/akd.2014.5885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
Affiliation(s)
- Esra Gücük İpek
- Department of Cardiology, Johns Hopkins University; Maryland-USA.
| |
Collapse
|
47
|
Comparison of preexisting and ablation-induced late gadolinium enhancement on left atrial magnetic resonance imaging. Heart Rhythm 2014; 12:668-72. [PMID: 25533586 DOI: 10.1016/j.hrthm.2014.12.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Indexed: 11/23/2022]
Abstract
BACKGROUND Postablation atrial fibrillation recurrence is positively associated with the extent of preexisting left atrial (LA) late gadolinium enhancement (LGE) on magnetic resonance imaging (MRI), but negatively associated with the extent of postablation LGE regardless of proximity to the pulmonary vein antra. The characteristics of pre- vs postablation LA LGE may provide insight into this seeming paradox and inform future strategies for ablation. OBJECTIVE The purpose of this study was to define the characteristics of preexisting vs ablation-induced LA LGE. METHODS LGE-MRI was prospectively performed before and ≥3 months after initial ablation in 20 patients. The intracardiac locations of ablation points were coregistered with the corresponding sites on axial planes of postablation LGE-MRI. The image intensity ratio (IIR), defined as the LA myocardial MRI signal intensity divided by the mean LA blood pool intensity, and LA myocardial wall thickness were calculated on pre- and postablation images. RESULTS Imaging data from 409 pairs of pre- and postablation axial LGE-MRI planes and 6961 pairs of pre- and postablation image sectors were analyzed. Ablation-induced LGE revealed a higher IIR, suggesting greater contrast uptake and denser fibrosis, than did preexisting LGE (1.25 ± 0.25 vs 1.14 ± 0.15; P < .001). In addition, ablation-induced LGE regions had thinner LA myocardium (2.10 ± 0.67 mm vs 2.37 ± 0.74 mm; P < .001). CONCLUSION Regions with ablation-induced LGE exhibit increased contrast uptake, likely signifying higher scar density, and thinner myocardium as compared with regions with preexisting LGE. Future studies examining the association of postablation LGE intensity and nonuniformity with ablation success are warranted and may inform strategies to optimize ablation outcome.
Collapse
|
48
|
|
49
|
CMR–Based Identification of Critical Isthmus Sites of Ischemic and Nonischemic Ventricular Tachycardia. JACC Cardiovasc Imaging 2014; 7:774-84. [DOI: 10.1016/j.jcmg.2014.03.013] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 03/13/2014] [Accepted: 03/19/2014] [Indexed: 11/23/2022]
|
50
|
Dukkipati SR, Sanz J. Contrast-Enhanced CMR Imaging of Ventricular Tachycardia Isthmus Sites to Guide Ablation. JACC Cardiovasc Imaging 2014; 7:785-7. [DOI: 10.1016/j.jcmg.2014.06.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 06/29/2014] [Indexed: 11/26/2022]
|