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Renard E, Surget E, Walton RD, Michel C, Benoist D, Dubes V, Guillot B, Martinez ME, Hocini M, Haïssaguerre M, Bernus O. Distinct Electrogram Features and Ventricular Arrhythmia Induction Modes Between Repolarization and Conduction Heterogeneities. JACC Clin Electrophysiol 2024; 10:1424-1438. [PMID: 38661605 DOI: 10.1016/j.jacep.2024.03.002] [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: 10/04/2023] [Revised: 03/01/2024] [Accepted: 03/04/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Recent clinical studies have indicated the presence of localized electrical abnormalities in idiopathic ventricular fibrillation and J-wave syndrome patients. OBJECTIVES This study aims to characterize the specific electrical signatures of localized repolarization and conduction heterogeneities and their respective role in vulnerability to arrhythmias. METHODS Optical mapping was performed in porcine right ventricles with local: 1) repolarization shortening; 2) conduction slowing; or 3) structural heterogeneity induced by locally perfusing: 1) pinacidil (20 μmol/L, n = 13); or 2) flecainide (2 μmol/L, n = 13) via an epicardial catheter; or 3) by local epicardial tissue destruction (9 radiofrequency lesions n = 12). Electrograms were recorded (n = 5 in each group) and spontaneous and induced arrhythmias were quantified and optically mapped. RESULTS Electrograms were normal in (1) but showed local fragmentation in 40% of preparations in (2) with greater effects observed at high pacing frequencies dependent on the wavefront direction. In (3), the structural substrate alone increased the width and number of peaks in the electrograms, and addition of flecainide induced pronounced fragmentation (≥3 peaks and ≥70 ms) in all cases. Occurrence of spontaneous arrhythmias was significantly increased in (1) and (2) (P < 0.0001 and 0.05, respectively, vs baseline) and were triggered by ectopies. Vulnerability to arrhythmias at high pacing frequencies (≥2 Hz) was the lowest in (1) and greatest in (2). CONCLUSIONS Microstructural substrates have the most pronounced impact on electrograms, especially when combined with sodium channel blockers, whereas local action potential duration shortening does not lead to electrogram fragmentation even though it is associated with the highest prevalence of spontaneous arrhythmias.
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Affiliation(s)
- Estelle Renard
- IHU LIRYC, L'Institut des maladies du RYthme Cardiaque, Fondation Bordeaux Université, Bordeaux, France; University of Bordeaux, Inserm, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France.
| | - Elodie Surget
- IHU LIRYC, L'Institut des maladies du RYthme Cardiaque, Fondation Bordeaux Université, Bordeaux, France; University of Bordeaux, Inserm, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Richard D Walton
- IHU LIRYC, L'Institut des maladies du RYthme Cardiaque, Fondation Bordeaux Université, Bordeaux, France; University of Bordeaux, Inserm, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Cindy Michel
- IHU LIRYC, L'Institut des maladies du RYthme Cardiaque, Fondation Bordeaux Université, Bordeaux, France; University of Bordeaux, Inserm, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - David Benoist
- IHU LIRYC, L'Institut des maladies du RYthme Cardiaque, Fondation Bordeaux Université, Bordeaux, France; University of Bordeaux, Inserm, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Virginie Dubes
- IHU LIRYC, L'Institut des maladies du RYthme Cardiaque, Fondation Bordeaux Université, Bordeaux, France; University of Bordeaux, Inserm, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Bastien Guillot
- IHU LIRYC, L'Institut des maladies du RYthme Cardiaque, Fondation Bordeaux Université, Bordeaux, France; University of Bordeaux, Inserm, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Marine E Martinez
- IHU LIRYC, L'Institut des maladies du RYthme Cardiaque, Fondation Bordeaux Université, Bordeaux, France; University of Bordeaux, Inserm, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Mélèze Hocini
- IHU LIRYC, L'Institut des maladies du RYthme Cardiaque, Fondation Bordeaux Université, Bordeaux, France; University of Bordeaux, Inserm, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France; CHU de Bordeaux, Département d'électrophysiologie et de stimulation cardiaques, Hôpital Cardiologique du Haut-Lévêque, Pessac, France
| | - Michel Haïssaguerre
- IHU LIRYC, L'Institut des maladies du RYthme Cardiaque, Fondation Bordeaux Université, Bordeaux, France; University of Bordeaux, Inserm, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France; CHU de Bordeaux, Département d'électrophysiologie et de stimulation cardiaques, Hôpital Cardiologique du Haut-Lévêque, Pessac, France
| | - Olivier Bernus
- IHU LIRYC, L'Institut des maladies du RYthme Cardiaque, Fondation Bordeaux Université, Bordeaux, France; University of Bordeaux, Inserm, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
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2
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Katritsis G, Kailey B, Jamil-Copley S, Luther V, Koa-Wing M, Cortez-Dias N, Carpinteiro L, de Sousa J, Martin R, Murray S, Das M, Whinnett Z, Lim PB, Peters NS, Ng FS, Chow AW, Linton NWF, Kanagaratnam P. RIPPLE-VT study: Multicenter prospective evaluation of ventricular tachycardia substrate ablation by targeting scar channels to eliminate latest scar potentials without direct ablation. Heart Rhythm 2024:S1547-5271(24)02659-6. [PMID: 38848856 DOI: 10.1016/j.hrthm.2024.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/21/2024] [Accepted: 05/24/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND Recurrent ventricular tachycardia (VT) can be treated by substrate modification of the myocardial scar by catheter ablation during sinus rhythm without VT induction. Better defining this arrhythmic substrate could help improve outcome and reduce ablation burden. OBJECTIVE The study aimed to limit ablation within postinfarction scar to conduction channels within the scar to reduce VT recurrence. METHODS Patients undergoing catheter ablation for recurrent implantable cardioverter-defibrillator therapy for postinfarction VT were recruited at 5 centers. Left ventricular maps were collected on CARTO using a Pentaray catheter. Ripple mapping was used to categorize infarct scar potentials (SPs) by timing. Earliest SPs were ablated sequentially until there was loss of the terminal SPs without their direct ablation. The primary outcome measure was sustained VT episodes as documented by device interrogations at 1 year, which was compared with VT episodes in the year before ablation. RESULTS The study recruited 50 patients (mean left ventricular ejection fraction, 33% ± 9%), and 37 patients (74%) met the channel ablation end point with successful loss of latest SPs without direct ablation. There were 16 recurrences during 1-year follow-up. There was a 90% reduction in VT burden from 30.2 ± 53.9 to 3.1 ± 7.5 (P < .01) per patient, with a concomitant 88% reduction in appropriate shocks from 2.1 ± 2.7 to 0.2 ± 0.9 (P < .01). There were 8 deaths during follow-up. Those who met the channel ablation end point had no significant difference in mortality, recurrence, or VT burden but had a significantly lower ablation burden of 25.7 ± 4.2 minutes vs 39.9 ± 6.1 minutes (P = .001). CONCLUSION Scar channel ablation is feasible by ripple mapping and can be an alternative to more extensive substrate modification techniques.
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Affiliation(s)
- George Katritsis
- Imperial College Healthcare NHS Trust and Imperial College London, London, United Kingdom
| | - Balrik Kailey
- Imperial College Healthcare NHS Trust and Imperial College London, London, United Kingdom
| | | | - Vishal Luther
- Imperial College Healthcare NHS Trust and Imperial College London, London, United Kingdom
| | - Michael Koa-Wing
- Imperial College Healthcare NHS Trust and Imperial College London, London, United Kingdom
| | | | | | | | - Ruairidh Martin
- Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Stephen Murray
- Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Moloy Das
- Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Zachary Whinnett
- Imperial College Healthcare NHS Trust and Imperial College London, London, United Kingdom
| | - Phang Boon Lim
- Imperial College Healthcare NHS Trust and Imperial College London, London, United Kingdom
| | - Nicholas S Peters
- Imperial College Healthcare NHS Trust and Imperial College London, London, United Kingdom
| | - Fu S Ng
- Imperial College Healthcare NHS Trust and Imperial College London, London, United Kingdom
| | - Anthony W Chow
- Barts Health NHS Trust and Queen Mary University London, London, United Kingdom
| | - Nick W F Linton
- Imperial College Healthcare NHS Trust and Imperial College London, London, United Kingdom
| | - Prapa Kanagaratnam
- Imperial College Healthcare NHS Trust and Imperial College London, London, United Kingdom.
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Ramdat Misier NL, de Groot NMS. Multimodality Assessment of Anatomical Isthmuses in Tetralogy of Fallot: Check the Weather Before Setting Sail! JACC Clin Electrophysiol 2024; 10:867-869. [PMID: 38811069 DOI: 10.1016/j.jacep.2024.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 03/09/2024] [Indexed: 05/31/2024]
Affiliation(s)
- Nawin L Ramdat Misier
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Natasja M S de Groot
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
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Wilhelm TI, Lewalter T, Reiser J, Werner J, Keil A, Oesterlein T, Gleirscher L, Tiemann K, Jilek C. Influence of Heart Rate and Change in Wavefront Direction through Pacing on Conduction Velocity and Voltage Amplitude in a Porcine Model: A High-Density Mapping Study. J Pers Med 2024; 14:473. [PMID: 38793055 PMCID: PMC11122149 DOI: 10.3390/jpm14050473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/04/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Understanding the dynamics of conduction velocity (CV) and voltage amplitude (VA) is crucial in cardiac electrophysiology, particularly for substrate-based catheter ablations targeting slow conduction zones and low voltage areas. This study utilizes ultra-high-density mapping to investigate the impact of heart rate and pacing location on changes in the wavefront direction, CV, and VA of healthy pig hearts. METHODS We conducted in vivo electrophysiological studies on four healthy juvenile pigs, involving various pacing locations and heart rates. High-resolution electroanatomic mapping was performed during intrinsic normal sinus rhythm (NSR) and electrical pacing. The study encompassed detailed analyses at three levels: entire heart cavities, subregions, and localized 5-mm-diameter circular areas. Linear mixed-effects models were used to analyze the influence of heart rate and pacing location on CV and VA in different regions. RESULTS An increase in heart rate correlated with an increase in conduction velocity and a decrease in voltage amplitude. Pacing influenced conduction velocity and voltage amplitude. Pacing also influenced conduction velocity and voltage amplitude, with varying effects observed based on the pacing location within different heart cavities. Pacing from the right atrium (RA) decreased CV in all heart cavities. The overall CV and VA changes in the whole heart cavities were not uniformly reflected in all subregions and subregional CV and VA changes were not always reflected in the overall analysis. Overall, there was a notable variability in absolute CV and VA changes attributed to pacing. CONCLUSIONS Heart rate and pacing location influence CV and VA within healthy juvenile pig hearts. Subregion analysis suggests that specific regions of the heart cavities are more susceptible to pacing. High-resolution mapping aids in detecting regional changes, emphasizing the substantial physiological variations in CV and VA.
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Affiliation(s)
- Theresa Isabelle Wilhelm
- Peter-Osypka Heart Centre Munich, Internistisches Klinikum München Süd, 81379 Munich, Germany (K.T.)
- Eye Center, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Medical Graduate Center, TUM School of Medicine and Health, Technical University of Munich, 81675 Munich, Germany
| | - Thorsten Lewalter
- Peter-Osypka Heart Centre Munich, Internistisches Klinikum München Süd, 81379 Munich, Germany (K.T.)
- Department of Medicine, University of Bonn, 53127 Bonn, Germany
| | - Judith Reiser
- Center for Preclinical Research, TUM School of Medicine and Health, Technical University of Munich, 81675 Munich, Germany; (J.R.)
| | - Julia Werner
- Center for Preclinical Research, TUM School of Medicine and Health, Technical University of Munich, 81675 Munich, Germany; (J.R.)
| | - Andreas Keil
- Boston Scientific Medizintechnik GmbH, 40468 Düsseldorf, Germany
| | | | - Lukas Gleirscher
- Peter-Osypka Heart Centre Munich, Internistisches Klinikum München Süd, 81379 Munich, Germany (K.T.)
| | - Klaus Tiemann
- Peter-Osypka Heart Centre Munich, Internistisches Klinikum München Süd, 81379 Munich, Germany (K.T.)
- Department of Internal Medicine I, TUM School of Medicine and Health, Technical University of Munich, 81675 Munich, Germany
| | - Clemens Jilek
- Peter-Osypka Heart Centre Munich, Internistisches Klinikum München Süd, 81379 Munich, Germany (K.T.)
- Department of Internal Medicine I, TUM School of Medicine and Health, Technical University of Munich, 81675 Munich, Germany
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5
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Hayase J, Salama G. A Catheter With a View: Characterizing the Conventional and Microelectrode Intracardiac "Field of View". JACC Clin Electrophysiol 2024; 10:651-653. [PMID: 38520435 DOI: 10.1016/j.jacep.2024.102336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 01/28/2024] [Indexed: 03/25/2024]
Affiliation(s)
- Justin Hayase
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
| | - Guy Salama
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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6
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Marashly Q, Najjar SN, Hahn J, Rector GJ, Khawaja M, Chelu MG. Innovations in ventricular tachycardia ablation. J Interv Card Electrophysiol 2023; 66:1499-1518. [PMID: 35879516 DOI: 10.1007/s10840-022-01311-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 07/18/2022] [Indexed: 11/30/2022]
Abstract
Catheter ablation of ventricular arrhythmias (VAs) has evolved significantly over the past decade and is currently a well-established therapeutic option. Technological advances and improved understanding of VA mechanisms have led to tremendous innovations in VA ablation. The purpose of this review article is to provide an overview of current innovations in VA ablation. Mapping techniques, such as ultra-high density mapping, isochronal late activation mapping, and ripple mapping, have provided improved arrhythmogenic substrate delineation and potential procedural success while limiting duration of ablation procedure and potential hemodynamic compromise. Besides, more advanced mapping and ablation techniques such as epicardial and intramyocardial ablation approaches have allowed operators to more precisely target arrhythmogenic substrate. Moreover, advances in alternate energy sources, such as electroporation, as well as stereotactic radiation therapy have been proposed to be effective and safe. New catheters, such as the lattice and the saline-enhanced radiofrequency catheters, have been designed to provide deeper and more durable tissue ablation lesions compared to conventional catheters. Contact force optimization and baseline impedance modulation are important tools to optimize VT radiofrequency ablation and improve procedural success. Furthermore, advances in cardiac imaging, specifically cardiac MRI, have great potential in identifying arrhythmogenic substrate and evaluating ablation success. Overall, VA ablation has undergone significant advances over the past years. Innovations in VA mapping techniques, alternate energy source, new catheters, and utilization of cardiac imaging have great potential to improve overall procedural safety, hemodynamic stability, and procedural success.
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Affiliation(s)
- Qussay Marashly
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Salim N Najjar
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA
| | - Joshua Hahn
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA
| | - Graham J Rector
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA
| | - Muzamil Khawaja
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA
| | - Mihail G Chelu
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA.
- Baylor St. Luke's Medical Center, Houston, USA.
- Texas Heart Institute, Houston, USA.
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Chrispin J, Tandri H. Association of Sinus Wavefront Activation and Ventricular Extrastimuli Mapping With Ventricular Tachycardia Re-Entrant Circuits. JACC Clin Electrophysiol 2023; 9:1697-1705. [PMID: 37480854 DOI: 10.1016/j.jacep.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/03/2023] [Accepted: 04/12/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Substrate-based ablation targets areas of delayed and fractionated electrograms during sinus rhythm, which are sensitive for identifying the ventricular tachycardia (VT) isthmus but is influenced by the activation wavefront direction and decremental pacing. OBJECTIVES The aim of this study was to correlate the areas of latest activation during varying wavefront activation mapping and decremental pacing mapping with sites critical to the VT isthmus. METHODS Three high-density electroanatomical substrate maps were created in patients presenting for ablation of monomorphic VT: 1) native sinus rhythm; 2) right ventricular (RV) apical pacing; and 3) an RV apical S2 map following the S1 drive train at 20 ms above the ventricular effective refractory period. Areas corresponding to the latest activation were compared with the VT isthmus identified by conventional mapping. RESULTS Twenty patients with structural heart disease with a mean age of 55.6 ± 16.9 years were included. The majority of the cohort consisted of patients with ischemic heart disease (50%) and arrhythmogenic RV cardiomyopathy (35%). Epicardial ablation was performed in 45% of patients. The concordance of the site of latest activation in sinus rhythm with the VT isthmus was 75%. The location of the latest activation during RV apical pacing corresponded with the VT isthmus in 85% of cases. However, in 95% of cases, the site of the latest activation following the S2 stimulus colocalized to the VT isthmus. CONCLUSIONS In a mix of underlying myocardial substrates, regions of conduction slowing during decremental pacing colocalize with the VT isthmus more frequently than sinus rhythm activation mapping and may have a role in substrate-based ablation where VT induction is undesirable.
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Affiliation(s)
- Jonathan Chrispin
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
| | - Harikrishna Tandri
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Freedman BL, Maher TR, Tracey M, Santangeli P, d'Avila A. Procedural Adaptations to Avoid Haemodynamic Instability During Catheter Ablation of Scar-related Ventricular Tachycardia. Arrhythm Electrophysiol Rev 2023; 12:e20. [PMID: 37465104 PMCID: PMC10350657 DOI: 10.15420/aer.2022.24] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/08/2022] [Indexed: 07/20/2023] Open
Abstract
Classically, catheter ablation for scar-related ventricular tachycardia (VT) relied upon activation and entrainment mapping of induced VT. Advances in post-MI therapies have led to VTs that are faster and haemodynamically less stable, because of more heterogeneous myocardial fibrosis patterns. The PAINESD score is one means of identifying patients at highest risk for haemodynamic decompensation during attempted VT induction, who may, therefore, benefit from alternative ablation strategies. One strategy is to use temporary mechanical circulatory support, although this warrants formal assessment of cost-effectiveness. A second strategy is to minimise or avoid VT induction altogether by employing a family of 'substrate'-based approaches aimed at identifying VT isthmuses during sinus or paced rhythm. Substrate mapping techniques are diverse, and focus on the timing, morphology and amplitude of local ventricular electrograms - sometimes aided by advanced non-invasive cardiac imaging modalities. In this review, the evolution of VT ablation over time is discussed, with an emphasis on procedural adaptations to the challenge of haemodynamic instability.
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Affiliation(s)
- Benjamin L Freedman
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, US
| | - Timothy R Maher
- Harvard-Thorndike Electrophysiology Institute and Arrhythmia Service, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, US
| | | | - Pasquale Santangeli
- Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, US
| | - Andre d'Avila
- Harvard-Thorndike Electrophysiology Institute and Arrhythmia Service, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, US
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9
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Hayase J, Bradfield J. T1 Mapping: A Complementary Tool for Substrate Visualization. JACC Clin Electrophysiol 2023:S2405-500X(23)00119-6. [PMID: 37115115 DOI: 10.1016/j.jacep.2023.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 04/29/2023]
Affiliation(s)
- Justin Hayase
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
| | - Jason Bradfield
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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10
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Khanra D, Calvert P, Hughes S, Waktare J, Modi S, Hall M, Todd D, Mahida S, Gupta D, Luther V. An approach to help differentiate postinfarct scar from borderzone tissue using Ripple Mapping during ventricular tachycardia ablation. J Cardiovasc Electrophysiol 2023; 34:664-672. [PMID: 36478627 DOI: 10.1111/jce.15766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 11/15/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ventricular scar is traditionally highlighted on a bipolar voltage (BiVolt) map in areas of myocardium <0.50 mV. We describe an alternative approach using Ripple Mapping (RM) superimposed onto a BiVolt map to differentiate postinfarct scar from conducting borderzone (BZ) during ventricular tachycardia (VT) ablation. METHODS Fifteen consecutive patients (left ventricular ejection fraction 30 ± 7%) underwent endocardial left ventricle pentaray mapping (median 5148 points) and ablation targeting areas of late Ripple activation. BiVolt maps were studied offline at initial voltage of 0.50-0.50 mV to binarize the color display (red and purple). RMs were superimposed, and the BiVolt limits were sequentially reduced until only areas devoid of Ripple bars appeared red, defined as RM-scar. The surrounding area supporting conducting Ripple wavefronts in tissue <0.50 mV defined the RM-BZ. RESULTS RM-scar was significantly smaller than the traditional 0.50 mV cutoff (median 4% vs. 12% shell area, p < .001). 65 ± 16% of tissue <0.50 mV supported Ripple activation within the RM-BZ. The mean BiVolt threshold that differentiated RM-scar from BZ tissue was 0.22 ± 0.07 mV, though this ranged widely (from 0.12 to 0.35 mV). In this study, septal infarcts (7/15) were associated with more rapid VTs (282 vs. 347 ms, p = .001), and had a greater proportion of RM-BZ to RM-scar (median ratio 3.2 vs. 1.2, p = .013) with faster RM-BZ conduction speed (0.72 vs. 0.34 m/s, p = .001). Conversely, scars that supported hemodynamically stable sustained VT (6/15) were slower (367 ± 38 ms), had a smaller proportion of RM-BZ to RM-scar (median ratio 1.2 vs. 3.2, p = .059), and slower RM-BZ conduction speed (0.36 vs. 0.63 m/s, p = .036). RM guided ablation collocated within 66 ± 20% of RM-BZ, most concentrated around the RM-scar perimeter, with significant VT reduction (median 4.0 episodes preablation vs. 0 post, p < .001) at 11 ± 6 months follow-up. CONCLUSION Postinfarct scars appear significantly smaller than traditional 0.50 mV cut-offs suggest, with voltage thresholds unique to each patient.
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Affiliation(s)
| | - Peter Calvert
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | | | | | - Simon Modi
- Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Mark Hall
- Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Derick Todd
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | - Saagar Mahida
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | - Dhiraj Gupta
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | - Vishal Luther
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
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11
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Sung E, Prakosa A, Kyranakis S, Berger RD, Chrispin J, Trayanova NA. Wavefront directionality and decremental stimuli synergistically improve identification of ventricular tachycardia substrate: insights from personalized computational heart models. Europace 2023; 25:223-235. [PMID: 36006658 PMCID: PMC10103576 DOI: 10.1093/europace/euac140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 07/16/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS Multiple wavefront pacing (MWP) and decremental pacing (DP) are two electroanatomic mapping (EAM) strategies that have emerged to better characterize the ventricular tachycardia (VT) substrate. The aim of this study was to assess how well MWP, DP, and their combination improve identification of electrophysiological abnormalities on EAM that reflect infarct remodelling and critical VT sites. METHODS AND RESULTS Forty-eight personalized computational heart models were reconstructed using images from post-infarct patients undergoing VT ablation. Paced rhythms were simulated by delivering an initial (S1) and an extra-stimulus (S2) from one of 100 locations throughout each heart model. For each pacing, unipolar signals were computed along the myocardial surface to simulate substrate EAM. Six EAM features were extracted and compared with the infarct remodelling and critical VT sites. Concordance of S1 EAM features between different maps was lower in hearts with smaller amounts of remodelling. Incorporating S1 EAM features from multiple maps greatly improved the detection of remodelling, especially in hearts with less remodelling. Adding S2 EAM features from multiple maps decreased the number of maps required to achieve the same detection accuracy. S1 EAM features from multiple maps poorly identified critical VT sites. However, combining S1 and S2 EAM features from multiple maps paced near VT circuits greatly improved identification of critical VT sites. CONCLUSION Electroanatomic mapping with MWP is more advantageous for characterization of substrate in hearts with less remodelling. During substrate EAM, MWP and DP should be combined and delivered from locations proximal to a suspected VT circuit to optimize identification of the critical VT site.
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Affiliation(s)
- Eric Sung
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21287, USA
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218, USA
| | - Adityo Prakosa
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21287, USA
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218, USA
| | - Stephen Kyranakis
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Ronald D Berger
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218, USA
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Jonathan Chrispin
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218, USA
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Natalia A Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21287, USA
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218, USA
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12
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Hawson J, Lee G. Multiple wavefront substrate mapping using a novel late potential mapping algorithm: Can one wavefront rule them all? J Cardiovasc Electrophysiol 2023; 34:400-402. [PMID: 36335631 DOI: 10.1111/jce.15737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 10/31/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Joshua Hawson
- Department of Cardiology, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Victoria, Melbourne, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine, Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Victoria, Melbourne, Australia
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13
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Temma T, Lux RL, Yoshie K, Hayase J, Bradfield JS, Shivkumar K, Ajijola OA. The derivative of tissue activation as a marker of arrhythmogenic myocardium. Heart Rhythm 2023; 20:261-271. [PMID: 36270579 DOI: 10.1016/j.hrthm.2022.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 10/06/2022] [Accepted: 10/12/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Mapping techniques to identify diseased myocardial substrate during ventricular tachycardia ablation procedures remain limited. OBJECTIVE We hypothesized that tissue derivative of the voltage with respect to time (dV/dt), the slope of the unipolar ventricular electrogram registered by local ventricular activation, represents a unique parameter for identifying potential arrhythmogenic tissue in the ischemic scar border zone. METHODS Using high-resolution electrical mapping, we examined dV/dt characteristics in the border zone of animals after chronic myocardial infarction (MI). RESULTS Minimum dV/dt (dV/dtmin) in MI animals was less than that in control animals (-344.7 ± 68.7 in controls vs -174.2 ± 104.5 in MI; P < .001) and related to ventricular fibrosis. In MI animals, dV/dtmin values were divided into high (≤-200 μV/ms) and low (>-200 μV/ms) dV/dtmin. Low dV/dtmin regions harbored arrhythmogenic substrates that were characterized by (1) high responsiveness to sympathetic stimulation, (2) presence of late potentials, and (3) lower unipolar and bipolar voltage amplitudes. CONCLUSION Our data indicate that dV/dtmin is a unique parameter for identifying arrhythmogenic myocardium and may add a useful metric to conventional mapping strategies.
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Affiliation(s)
- Taro Temma
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, University of California, Los Angeles, California
| | - Robert L Lux
- Cardiovascular Research and Training Institute, University of Utah, Salt Lake, Utah
| | - Koji Yoshie
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, University of California, Los Angeles, California; Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Justin Hayase
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, University of California, Los Angeles, California
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, University of California, Los Angeles, California
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, University of California, Los Angeles, California
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center, UCLA Neurocardiology Research Program of Excellence, University of California, Los Angeles, California.
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14
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Lima da Silva G, Cortez-Dias N, Nunes Ferreira A, Nakar E, Francisco R, Pereira M, Moreno J, Martins RP, Pinto FJ, de Sousa J. Impact of different activation wavefronts on ischemic myocardial scar electrophysiological properties during high-density ventricular tachycardia mapping and ablation. J Cardiovasc Electrophysiol 2023; 34:389-399. [PMID: 36335623 DOI: 10.1111/jce.15740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/02/2022] [Accepted: 10/12/2022] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Scar-related ventricular tachycardia (VT) usually results from an underlying reentrant circuit facilitated by anatomical and functional barriers. The later are sensitive to the direction of ventricular activation wavefronts. We aim to evaluate the impact of different ventricular activation wavefronts on the functional electrophysiological properties of myocardial tissue. METHODS Patients with ischemic heart disease referred for VT ablation underwent high-density mapping using Carto®3 (Biosense Webster). Maps were generated during sinus rhythm, right and left ventricular pacing, and analyzed using a new late potential map software, which allows to assess local conduction velocities and facilitates the delineation of intra-scar conduction corridors (ISCC); and for all stable VTs. RESULTS In 16 patients, 31 high-resolution substrate maps from different ventricular activation wavefronts and 7 VT activation maps were obtained. Local abnormal ventricular activities (LAVAs) were found in VT isthmus, but also in noncritical areas. The VT isthmus was localized in areas of LAVAs overlapping surface between the different activation wavefronts. The deceleration zone location differed depending on activation wavefronts. Sixty-six percent of ISCCs were similarly identified in all activating wavefronts, but the one acting as VT isthmus was simultaneously identified in all activation wavefronts in all cases. CONCLUSION Functional based substrate mapping may improve the specificity to localize the most arrhythmogenic regions within the scar, making the use of different activation wavefronts unnecessary in most cases.
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Affiliation(s)
- Gustavo Lima da Silva
- Cardiology Department, Santa Maria University Hospital (CHULN), Lisbon Academic Medical Centre, Lisbon, Portugal.,Cardiac Rhythm Abnormalities Unit, Cardiovascular Centre of the University of Lisbon, Lisbon School of Medicine of the Universidade de Lisboa, Lisbon, Portugal
| | - Nuno Cortez-Dias
- Cardiology Department, Santa Maria University Hospital (CHULN), Lisbon Academic Medical Centre, Lisbon, Portugal.,Cardiac Rhythm Abnormalities Unit, Cardiovascular Centre of the University of Lisbon, Lisbon School of Medicine of the Universidade de Lisboa, Lisbon, Portugal
| | - Afonso Nunes Ferreira
- Cardiology Department, Santa Maria University Hospital (CHULN), Lisbon Academic Medical Centre, Lisbon, Portugal.,Cardiac Rhythm Abnormalities Unit, Cardiovascular Centre of the University of Lisbon, Lisbon School of Medicine of the Universidade de Lisboa, Lisbon, Portugal
| | - Elad Nakar
- Research and Development Department, Biosense Webster, Johnson & Johnson, Yokneam, Israel
| | - Raquel Francisco
- Biosense Webster, Johnson & Johnson, EMEA Clinical Development, Diegem, Belgium
| | - Mariana Pereira
- Biosense Webster, Johnson & Johnson, Clinical Support, Porto Salvo, Portugal
| | - Javier Moreno
- Cardiology Department, Arrhythmia Unit, University Hospital Ramón y Cajal and CIBER-CV Madrid, Madrid, Spain
| | - Raphaël P Martins
- Department of Cardiology, Rennes University Hospital, Rennes, France
| | - Fausto J Pinto
- Cardiology Department, Santa Maria University Hospital (CHULN), Lisbon Academic Medical Centre, Lisbon, Portugal.,Cardiac Rhythm Abnormalities Unit, Cardiovascular Centre of the University of Lisbon, Lisbon School of Medicine of the Universidade de Lisboa, Lisbon, Portugal
| | - João de Sousa
- Cardiology Department, Santa Maria University Hospital (CHULN), Lisbon Academic Medical Centre, Lisbon, Portugal.,Cardiac Rhythm Abnormalities Unit, Cardiovascular Centre of the University of Lisbon, Lisbon School of Medicine of the Universidade de Lisboa, Lisbon, Portugal
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15
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Tschabrunn CM, Callans DJ. Identifying the ventricular tachycardia arrhythmogenic substrate: The quest for the holy grail continues. Heart Rhythm 2023; 20:272-273. [PMID: 36336302 DOI: 10.1016/j.hrthm.2022.10.024] [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: 10/27/2022] [Accepted: 10/27/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Cory M Tschabrunn
- Cardiac Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - David J Callans
- Cardiac Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
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16
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Nakahara S. Catheter ablation of ventricular tachycardia associated with structural heart disease: Current status and perspectives. J Cardiol 2023; 81:57-62. [PMID: 36174816 DOI: 10.1016/j.jjcc.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 09/06/2022] [Indexed: 11/25/2022]
Abstract
Catheter ablation is an effective and safe treatment for ventricular tachycardia attributable to structural heart disease, reducing the risk of recurrent arrhythmias and defibrillator shock therapy. Advances in medical technology and an accumulation of data have led to the development of detailed guidelines. Successful ablation requires accurate identification of the arrhythmia substrate and effective delivery of radiofrequency energy to the target tissue. Modern practice requires use of traditional electrophysiological mapping processes such as entrainment mapping and three-dimensional activation sequence mapping in combination with newer functional mapping techniques for which there is growing support. Thorough non-invasive preoperative assessment is also necessary before an invasive procedure is undertaken. In this review, we summarize contemporary practice and recent randomized controlled trials underpinning the latest developments in mapping and ablation and discuss potential future developments in this field.
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Affiliation(s)
- Shiro Nakahara
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan.
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17
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Kotake Y, Nalliah CJ, Campbell T, Bennett RG, Turnbull S, Kumar S. Comparison of the arrhythmogenic substrate for ventricular tachycardia in patients with ischemic vs non-ischemic cardiomyopathy - insights from high-density, multi-electrode catheter mapping. JOURNAL OF INTERVENTIONAL CARDIAC ELECTROPHYSIOLOGY : AN INTERNATIONAL JOURNAL OF ARRHYTHMIAS AND PACING 2023; 66:5-14. [PMID: 34787768 DOI: 10.1007/s10840-021-01088-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 11/04/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to compare the differences of arrhythmogenic substrate using high-density mapping in ventricular tachycardia (VT) patients with ischemic (ICM) vs non-ischemic cardiomyopathy (NICM). METHODS Data from patients presenting for VT ablation from December 2016 to December 2020 at Westmead Hospital were reviewed. RESULTS Sixty consecutive patients with structural heart disease (ICM 57%, NICM 43%, mean age 66 years) having catheter ablation of scar-related VT with pre-dominant left ventricular involvement were included. ICM was associated with larger proportion of dense scar area (bipolar; 19 [12-29]% vs 6 [3-10]%, P < 0.001, unipolar; 20 [12-32]% vs 11 [7-19]%, P = 0.01) compared with NICM. However, the scar ratio (unipolar dense scar [%]/bipolar dense scar [%]) was significantly higher in NICM patients (1.2 [0.8-1.7] vs 1.7 [1.3-2.3], P = 0.003). Larger scar area in ICM was paralleled by higher proportion of complex electrograms (6 [2-13] % vs 3 [1-5] %, P = 0.01), longer and wider voltage based conducting channels, higher incidence of late potential-based conducting channels, longer VT cycle-length (399 ± 80 ms vs 359 ± 68 ms, P = 0.04) and greater maximal stimulation-QRS interval among sites with good pace-map correlation (75 [51-99]ms vs 48 [31-73]ms, P = 0.02). Ventricular arrhythmia (VA) storm was more highly prevalent in ICM than NICM (50% vs 23%, P = 0.03). During the follow-up period, NICM had a significantly higher cumulative incidence for the VA recurrence than ICM (P = 0.03). CONCLUSIONS High-density multi-electrode catheter mapping of left ventricular arrhythmogenic substrate of NICM tends to show smaller dense scar area and higher scar ratio, compared with ICM, suggestive the extent of epicardial/intramural substrate, with paucity of substrate targets for ablation, which results in the worse outcomes with ablation.
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Affiliation(s)
- Yasuhito Kotake
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Hawkesbury Road, Westmead, NSW, 2145, Australia
| | - Chrishan J Nalliah
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Hawkesbury Road, Westmead, NSW, 2145, Australia
| | - Timothy Campbell
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Hawkesbury Road, Westmead, NSW, 2145, Australia
| | - Richard G Bennett
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Hawkesbury Road, Westmead, NSW, 2145, Australia
| | - Samual Turnbull
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Hawkesbury Road, Westmead, NSW, 2145, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Hawkesbury Road, Westmead, NSW, 2145, Australia.
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18
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Nayyar S. Intracardiac Electrogram Targets for Ventricular Tachycardia Ablation. Card Electrophysiol Clin 2022; 14:559-570. [PMID: 36396178 DOI: 10.1016/j.ccep.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
The pathogenesis of ventricular tachycardia (VT) in most patients with a prior myocardial scarring is reentry involving compartmentalized muscle fibers protected within the scar. Often the 12-lead ECG morphology of the VT itself is not available when treated with a defibrillator. Consequently, VT ablation takes on an interesting challenge of finding critical targets in sinus rhythm. High-density recordings are essential to evaluate a substrate based on whole electrogram voltage and activation delay, supplemented with substrate perturbation through alternate site pacing or introducing an extra stimulation. In this article, we discuss contemporary intracardiac electrogram targets for VT ablation, with explanation on each of their specific fundamental physiology.
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Affiliation(s)
- Sachin Nayyar
- Townsville University Hospital, James Cook University, Townsville, Queensland, Australia.
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19
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Newlon C, Yukiko Asaki S, Pilcher TA, Ou Z, Etheridge SP, Niu MC. The High-Density Grid Catheter: a Safe Adjunctive Tool in Pediatric and Complex Congenital Heart Disease Patients. J Cardiovasc Electrophysiol 2022; 33:2344-2350. [PMID: 36041222 DOI: 10.1111/jce.15667] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 08/11/2022] [Accepted: 08/24/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The safety and utility of the Advisor™ High Density Grid mapping catheter (HDGC) in children and congenital heart disease (CHD) patients are not well described. METHODS Single-center retrospective cohort study of pediatric and CHD patients undergoing electrophysiology study and ablation to determine the effect of HDGC use on outcomes including: acute ablation success, complications, arrhythmia recurrence, fluoroscopy use, and procedure duration. RESULTS HDGC was used in 74/261 (28.3%) cases. HDGC subjects differed by median age (17 vs. 13 years; p < 0.001), weight (68 vs. 50 kg; p < 0.001), and prevalence of significant CHD (42% vs. 3%; p < 0.001). Arrhythmia substrates were dissimilar: HGDC cases had higher frequencies of intra-atrial re-entrant tachycardia (25.7% vs. 0.5%), atrial flutter (8.1% vs. 1.1%), ectopic atrial tachycardia (13.5% vs. 3.7%), and premature ventricular contractions (9.5% vs. 0.5%), and lower incidences of atrioventricular re-entrant tachycardia (16.2% vs. 46.1%). Complications were rare (n=5, 1.9%) with no significant difference between groups (p = 1.00). Procedure duration - but not fluoroscopy exposure - was significantly longer in HDGC cases (median 256 vs. 216 min, p < 0.001). Acute success was lower (93.2% vs. 99.4%; p = 0.01) and recurrences higher (13.2% vs. 3.8%; p = 0.016) in HDGC compared to non-HDGC cases. CONCLUSION HDGC use in children and CHD patients is safe and not associated with higher complication rates. The lower acute success and higher recurrence rates in HDGC cases likely reflects bias towards HDGC use in more complex arrhythmia substrates rather than less favorable ablation outcomes. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Claire Newlon
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Primary Children's Hospital, Salt Lake City, Utah
| | - S Yukiko Asaki
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Primary Children's Hospital, Salt Lake City, Utah
| | - Thomas A Pilcher
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Primary Children's Hospital, Salt Lake City, Utah
| | - Zhining Ou
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Susan P Etheridge
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Primary Children's Hospital, Salt Lake City, Utah
| | - Mary C Niu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Primary Children's Hospital, Salt Lake City, Utah
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20
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Comparison between Standard and High-Definition Multi-Electrode Mapping Catheter in Ventricular Tachycardia Ablation. J Cardiovasc Dev Dis 2022; 9:jcdd9080232. [PMID: 35893222 PMCID: PMC9330382 DOI: 10.3390/jcdd9080232] [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: 06/26/2022] [Revised: 07/16/2022] [Accepted: 07/19/2022] [Indexed: 12/10/2022] Open
Abstract
A high-definition mapping catheter has been introduced, allowing for bipolar recording along and across the spline with a rapid assessment of voltage, activation, and directionality of conduction. We aimed to evaluate differences in mapping density, accuracy, time, and consequently RF time between different mapping catheters used for ventricular tachycardia (VT) ablation. We enrolled consecutive patients undergoing VT ablation at our center. Patients were divided into the LiveWire 2-2-2 mm catheter (group A) and the HD Grid SE (group B). Primary endpoints were total RF delivery time, the number of points acquired in sinus rhythm and VT, and the scar area. Fifty-one patients were enrolled, 22 in group A and 29 in group B. More points were acquired in the Grid group in sinus rhythm (SR) and during VT (2060.78 ± 1600.38 vs. 3278.63 ± 3214.45, p = 0.05; 4201.13 ± 5141.61 vs. 10,569.43 ± 13,644.94, p = 0.02, respectively). The scar area was smaller in group B (Bipolar area, cm2 4.52 ± 2.72 vs. 2.89 ± 2.81, p = 0.05. Unipolar area, cm2 7.47 ± 4.55 vs. 5.56 ± 2.79, p = 0.03). Radiofrequency (RF) time was shorter in the Grid group (30.52 ± 13.94 vs. 22.16 ± 11.03, p = 0.014). LPs and LAVAs were eliminated in overall >93% of patients. No differences were found in terms of arrhythmia-free survival at follow-up. In conclusion, the use of a high-definition mapping catheter was associated with significantly shorter mapping time during VT and RF time. Significantly more points were acquired in SR and during VT. During remap, we also observed more LAVAs and LPs requiring further ablation.
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21
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Wiles BM, Li AC, Waight MC, Saba MM. Contemporary Management of Complex Ventricular Arrhythmias. Arrhythm Electrophysiol Rev 2022; 11:e04. [PMID: 35734144 PMCID: PMC9194914 DOI: 10.15420/aer.2021.66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/06/2022] [Indexed: 12/02/2022] Open
Abstract
Percutaneous catheter ablation is an effective and safe therapy that can eliminate ventricular tachycardia, reducing the risks of both recurrent arrhythmia and shock therapies from a defibrillator. Successful ablation requires accurate identification of arrhythmic substrate and the effective delivery of energy to the targeted tissue. A thorough pre-procedural assessment is needed before considered 3D electroanatomical mapping can be performed. In contemporary practice, this must combine traditional electrophysiological techniques, such as activation and entrainment mapping, with more novel physiological mapping techniques for which there is an ever-increasing evidence base. Novel techniques to maximise energy delivery to the tissue must also be considered and balanced against their associated risks of complication. This review provides a comprehensive appraisal of contemporary practice and the evidence base that supports recent developments in mapping and ablation, while also considering potential future developments in the field.
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Affiliation(s)
- Benedict M Wiles
- Advanced Ventricular Arrhythmia Training and Research (AVATAR) Program, St George's University Hospitals NHS Foundation Trust, London, UK
- Cardiology Clinical Academic Group, St George's University of London, London, UK
| | - Anthony C Li
- Advanced Ventricular Arrhythmia Training and Research (AVATAR) Program, St George's University Hospitals NHS Foundation Trust, London, UK
- Cardiology Clinical Academic Group, St George's University of London, London, UK
| | - Michael C Waight
- Advanced Ventricular Arrhythmia Training and Research (AVATAR) Program, St George's University Hospitals NHS Foundation Trust, London, UK
- Cardiology Clinical Academic Group, St George's University of London, London, UK
| | - Magdi M Saba
- Advanced Ventricular Arrhythmia Training and Research (AVATAR) Program, St George's University Hospitals NHS Foundation Trust, London, UK
- Cardiology Clinical Academic Group, St George's University of London, London, UK
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22
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Spectral characterisation of ventricular intracardiac potentials in human post-ischaemic bipolar electrograms. Sci Rep 2022; 12:4782. [PMID: 35314732 PMCID: PMC8938475 DOI: 10.1038/s41598-022-08743-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 03/11/2022] [Indexed: 11/08/2022] Open
Abstract
AbstractAbnormal ventricular potentials (AVPs) are frequently referred to as high-frequency deflections in intracardiac electrograms (EGMs). However, no scientific study performed a deep spectral characterisation of AVPs and physiological potentials in real bipolar intracardiac recordings across the entire frequency range imposed by their sampling frequency. In this work, the power contributions of post-ischaemic physiological potentials and AVPs, along with some spectral features, were evaluated in the frequency domain and then statistically compared to highlight specific spectral signatures for these signals. To this end, 450 bipolar EGMs from seven patients affected by post-ischaemic ventricular tachycardia were retrospectively annotated by an experienced cardiologist. Given the high variability of the morphologies observed, three different sub-classes of AVPs and two sub-categories of post-ischaemic physiological potentials were considered. All signals were acquired by the CARTO® 3 system during substrate-guided catheter ablation procedures. Our findings indicated that the main frequency contributions of physiological and pathological post-ischaemic EGMs are found below 320 Hz. Statistical analyses showed that, when biases due to the signal amplitude influence are eliminated, not only physiological potentials show greater contributions below 20 Hz whereas AVPs demonstrate higher spectral contributions above ~ 40 Hz, but several finer differences may be observed between the different AVP types.
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23
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Haissaguerre M, Cheniti G, Hocini M, Sacher F, Ramirez FD, Cochet H, Bear L, Tixier R, Duchateau J, Walton R, Surget E, Kamakura T, Marchand H, Derval N, Bordachar P, Ploux S, Takagi T, Pambrun T, Jais P, Labrousse L, Strik M, Ashikaga H, Calkins H, Vigmond E, Nademanee K, Bernus O, Dubois R. Purkinje network and myocardial substrate at the onset of human ventricular fibrillation: implications for catheter ablation. Eur Heart J 2022; 43:1234-1247. [PMID: 35134898 PMCID: PMC8934691 DOI: 10.1093/eurheartj/ehab893] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 10/25/2021] [Accepted: 12/16/2021] [Indexed: 11/13/2022] Open
Abstract
AIMS Mapping data of human ventricular fibrillation (VF) are limited. We performed detailed mapping of the activities underlying the onset of VF and targeted ablation in patients with structural cardiac abnormalities. METHODS AND RESULTS We evaluated 54 patients (50 ± 16 years) with VF in the setting of ischaemic (n = 15), hypertrophic (n = 8) or dilated cardiomyopathy (n = 12), or Brugada syndrome (n = 19). Ventricular fibrillation was mapped using body-surface mapping to identify driver (reentrant and focal) areas and invasive Purkinje mapping. Purkinje drivers were defined as Purkinje activities faster than the local ventricular rate. Structural substrate was delineated by electrogram criteria and by imaging. Catheter ablation was performed in 41 patients with recurrent VF. Sixty-one episodes of spontaneous (n = 10) or induced (n = 51) VF were mapped. Ventricular fibrillation was organized for the initial 5.0 ± 3.4 s, exhibiting large wavefronts with similar cycle lengths (CLs) across both ventricles (197 ± 23 vs. 196 ± 22 ms, P = 0.9). Most drivers (81%) originated from areas associated with the structural substrate. The Purkinje system was implicated as a trigger or driver in 43% of patients with cardiomyopathy. The transition to disorganized VF was associated with the acceleration of initial reentrant activities (CL shortening from 187 ± 17 to 175 ± 20 ms, P < 0.001), then spatial dissemination of drivers. Purkinje and substrate ablation resulted in the reduction of VF recurrences from a pre-procedural median of seven episodes [interquartile range (IQR) 4-16] to 0 episode (IQR 0-2) (P < 0.001) at 56 ± 30 months. CONCLUSIONS The onset of human VF is sustained by activities originating from Purkinje and structural substrate, before spreading throughout the ventricles to establish disorganized VF. Targeted ablation results in effective reduction of VF burden. KEY QUESTION The initial phase of human ventricular fibrillation (VF) is critical as it involves the primary activities leading to sustained VF and arrhythmic sudden death. The origin of such activities is unknown. KEY FINDING Body-surface mapping shows that most drivers (≈80%) during the initial VF phase originate from electrophysiologically defined structural substrates. Repetitive Purkinje activities can be elicited by programmed stimulation and are implicated as drivers in 37% of cardiomyopathy patients. TAKE-HOME MESSAGE The onset of human VF is mostly associated with activities from the Purkinje network and structural substrate, before spreading throughout the ventricles to establish sustained VF. Targeted ablation reduces or eliminates VF recurrence.
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Affiliation(s)
- Michel Haissaguerre
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Ghassen Cheniti
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Meleze Hocini
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Frederic Sacher
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - F. Daniel Ramirez
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
| | - Hubert Cochet
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Laura Bear
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Romain Tixier
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Josselin Duchateau
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Rick Walton
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Elodie Surget
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Tsukasa Kamakura
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
| | - Hugo Marchand
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
| | - Nicolas Derval
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Pierre Bordachar
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Sylvain Ploux
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Takamitsu Takagi
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
| | - Thomas Pambrun
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Pierre Jais
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Louis Labrousse
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
| | - Mark Strik
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Hiroshi Ashikaga
- Arrhythmia Service, Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Hugh Calkins
- Arrhythmia Service, Johns Hopkins University School of Medicine, 600 N Wolfe St, Baltimore, MD 21287, USA
| | - Ed Vigmond
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, IMB, U1045 Pessac, France
| | | | - Olivier Bernus
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
| | - Remi Dubois
- Department of Electrophysiology and Cardiac Stimulation, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
- Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Pessac, France
- Univ Bordeaux, CRCTB, Inserm, U1045 Pessac, France
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Ciaccio EJ, Anter E, Coromilas J, Wan EY, Yarmohammadi H, Wit AL, Peters NS, Garan H. Structure and function of the ventricular tachycardia isthmus. Heart Rhythm 2022; 19:137-153. [PMID: 34371192 DOI: 10.1016/j.hrthm.2021.08.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/22/2021] [Accepted: 08/01/2021] [Indexed: 12/24/2022]
Abstract
Catheter ablation of postinfarction reentrant ventricular tachycardia (VT) has received renewed interest owing to the increased availability of high-resolution electroanatomic mapping systems that can describe the VT circuits in greater detail, and the emergence and need to target noninvasive external beam radioablation. These recent advancements provide optimism for improving the clinical outcome of VT ablation in patients with postinfarction and potentially other scar-related VTs. The combination of analyses gleaned from studies in swine and canine models of postinfarction reentrant VT, and in human studies, suggests the existence of common electroanatomic properties for reentrant VT circuits. Characterizing these properties may be useful for increasing the specificity of substrate mapping techniques and for noninvasive identification to guide ablation. Herein, we describe properties of reentrant VT circuits that may assist in elucidating the mechanisms of onset and maintenance, as well as a means to localize and delineate optimal catheter ablation targets.
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Affiliation(s)
- Edward J Ciaccio
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York; ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom.
| | - Elad Anter
- Department of Cardiovascular Medicine, Cardiac Electrophysiology, Cleveland Clinic, Cleveland, Ohio
| | - James Coromilas
- Department of Medicine, Division of Cardiovascular Disease and Hypertension, Rutgers University, New Brunswick, New Jersey
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Hirad Yarmohammadi
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Andrew L Wit
- Department of Pharmacology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Nicholas S Peters
- ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom
| | - Hasan Garan
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York
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25
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Masjedi M, Jungen C, Kuklik P, Alken FA, Kahle AK, Klatt N, Scherschel K, Lorenz J, Meyer C. A novel algorithm for 3-D visualization of electrogram duration for substrate-mapping in patients with ischemic heart disease and ventricular tachycardia. PLoS One 2021; 16:e0254683. [PMID: 34260658 PMCID: PMC8279369 DOI: 10.1371/journal.pone.0254683] [Citation(s) in RCA: 2] [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: 09/10/2020] [Accepted: 06/30/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Myocardial slow conduction is a cornerstone of ventricular tachycardia (VT). Prolonged electrogram (EGM) duration is a useful surrogate parameter and manual annotation of EGM characteristics are widely used during catheter-based ablation of the arrhythmogenic substrate. However, this remains time-consuming and prone to inter-operator variability. We aimed to develop an algorithm for 3-D visualization of EGM duration relative to the 17-segment American Heart Association model. METHODS To calculate and visualize EGM duration, in sinus rhythm acquired high-density maps of patients with ischemic cardiomyopathy undergoing substrate-based VT ablation using a 64-mini polar basket-catheter with low noise of 0.01 mV were analyzed. Using a custom developed algorithm based on standard deviation and threshold, the relationship between EGM duration, endocardial voltage and ablation areas was studied by creating 17-segment 3-D models and 2-D polar plots. RESULTS 140,508 EGMs from 272 segments (n = 16 patients, 94% male, age: 66±2.4, ejection fraction: 31±2%) were studied and 3-D visualization of EGM duration was performed. Analysis of signal processing parameters revealed that a 40 ms sliding SD-window, 15% SD-threshold and >70 ms EGM duration cutoff was chosen based on diagnostic odds ratio of 12.77 to visualize rapidly prolonged EGM durations. EGMs > 70 ms matched to 99% of areas within dense scar (<0.2 mV), in 95% of zones within scar border zone (0.2-1.0 mV) and detected ablated areas having resulted in non-inducibility at the end of the procedure. Ablation targets were identified with a sensitivity of 65.6% and a specificity of 94.6% avoiding false positive labeling of prolonged EGMs in segments with healthy myocardium. CONCLUSION The novel algorithm allows rapid visualization of prolonged EGM durations. This may facilitate more objective characterization of arrhythmogenic substrate in patients with ischemic cardiomyopathy.
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Affiliation(s)
- Mustafa Masjedi
- Department of Cardiology, Angiology and Intensive Care, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Düsseldorf, Germany
- Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Christiane Jungen
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
- Department of Cardiology, University Heart & Vascular Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Pawel Kuklik
- Department of Cardiology, Asklepios Hospital St. Georg, Hamburg, Germany
| | - Fares-Alexander Alken
- Department of Cardiology, Angiology and Intensive Care, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Düsseldorf, Germany
- Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ann-Kathrin Kahle
- Department of Cardiology, Angiology and Intensive Care, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Düsseldorf, Germany
- Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Niklas Klatt
- Department of Cardiology, Schoen Hospital Neustadt, Neustadt in Holstein, Germany
| | - Katharina Scherschel
- Department of Cardiology, Angiology and Intensive Care, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Düsseldorf, Germany
- Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Jürgen Lorenz
- Faculty of Life Sciences, Department of Biomedical Engineering, Applied Science University Hamburg, Hamburg, Germany
| | - Christian Meyer
- Department of Cardiology, Angiology and Intensive Care, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Düsseldorf, Germany
- Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
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26
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Bennett RG, Campbell TG, Kumar S. Automatic identification of VT substrate in the era of ultrahigh-density mapping: Do humans or machines emerge victoriously? J Cardiovasc Electrophysiol 2021; 32:2225-2227. [PMID: 34216074 DOI: 10.1111/jce.15146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 06/27/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Richard G Bennett
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Westmead, New South Wales, Australia
| | - Timothy G Campbell
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Westmead, New South Wales, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Westmead, New South Wales, Australia
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Zoppo F, Gagno G, Perazza L, Cocciolo A, Mugnai G, Vaccari D, Calzolari V. Electroanatomic voltage mapping for tissue characterization beyond arrhythmia definition: A systematic review. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1432-1448. [PMID: 34096635 DOI: 10.1111/pace.14288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 05/17/2021] [Accepted: 05/30/2021] [Indexed: 11/28/2022]
Abstract
Three-dimensional (3D) reconstruction by means of electroanatomic mapping (EAM) systems, allows for the understanding of the mechanism of focal or re-entrant arrhythmic circuits, which can be identified by means of dynamic (activation and propagation) and static (voltage) color-coded maps. However, besides this conventional use, EAM may offer helpful anatomical and functional information for tissue characterisation in several clinical settings. Today, data regarding electromechanical myocardial viability, scar detection in ischaemic and nonischaemic cardiomyopathy and arrhythmogenic right ventricle dysplasia (ARVC/D) definition are mostly consolidated, while emerging results are becoming available in contexts such as Brugada syndrome and cardiac resynchronisation therapy (CRT) implant procedures. As part of an invasive procedure, EAM has not yet been widely adopted as a stand-alone tool in the diagnostic path. We aim to review the data in the current literature regarding the use of 3D EAM systems beyond the definition of arrhythmia.
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Affiliation(s)
- Franco Zoppo
- Elettrofisiologia, U.O.C. di Cardiologia, Ospedale Civile Gorizia, Gorizia, Italy
| | - Giulia Gagno
- Dipartimento di Cardiologia, Azienda Sanitaria Universitaria Giuliano Isontina, ed Università degli Studi di Trieste, Trieste, Italy
| | - Luca Perazza
- Elettrofisiologia, U.O.C. di Cardiologia, Ospedale Civile Gorizia, Gorizia, Italy
| | - Andrea Cocciolo
- Elettrofisiologia, U.O.C. di Cardiologia, Ospedale Civile Gorizia, Gorizia, Italy
| | - Giacomo Mugnai
- Elettrofisiologia, U.O.C di Cardiologia, Ospedale Civile Arzignano, Vicenza, Italy
| | - Diego Vaccari
- Elettrofisiologia, U.O.C di Cardiologia, Ospedale Civile Feltre, Belluno, Italy
| | - Vittorio Calzolari
- Elettrofisiologia, U.O.C di Cardiologia, Ospedale Civile Treviso, Treviso, Italy
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Tschabrunn CM, Tzou WS. The Evolution of Ventricular Scar Substrate Assessment by Using High-Resolution Mapping Platforms: Ongoing Quest for "Ground Truth". JACC Clin Electrophysiol 2021; 7:206-209. [PMID: 33602401 DOI: 10.1016/j.jacep.2020.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 11/18/2020] [Accepted: 11/18/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Cory M Tschabrunn
- Cardiac Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; Penn Cardiovascular Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Wendy S Tzou
- Cardiac Electrophysiology Section, Division of Cardiovascular Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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Ragot D, Nayyar S, Massin SZ, Ha ACT, Singh SM, Labos C, Suszko A, Dalvi R, Chauhan VS. Unipolar electrogram-based voltage mapping with far-field cancellation to improve detection of abnormal atrial substrate during atrial fibrillation. J Cardiovasc Electrophysiol 2021; 32:1572-1583. [PMID: 33694221 DOI: 10.1111/jce.14999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 02/18/2021] [Accepted: 03/03/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION An important substrate for atrial fibrillation (AF) is fibrotic atrial myopathy. Identifying low voltage, myopathic regions during AF using traditional bipolar voltage mapping is limited by the directional dependency of wave propagation. Our objective was to evaluate directionally independent unipolar voltage mapping, but with far-field cancellation, to identify low-voltage regions during AF. METHODS In 12 patients undergoing pulmonary vein isolation for AF, high-resolution voltage mapping was performed in the left atrium during sinus rhythm and AF using a roving 20-pole circular catheter. Bipolar electrograms (EGMs) (Bi) < 0.5 mV in sinus rhythm identified low-voltage regions. During AF, bipolar voltage and unipolar voltage maps were created, the latter with (uni-res) and without (uni-orig) far-field cancellation using a novel, validated least-squares algorithm. RESULTS Uni-res voltage was ~25% lower than uni-orig for both low voltage and normal atrial regions. Far-field EGM had a dominant frequency (DF) of 4.5-6.0 Hz, and its removal resulted in a lower DF for uni-orig compared with uni-res (5.1 ± 1.5 vs. 4.8 ± 1.5 Hz; p < .001). Compared with Bi, uni-res had a significantly greater area under the receiver operator curve (0.80 vs. 0.77; p < .05), specificity (86% vs. 76%; p < .001), and positive predictive value (43% vs. 30%; p < .001) for detecting low-voltage during AF. Similar improvements in specificity and positive predictive value were evident for uni-res versus uni-orig. CONCLUSION Far-field EGM can be reliably removed from uni-orig using our novel, least-squares algorithm. Compared with Bi and uni-orig, uni-res is more accurate in detecting low-voltage regions during AF. This approach may improve substrate mapping and ablation during AF, and merits further study.
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Affiliation(s)
- Don Ragot
- Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Sachin Nayyar
- Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Sophia Z Massin
- Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Andrew C T Ha
- Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Sheldon M Singh
- Sunnybrook Health Sciences Center, Division of Cardiology, University Health Network, Toronto, Canada
| | - Christopher Labos
- Queen Elizabeth Health Complex, Division of Cardiology, University Health Network, Montreal, Canada
| | - Adrian Suszko
- Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Rupin Dalvi
- Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Vijay S Chauhan
- Peter Munk Cardiac Center, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, Canada
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30
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Patel AG. Foreword. J Innov Card Rhythm Manag 2021; 12:6. [PMID: 33604103 PMCID: PMC7885962 DOI: 10.19102/icrm.2021.120126s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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31
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Berruezo A, Penela D, Jáuregui B, Soto-Iglesias D. The role of imaging in catheter ablation of ventricular arrhythmias. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1115-1125. [PMID: 33527461 DOI: 10.1111/pace.14183] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 01/15/2021] [Accepted: 01/24/2021] [Indexed: 02/01/2023]
Abstract
Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) and multidetector cardiac computed tomography (MDCT) have emerged as novel, fascinating imaging tools for arrhythmogenic substrate identification and characterization. The role of these techniques for aiding and guiding the catheter ablation of ventricular tachycardia, either as a complement or a surrogate of the electroanatomic map, has been rising in recent years. Integrating pixel signal intensity maps or wall thickness maps delivered from LGE-CMR or MDCT, respectively, into the navigation system has become a cornerstone for VT ablation procedures in a few centers of excellence around the world. The pre-procedure scar characterization offers some advantages, helping decide for the best procedure planning and approach; complete substrate identification and characterization, helping to focus electroanatomical mapping in regions of interest and also has a positive impact in procedure efficiency and outcomes. In the present article, we perform a review of the most practical aspects for using LGE-CMR or MDCT when a VT ablation procedure is planned, from the image acquisition to the integration into the navigation system, analyzing the current role of the LGE-CMR and MDCT for arrhythmogenic substrate characterization as well as for guiding VT ablation.
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Affiliation(s)
| | - Diego Penela
- Heart Institute, Teknon Medical Center, Barcelona, Spain
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32
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Substrate mapping of the left atrium in persistent atrial fibrillation: spatial correlation of localized complex conduction patterns in global charge-density maps to low-voltage areas in 3D contact bipolar voltage maps. J Interv Card Electrophysiol 2021; 62:539-547. [PMID: 33420713 PMCID: PMC8645534 DOI: 10.1007/s10840-020-00926-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 12/27/2020] [Indexed: 12/02/2022]
Abstract
Purpose This study aimed to investigate the spatial relationship between low-voltage areas (LVAs) in bipolar voltage mapping (BVM) and localized complex conduction (LCC)-cores in a global, non-contact, charge-density-based imaging, and mapping system (AcM). Methods Patients with history of index PVI for PsAF and scheduled for a repeat ablation procedure for recurrence of the same arrhythmia were enrolled between August 2018 and February 2020. All patients underwent both substrate mappings of the left atrium (LA) with the CARTO 3D map-ping system and with AcM. Results Ten patients where included in our analysis. All presented with persistency of PVI in all veins at the moment of repeat procedure. There was no linear relationship in BVM maps between SR and CSd (correlation coefficient 0.31 ± 0.15), SR and CSp (0.36 ± 0.12) and CSd and CSp (0.43 ± 0.10). The % overlap of localized irregular activation (LIA), localized rotational activation (LRA) and Focal (F) regions with LVA was lower at 0.2 mV compared to 0.5 mV (4.97 ± 7.39%, 3.27 ± 5.25%, 1.09 ± 1.92% and 12.59 ± 11.81%, 7.8 ± 9.20%, 4.62 ± 5.27%). Sensitivity and specificity are not significantly different when comparing composite maps with different LVA cut-offs. AURC was 0.46, 0.48, and 0.39 for LIA, LRA, and Focal, respectively. Conclusion Due to wave front direction dependency, LVAs mapped with BVM in sinus rhythm and during coronary sinus pacing only partially overlap in patients with PsAF. LCC-cores mapped during PsAF partially co-localize with LVAs.
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Proietti R, Dowd R, Gee LV, Yusuf S, Panikker S, Hayat S, Osman F, Patel K, Salim H, Aldhoon B, Foster W, Merghani A, Kuehl M, Banerjee P, Lellouche N, Dhanjal T. Impact of a high-density grid catheter on long-term outcomes for structural heart disease ventricular tachycardia ablation. J Interv Card Electrophysiol 2021; 62:519-529. [PMID: 33392856 PMCID: PMC8645535 DOI: 10.1007/s10840-020-00918-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/31/2020] [Indexed: 01/04/2023]
Abstract
Background Substrate mapping has highlighted the importance of targeting diastolic conduction channels and late potentials during ventricular tachycardia (VT) ablation. State-of-the-art multipolar mapping catheters have enhanced mapping capabilities. The purpose of this study was to investigate whether long-term outcomes were improved with the use of a HD Grid mapping catheter combining complementary mapping strategies in patients with structural heart disease VT. Methods Consecutive patients underwent VT ablation assigned to either HD Grid, Pentaray, Duodeca, or point-by-point (PbyP) RF mapping catheters. Clinical endpoints included recurrent anti-tachycardia pacing (ATP), appropriate shock, asymptomatic non-sustained VT, or all-cause death. Results Seventy-three procedures were performed (33 HD Grid, 22 Pentaray, 12 Duodeca, and 6 PbyP) with no significant difference in baseline characteristics. Substrate mapping was performed in 97% of cases. Activation maps were generated in 82% of HD Grid cases (Pentaray 64%; Duodeca 92%; PbyP 33% (p = 0.025)) with similar trends in entrainment and pace mapping. Elimination of all VTs occurred in 79% of HD Grid cases (Pentaray 55%; Duodeca 83%; PbyP 33% (p = 0.04)). With a mean follow-up of 372 ± 234 days, freedom from recurrent ATP and shock was 97% and 100% respectively in the HD Grid group (Pentaray 64%, 82%; Duodeca 58%, 83%; PbyP 33%, 33% (log rank p = 0.0042, p = 0.0002)). Conclusions This study highlights a step-wise improvement in survival free from ICD therapies as the density of mapping capability increases. By using a high-density mapping catheter and combining complementary mapping strategies in a strict procedural workflow, long-term clinical outcomes are improved.
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Affiliation(s)
- Riccardo Proietti
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK.,Department of Cardiac, Thoracic, Vascular Sciences, and University of Padua, Padua, Italy
| | - Rory Dowd
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Lim Ven Gee
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Shamil Yusuf
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Sandeep Panikker
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Sajad Hayat
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Faizel Osman
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK.,University of Warwick (Medical School), Gibbet Hill, Coventry, CV4 7AJ, UK
| | - Kiran Patel
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK.,University of Warwick (Medical School), Gibbet Hill, Coventry, CV4 7AJ, UK
| | - Handi Salim
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Bashar Aldhoon
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Will Foster
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Ahmed Merghani
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Michael Kuehl
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Prithwish Banerjee
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Nicolas Lellouche
- Hopital Henri Mondor Albert Chenevier, University Paris Est Creteil Paris XII, Avenue du Marechal de Lattre de Tassigny, 94000, Creteil, Inserm U955, Paris, France
| | - Tarvinder Dhanjal
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK. .,University of Warwick (Medical School), Gibbet Hill, Coventry, CV4 7AJ, UK.
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Sáenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Europace 2020; 21:1143-1144. [PMID: 31075787 DOI: 10.1093/europace/euz132] [Citation(s) in RCA: 232] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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Ciaccio EJ, Coromilas J, Wan EY, Yarmohammadi H, Saluja DS, Biviano AB, Wit AL, Peters NS, Garan H. Slow uniform electrical activation during sinus rhythm is an indicator of reentrant VT isthmus location and orientation in an experimental model of myocardial infarction. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2020; 196:105666. [PMID: 32717622 DOI: 10.1016/j.cmpb.2020.105666] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/12/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND To validate the predictability of reentrant circuit isthmus locations without ventricular tachycardia (VT) induction during high-definition mapping, we used computer methods to analyse sinus rhythm activation in experiments where isthmus location was subsequently verified by mapping reentrant VT circuits. METHOD In 21 experiments using a canine postinfarction model, bipolar electrograms were obtained from 196-312 recordings with 4mm spacing in the epicardial border zone during sinus rhythm and during VT. From computerized electrical activation maps of the reentrant circuit, areas of conduction block were determined and the isthmus was localized. A linear regression was computed at three different locations about the reentry isthmus using sinus rhythm electrogram activation data. From the regression analysis, the uniformity, a measure of the constancy at which the wavefront propagates, and the activation gradient, a measure that may approximate wavefront speed, were computed. The purpose was to test the hypothesis that the isthmus locates in a region of slow uniform activation bounded by areas of electrical discontinuity. RESULTS Based on the regression parameters, sinus rhythm activation along the isthmus near its exit proceeded uniformly (mean r2= 0.95±0.05) and with a low magnitude gradient (mean 0.37±0.10mm/ms). Perpendicular to the isthmus long-axis across its boundaries, the activation wavefront propagated much less uniformly (mean r2= 0.76±0.24) although of similar gradient (mean 0.38±0.23mm/ms). In the opposite direction from the exit, at the isthmus entrance, there was also less uniformity (mean r2= 0.80±0.22) but a larger magnitude gradient (mean 0.50±0.25mm/ms). A theoretical ablation line drawn perpendicular to the last sinus rhythm activation site along the isthmus long-axis was predicted to prevent VT reinduction. Anatomical conduction block occurred in 7/21 experiments, but comprised only small portions of the isthmus lateral boundaries; thus detection of sinus rhythm conduction block alone was insufficient to entirely define the VT isthmus. CONCLUSIONS Uniform activation with a low magnitude gradient during sinus rhythm is present at the VT isthmus exit location but there is less uniformity across the isthmus lateral boundaries and at isthmus entrance locations. These factors may be useful to verify any proposed VT isthmus location, reducing the need for VT induction to ablate the isthmus. Measured computerized values similar to those determined herein could therefore be assistive to sharpen specificity when applying sinus rhythm mapping to localize EP catheter ablation sites.
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Affiliation(s)
- Edward J Ciaccio
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA; ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.
| | - James Coromilas
- Department of Medicine - Division of Cardiovascular Disease and Hypertension, Rutgers University, New Brunswick, NJ, USA
| | - Elaine Y Wan
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Hirad Yarmohammadi
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Deepak S Saluja
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Angelo B Biviano
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Andrew L Wit
- Department of Pharmacology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Nicholas S Peters
- ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Hasan Garan
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
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Berte B, Zeppenfeld K, Tung R. Impact of Micro-, Mini- and Multi-Electrode Mapping on Ventricular Substrate Characterisation. Arrhythm Electrophysiol Rev 2020; 9:128-135. [PMID: 33240508 PMCID: PMC7675146 DOI: 10.15420/aer.2020.24] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/23/2020] [Indexed: 12/29/2022] Open
Abstract
Accurate substrate characterisation may improve the evolving understanding and treatment of cardiac arrhythmias. During substrate-based ablation techniques, wide practice variations exist with mapping via dedicated multi-electrode catheter or conventional ablation catheters. Recently, newer ablation catheter technology with embedded mapping electrodes have been introduced. This article focuses on the general misconceptions of voltage mapping and more specific differences in unipolar and bipolar signal morphology, field of view, signal-to-noise ratio, mapping capabilities (density and resolution), catheter-specific voltage thresholds and impact of micro-, mini- and multi-electrodes for substrate mapping. Efficiency and cost-effectiveness of different catheter types are discussed. Increasing sampling density with smaller electrodes allows for higher resolution with a greater likelihood to record near-field electrical information. These advances may help to further improve our mechanistic understanding of the correlation between substrate and ventricular tachycardia, as well as macro-reentry arrhythmia in humans.
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Affiliation(s)
- Benjamin Berte
- Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Roderick Tung
- Center for Arrhythmia Care, Pritzker School of Medicine University of Chicago Medicine, Chicago, IL, US
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Porta-Sánchez A, Magtibay K, Nayyar S, Bhaskaran A, Lai PFH, Massé S, Labos C, Qiang B, Romagnuolo R, Masoudpour H, Biswas L, Ghugre N, Laflamme M, Deno DC, Nanthakumar K. Omnipolarity applied to equi-spaced electrode array for ventricular tachycardia substrate mapping. Europace 2020; 21:813-821. [PMID: 30726937 PMCID: PMC6479413 DOI: 10.1093/europace/euy304] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 12/04/2018] [Indexed: 11/17/2022] Open
Abstract
Aims Bipolar electrogram (BiEGM)-based substrate maps are heavily influenced by direction of a wavefront to the mapping bipole. In this study, we evaluate high-resolution, orientation-independent peak-to-peak voltage (Vpp) maps obtained with an equi-spaced electrode array and omnipolar EGMs (OTEGMs), measure its beat-to-beat consistency, and assess its ability to delineate diseased areas within the myocardium compared against traditional BiEGMs on two orientations: along (AL) and across (AC) array splines. Methods and results The endocardium of the left ventricle of 10 pigs (three healthy and seven infarcted) were each mapped using an Advisor™ HD grid with a research EnSite Precision™ system. Cardiac magnetic resonance images with late gadolinium enhancement were registered with electroanatomical maps and were used for gross scar delineation. Over healthy areas, OTEGM Vpp values are larger than AL bipoles by 27% and AC bipoles by 26%, and over infarcted areas OTEGM Vpp values are 23% larger than AL bipoles and 27% larger than AC bipoles (P < 0.05). Omnipolar EGM voltage maps were 37% denser than BiEGM maps. In addition, OTEGM Vpp values are more consistent than bipolar Vpps showing less beat-by-beat variation than BiEGM by 39% and 47% over both infarcted and healthy areas, respectively (P < 0.01). Omnipolar EGM better delineate infarcted areas than traditional BiEGMs from both orientations. Conclusion An equi-spaced electrode grid when combined with omnipolar methodology yielded the largest detectable bipolar-like voltage and is void of directional influences, providing reliable voltage assessment within infarcted and non-infarcted regions of the heart.
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Affiliation(s)
- Andreu Porta-Sánchez
- Dept de Medicina, Universitat de Barcelona, Barcelona and Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain.,Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Karl Magtibay
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Sachin Nayyar
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Abhishek Bhaskaran
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Patrick F H Lai
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Stéphane Massé
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Christopher Labos
- Office for Science and Society, McGill University, Montreal, Quebec, Canada
| | - Beiping Qiang
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Rocco Romagnuolo
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Hassan Masoudpour
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Nilesh Ghugre
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Michael Laflamme
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Kumaraswamy Nanthakumar
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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38
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Srinivasan NT, Garcia J, Schilling RJ, Ahsan S, Babu GG, Ang R, Dhinoja MB, Hunter RJ, Lowe M, Chow AW, Lambiase PD. Multicenter Study of Dynamic High-Density Functional Substrate Mapping Improves Identification of Substrate Targets for Ischemic Ventricular Tachycardia Ablation. JACC Clin Electrophysiol 2020; 6:1783-1793. [PMID: 33357574 PMCID: PMC7769061 DOI: 10.1016/j.jacep.2020.06.037] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 06/26/2020] [Accepted: 06/29/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVES The goal of this study was to evaluate the role of dynamic substrate changes in facilitating conduction delay and re-entry in ventricular tachycardia (VT) circuits. BACKGROUND The presence of dynamic substrate changes facilitate functional block and re-entry in VT but are rarely studied as part of clinical VT mapping. METHODS Thirty patients (age 67 ± 9 years; 27 male subjects) underwent ablation. Mapping was performed with the Advisor HD Grid multipolar catheter. A bipolar voltage map was obtained during sinus rhythm (SR) and right ventricular sense protocol (SP) single extra pacing. SR and SP maps of late potentials (LP) and local abnormal ventricular activity (LAVA) were made and compared with critical sites for ablation, defined as sites of best entrainment or pace mapping. Ablation was then performed to critical sites, and LP/LAVA identified by the SP. RESULTS At a median follow-up of 12 months, 90% of patients were free from antitachycardia pacing (ATP) or implantable cardioverter-defibrillator shocks. SP pacing resulted in a larger area of LP identified for ablation (19.3 mm2 vs. 6.4 mm2) during SR mapping (p = 0.001), with a sensitivity of 87% and a specificity of 96%, compared with 78% and 65%, respectively, in SR. CONCLUSIONS LP and LAVA observed during the SP were able to identify regions critical for ablation in VT with a greater accuracy than SR mapping. This may improve substrate characterization in VT ablation. The combination of ablation to critical sites and SP-derived LP/LAVA requires further assessment in a randomized comparator study.
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Affiliation(s)
- Neil T Srinivasan
- Department of Cardiac Electrophysiology, The Barts Heart Center, St. Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom.
| | - Jason Garcia
- Department of Cardiac Electrophysiology, The Barts Heart Center, St. Bartholomew's Hospital, London, United Kingdom
| | - Richard J Schilling
- Department of Cardiac Electrophysiology, The Barts Heart Center, St. Bartholomew's Hospital, London, United Kingdom
| | - Syed Ahsan
- Department of Cardiac Electrophysiology, The Barts Heart Center, St. Bartholomew's Hospital, London, United Kingdom
| | - Girish G Babu
- Royal Bournemouth and Christchurch Hospitals, Bournemouth, United Kingdom
| | - Richard Ang
- Department of Cardiac Electrophysiology, The Barts Heart Center, St. Bartholomew's Hospital, London, United Kingdom
| | - Mehul B Dhinoja
- Department of Cardiac Electrophysiology, The Barts Heart Center, St. Bartholomew's Hospital, London, United Kingdom
| | - Ross J Hunter
- Department of Cardiac Electrophysiology, The Barts Heart Center, St. Bartholomew's Hospital, London, United Kingdom
| | - Martin Lowe
- Department of Cardiac Electrophysiology, The Barts Heart Center, St. Bartholomew's Hospital, London, United Kingdom
| | - Anthony W Chow
- Department of Cardiac Electrophysiology, The Barts Heart Center, St. Bartholomew's Hospital, London, United Kingdom
| | - Pier D Lambiase
- Department of Cardiac Electrophysiology, The Barts Heart Center, St. Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
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De Mattia L, Martini B, Calzolari V, Genovese D, Cernetti C, Buja G. Sudden and significant R-wave sensing variation detected on remote monitoring of ICD: What is the mechanism? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:1020-1023. [PMID: 32715483 DOI: 10.1111/pace.14017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 07/13/2020] [Accepted: 07/19/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Luca De Mattia
- Department of Cardiology, Presidio Ospedaliero di Treviso, Treviso, Italy
| | - Bortolo Martini
- Department of Cardiology, Alto Vicentino Hospital, Santorso, Italy
| | - Vittorio Calzolari
- Department of Cardiology, Presidio Ospedaliero di Treviso, Treviso, Italy
| | - Davide Genovese
- Department of Cardiology, Presidio Ospedaliero di Treviso, Treviso, Italy
| | - Carlo Cernetti
- Department of Cardiology, Presidio Ospedaliero di Treviso, Treviso, Italy
| | - Gianfranco Buja
- Department of Cardiac, Thoracic and Vascular Science, University of Padova School of Medicine and Surgery, Padova, Italy
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Chieng D, Lahiri A, Sugumar H, Al‐Kaisey A, Parameswaran R, Anderson RD, Prabhu S, Ling L, Morton JB, McLellan AJ, Lee G, Kalman JM, McGavigan AD, Kistler PM. Multipolar mapping with the high‐density grid catheter compared with conventional point‐by‐point mapping to guide catheter ablation for focal arrhythmias. J Cardiovasc Electrophysiol 2020; 31:2288-2297. [DOI: 10.1111/jce.14636] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/02/2020] [Accepted: 06/06/2020] [Indexed: 11/28/2022]
Affiliation(s)
- David Chieng
- Clinical Electrophysiology Laboratory The Baker Heart Research Institute Melbourne Australia
- Department of Cardiology The Alfred Hospital Melbourne Australia
- Department of Medicine University of Melbourne Melbourne Australia
| | | | - Hariharan Sugumar
- Clinical Electrophysiology Laboratory The Baker Heart Research Institute Melbourne Australia
- Department of Cardiology The Alfred Hospital Melbourne Australia
- Department of Medicine University of Melbourne Melbourne Australia
| | - Ahmed Al‐Kaisey
- Department of Medicine University of Melbourne Melbourne Australia
- Department of Cardiology Royal Melbourne Hospital Melbourne Australia
| | - Ramanathan Parameswaran
- Department of Medicine University of Melbourne Melbourne Australia
- Department of Cardiology Royal Melbourne Hospital Melbourne Australia
| | - Robert D. Anderson
- Department of Medicine University of Melbourne Melbourne Australia
- Department of Cardiology Royal Melbourne Hospital Melbourne Australia
| | - Sandeep Prabhu
- Clinical Electrophysiology Laboratory The Baker Heart Research Institute Melbourne Australia
- Department of Cardiology The Alfred Hospital Melbourne Australia
- Department of Medicine University of Melbourne Melbourne Australia
| | - Liang‐Han Ling
- Clinical Electrophysiology Laboratory The Baker Heart Research Institute Melbourne Australia
- Department of Cardiology The Alfred Hospital Melbourne Australia
- Department of Medicine University of Melbourne Melbourne Australia
| | - Joseph B. Morton
- Department of Medicine University of Melbourne Melbourne Australia
- Department of Cardiology Royal Melbourne Hospital Melbourne Australia
| | - Alex J. McLellan
- Clinical Electrophysiology Laboratory The Baker Heart Research Institute Melbourne Australia
- Department of Cardiology Royal Melbourne Hospital Melbourne Australia
| | - Geoffrey Lee
- Department of Medicine University of Melbourne Melbourne Australia
- Department of Cardiology Royal Melbourne Hospital Melbourne Australia
| | - Jonathan M. Kalman
- Department of Medicine University of Melbourne Melbourne Australia
- Department of Cardiology Royal Melbourne Hospital Melbourne Australia
- Department of Medicine Monash Health Melbourne Australia
| | - Andrew D. McGavigan
- Department of Cardiology Flinders Medical Centre Adelaide Australia
- Faculty of Medicine Flinders University Adelaide Australia
| | - Peter M. Kistler
- Clinical Electrophysiology Laboratory The Baker Heart Research Institute Melbourne Australia
- Department of Cardiology The Alfred Hospital Melbourne Australia
- Department of Medicine University of Melbourne Melbourne Australia
- Department of Medicine Monash Health Melbourne Australia
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Voglimacci-Stephanopoli Q, Sacher F, Martin C, Meyer C, Martin R, Rollin A, Capellino S, Mondoly P, Mandel F, Jaïs P, Tabuteau M, Maury P. Creation of sinus rhythm and paced maps using a single acquisition step: the "one acquisition-two maps" technique-a feasibility study. J Interv Card Electrophysiol 2020; 61:235-243. [PMID: 32562193 DOI: 10.1007/s10840-020-00793-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 06/01/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Scars and abnormal electrograms may significantly differ according to the activation wavefront. We propose a new fast technique for reliable comparison between sinus rhythm and ventricular pacing using a single map acquisition and the Rhythmia™ 3D mapping system. METHODS A special programming of the external stimulator was assuring full stable regular paced-beat bigeminy during spontaneous rhythm. A first map was acquired for the spontaneous cardiac beat. Then the window of detection was moved to the following paced beat, and a second map was available after recalculation by the system, depicting activation and voltage of the paced cardiac beat at the same locations, with an exactly the same number of beats in both maps. RESULTS Thirty patients with structural heart disease referred for ablation of ventricular tachycardia underwent this protocol, who were compared with 19 similar patients undergoing repeated maps. Duration of the mapping was significantly shorter compared to controls (34 ± 12 vs 57 ± 14 min, p < 0.0001) without differences in the number of electrograms (6978 ± 7067 vs 9554 ± 4424 for sinus rhythm map and 6610 ± 7240 vs 7783 ± 3804 for paced map, p = ns for both). The technique cannot be completed in five patients (17%), because of arrhythmogenicity, mechanical right bundle branch block, hemodynamical impairment, or bradycardia. CONCLUSION We propose a novel technique for performing maps during sinus rhythm and ventricular pacing using a single acquisition. Beside time saving, this will allow more strict comparisons between different activation wavefronts.
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Affiliation(s)
| | - Frederic Sacher
- Bordeaux University Hospital, Bordeaux, France
- LIRYC Institute/INSERM 1045, Bordeaux University, Bordeaux, France
| | - Claire Martin
- Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | | | | | - Anne Rollin
- Department of Cardiology, University Hospital Rangueil, 31059, Toulouse, Cedex 09, France
| | | | - Pierre Mondoly
- Department of Cardiology, University Hospital Rangueil, 31059, Toulouse, Cedex 09, France
| | - Franck Mandel
- Department of Cardiology, University Hospital Rangueil, 31059, Toulouse, Cedex 09, France
| | - Pierre Jaïs
- Bordeaux University Hospital, Bordeaux, France
- LIRYC Institute/INSERM 1045, Bordeaux University, Bordeaux, France
| | | | - Philippe Maury
- Department of Cardiology, University Hospital Rangueil, 31059, Toulouse, Cedex 09, France.
- Unité Inserm U 1048, Toulouse, France.
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42
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Solimene F, Maddaluno F, Malacrida M, Stabile G. How to unmask septal local abnormal ventricular activities with the new LUMIPOINT
TM
software. J Arrhythm 2020; 36:528-531. [PMID: 32528583 PMCID: PMC7279972 DOI: 10.1002/joa3.12344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/09/2020] [Accepted: 03/29/2020] [Indexed: 11/06/2022] Open
Abstract
We report the use of the new automated tool LumipointTM for the detection of LAVA (local abnormal ventricular activities) when they are buried within the far‐field ventricular signal, especially in regions of preserved myocardial thickness, such as the left ventricular (LV) septum. The LV substrate and the tachycardia circuit during ventricular tachycardias of a 60‐year‐old man with dilated cardiomyopathy were mapped using an ultra‐high‐density mapping system and then the LumipointTM, analyzing the EGMs of interest, identified the LAVA in the inferoseptal region. This algorithm may be helpful to quickly target the septal substrate avoiding misleading interpretation.
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Abstract
High-density (HD) mapping presents opportunities to enhance delineation of atrial fibrillation (AF) substrate, improve efficiency of the mapping procedure without sacrificing safety, and afford new mechanistic insights regarding AF. Innovations in hardware, software algorithms, and development of novel multielectrode catheters have allowed HD mapping to be feasible and reliable. Patients to particularly benefit from this technology are those with paroxysmal AF in setting of preexisting atrial scar, persistent AF, and AF in the setting of complex congenital heart disease. The future will bring refinements in automated HD mapping including evolution of noncontact methodologies and artificial intelligence to supplant current techniques.
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Kim Y, Chen S, Ernst S, Guzman CE, Han S, Kalarus Z, Labadet C, Lin Y, Lo L, Nogami A, Saad EB, Sapp J, Sticherling C, Tilz R, Tung R, Kim YG, Stiles MK. 2019 APHRS expert consensus statement on three-dimensional mapping systems for tachycardia developed in collaboration with HRS, EHRA, and LAHRS. J Arrhythm 2020; 36:215-270. [PMID: 32256872 PMCID: PMC7132207 DOI: 10.1002/joa3.12308] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 01/20/2020] [Indexed: 12/24/2022] Open
Affiliation(s)
- Young‐Hoon Kim
- Department of Internal MedicineArrhythmia CenterKorea University Medicine Anam HospitalSeoulRepublic of Korea
| | - Shih‐Ann Chen
- Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalTaipeiROC
| | - Sabine Ernst
- Department of CardiologyRoyal Brompton and Harefield HospitalImperial College LondonLondonUK
| | | | - Seongwook Han
- Division of CardiologyDepartment of Internal MedicineKeimyung University School of MedicineDaeguRepublic of Korea
| | - Zbigniew Kalarus
- Department of CardiologyMedical University of SilesiaKatowicePoland
| | - Carlos Labadet
- Cardiology DepartmentArrhythmias and Electrophysiology ServiceClinica y Maternidad Suizo ArgentinaBuenos AiresArgentina
| | - Yenn‐Jian Lin
- Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalTaipeiROC
| | - Li‐Wei Lo
- Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalTaipeiROC
| | - Akihiko Nogami
- Department of CardiologyFaculty of MedicineUniversity of TsukubaTsukubaJapan
| | - Eduardo B. Saad
- Center for Atrial FibrillationHospital Pro‐CardiacoRio de JaneiroBrazil
| | - John Sapp
- Division of CardiologyDepartment of MedicineQEII Health Sciences CentreDalhousie UniversityHalifaxNSCanada
| | | | - Roland Tilz
- Medical Clinic II (Department of Cardiology, Angiology and Intensive Care Medicine)University Hospital Schleswig‐Holstein (UKSH) – Campus LuebeckLuebeckGermany
| | - Roderick Tung
- Center for Arrhythmia CarePritzker School of MedicineUniversity of Chicago MedicineChicagoILUSA
| | - Yun Gi Kim
- Department of Internal MedicineArrhythmia CenterKorea University Medicine Anam HospitalSeoulRepublic of Korea
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Campbell T, Trivic I, Bennett RG, Anderson RD, Turnbull S, Pham T, Nalliah C, Kizana E, Watts T, Lee G, Kumar S. Catheter ablation of ventricular arrhythmia guided by a high-density grid catheter. J Cardiovasc Electrophysiol 2020; 31:474-484. [PMID: 31930658 DOI: 10.1111/jce.14351] [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] [Received: 10/16/2019] [Revised: 12/12/2019] [Accepted: 12/15/2019] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Minimal data exist on the Advisor HD Grid (HDG) catheter and the Precision electroanatomic mapping (EAM) system for ventricular arrhythmia (VA) procedures. Using the HDG catheter, the EAM uses the high-density (HD) wave mapping and best duplicate software to compare the maximum peak-to-peak bipolar voltages within a small zone independent of wavefront direction and catheter orientation. This study aimed to summarize the procedural experience for VAs using the HDG catheter. METHODS Clinical and procedural characteristics of VA ablation procedures were retrospectively reviewed that used the HDG catheter and the Precision EAM over a 12-month period. RESULTS A total of 22 patients, 18 with sustained ventricular tachycardia and 4 with premature ventricular contractions were included. Clinically indicated left and/or right ventricular (LV, RV, respectively), and aortic maps were created. LV substrate maps (n = 13) used a median 1700 points (interquartile range [IQR]25%-75% , 1427-2412) out of a median 18 573 (IQR25%-75% , 15 713-41 067) total points collected. RV substrate maps (n = 11) used a median 1435 points (IQR25%-75% , 1114-1871) out of a median 16 005 (IQR25%-75% , 11 063-21 405) total points collected. Total point utilization, used vs collected, was 9%. Mean mapping time was 43 ± 17 minutes (substrate, 34 ± 18 minutes; activation/pace mapping, 9 ± 13 minutes). Acute success was achieved in 56 (86%) and short-term success achieved in 16 patients (73%) at a median follow-up of 145 days (IQR25%-75% , 62-273 days). There were no procedural complications. CONCLUSION HD wave mapping using the novel HDG catheter integrated with the Precision EAM is safe and feasible in VA procedures in the LV, RV, and aorta. Mapping times are consistent with other multielectrode mapping catheters.
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Affiliation(s)
- Timothy Campbell
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Ivana Trivic
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia.,Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Richard G Bennett
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Robert D Anderson
- Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Samual Turnbull
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Timmy Pham
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Chrishan Nalliah
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Eddy Kizana
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Troy Watts
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
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Mechanism and magnitude of bipolar electrogram directional sensitivity: Characterizing underlying determinants of bipolar amplitude. Heart Rhythm 2019; 17:777-785. [PMID: 31843674 DOI: 10.1016/j.hrthm.2019.12.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND The amplitude of bipolar electrograms (EGMs) is directionally sensitive, decreasing when measured from electrode pairs oriented oblique to a propagating wavefront. OBJECTIVE The purpose of this study was to use a computational model and clinical data to establish the mechanism and magnitude of directional sensitivity. METHODS Simulated EGMs were created using a computational model with electrode pairs rotated relative to a passing wavefront. A clinical database of 18,740 EGMs with varying electrode separation and orientations was recorded from the left atrium of 10 patients with atrial fibrillation during pacing. For each EGM, the angle of incidence between the electrodes and the wavefront was measured using local conduction velocity (CV) mapping. RESULTS A theoretical model was derived describing the effect of the changing angle of incidence, electrode spacing, and CV on the local activation time difference between a pair of electrodes. Model predictions were validated using simulated and clinical EGMs. Bipolar amplitude measured by an electrode pair is decreased (directionally sensitive) at angles of incidence resulting in local activation time differences shorter than unipolar downstroke duration. Directional sensitivity increases with closer electrode spacing, faster CV, and longer unipolar EGM duration. For narrowly spaced electrode pairs (<5 mm), it is predicted at all orientations. CONCLUSION Directional sensitivity occurs because bipolar amplitude is reduced when the component unipolar EGMs overlap, such that neither electrode is "indifferent." At the electrode spacing of clinical catheters, this is predicted to occur regardless of catheter orientation. This suggests that bipolar directional sensitivity can be lessened but not overcome by recently introduced catheters with additional rotated electrode pairs.
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Evaluation of the reentry vulnerability index to predict ventricular tachycardia circuits using high-density contact mapping. Heart Rhythm 2019; 17:576-583. [PMID: 31751771 PMCID: PMC7105818 DOI: 10.1016/j.hrthm.2019.11.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Indexed: 11/24/2022]
Abstract
Background Identifying arrhythmogenic sites to improve ventricular tachycardia (VT) ablation outcomes remains unresolved. The reentry vulnerability index (RVI) combines activation and repolarization timings to identify sites critical for reentrant arrhythmia initiation without inducing VT. Objective The purpose of this study was to provide the first assessment of RVI’s capability to identify VT sites of origin using high-density contact mapping and comparison with other activation-repolarization markers of functional substrate. Methods Eighteen VT ablation patients (16 male; 72% ischemic) were studied. Unipolar electrograms were recorded during ventricular pacing and analyzed offline. Activation time (AT), activation–recovery interval (ARI), and repolarization time (RT) were measured. Vulnerability to reentry was mapped based on RVI and spatial distribution of AT, ARI, and RT. The distance from sites identified as vulnerable to reentry to the VT site of origin was measured, with distances <10 mm and >20 mm indicating accurate and inaccurate localization, respectively. Results The origins of 18 VTs (6 entrainment, 12 pace-mapping) were identified. RVI maps included 1012 (408–2098) (median, 1st–3rd quartiles) points per patient. RVI accurately localized 72.2% VT sites of origin, with median distance of 5.1 (3.2–10.1) mm. Inaccurate localization was significantly less frequent for RVI than AT (5.6% vs 33.3%; odds ratio 0.12; P = .035). Compared to RVI, distance to VT sites of origin was significantly larger for sites showing prolonged RT and ARI and were nonsignificantly larger for sites showing highest AT and ARI gradients. Conclusion RVI identifies vulnerable regions closest to VT sites of origin. Activation-repolarization metrics may improve VT substrate delineation and inform novel ablation strategies.
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Abstract
Ventricular tachycardia is typically hemodynamically unstable. Strategies to target the arrhythmogenic substrate during sinus rhythm are essential for therapeutic ablation. Electroanatomic mapping is the cornerstone of substrate-based strategies; ablation can be directed within a delineated scar region defined by low voltage. Bipolar voltage mapping has inherent limitations. Specific electrogram characteristics may improve the specificity of localizing the most arrhythmogenic regions within the substrate. Deceleration zones during sinus rhythm are niduses for reentry and can be identified by isochronal late activation mapping, which is a functional analysis of substrate propagation with local annotation to electrogram offset.
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Affiliation(s)
- Roderick Tung
- Department of Medicine, Section of Cardiology, The University of Chicago Medicine, Center for Arrhythmia Care, Pritzker School of Medicine, 5841 South Maryland Avenue, MC 6080, Chicago, IL 60637, USA.
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Tzou WS, Tschabrunn CM. Looking Near and Far. JACC Clin Electrophysiol 2019; 5:1141-1143. [DOI: 10.1016/j.jacep.2019.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 07/11/2019] [Indexed: 10/25/2022]
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Okubo K, Frontera A, Bisceglia C, Paglino G, Radinovic A, Foppoli L, Calore F, Della Bella P. Grid Mapping Catheter for Ventricular Tachycardia Ablation. Circ Arrhythm Electrophysiol 2019; 12:e007500. [DOI: 10.1161/circep.119.007500] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
A new grid mapping catheter (GMC)—allowing for bipolar recordings of the electrograms in each orthogonal direction—became available. The aim of the current study is to evaluate the utility of the GMC in creating substrate and ventricular tachycardia (VT) activation maps during VT ablation procedures.
Methods:
From December 2017 to July 2018, 41 consecutive patients undergoing a VT ablation procedure using a GMC were studied. During the substrate mapping, 3 different maps were created using the 3 GMC bipolar configurations (along the spline, across the spline, HD wave solution); the low voltage area and late potential areas were compared. In case of inducible VTs, the GMC was used to create the VT activation maps focusing on the diastolic interval. The relation between diastolic activities during VT and substrate abnormality during sinus rhythm was also investigated.
Results:
The median low-voltage area drawn by the HD wave configuration was 28.9 cm
2
, 13% and 15% smaller than the low-voltage areas identified by the along and across configuration, respectively (33.1 and 33.9 cm
2
;
P
<0.0001). The late potential areas obtained with the 3 GMC configuration did not differ (
P
>0.05). VT activation mappings using the GMC were performed in 40 VTs, visualizing the full diastolic pathway in 22 (55%) of them. While the latest late potential areas were included in VT diastolic pathway in 17 VTs, the other 6 VTs showed mismatching of them. Identifying the full diastolic pathway led to a higher ongoing VT termination rate during the ablation than in case of partial recordings (88% versus 45%;
P
=0.03); furthermore, in the former situation, the noninducibility of the targeted VTs was achieved in all cases.
Conclusions:
The GMC is a useful tool for performing substrate and VT activation mappings during the VT ablation procedure, precisely identifying the low-voltage areas and quickly visualizing the diastolic pathways.
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Affiliation(s)
- Kenji Okubo
- Arrhythmology Unit, San Raffaele Hospital, Milan, Italy (K.O, A.F., C.B., G.P., A.R., L.F., P.D.B.)
| | - Antonio Frontera
- Arrhythmology Unit, San Raffaele Hospital, Milan, Italy (K.O, A.F., C.B., G.P., A.R., L.F., P.D.B.)
| | - Caterina Bisceglia
- Arrhythmology Unit, San Raffaele Hospital, Milan, Italy (K.O, A.F., C.B., G.P., A.R., L.F., P.D.B.)
| | - Gabriele Paglino
- Arrhythmology Unit, San Raffaele Hospital, Milan, Italy (K.O, A.F., C.B., G.P., A.R., L.F., P.D.B.)
| | - Andrea Radinovic
- Arrhythmology Unit, San Raffaele Hospital, Milan, Italy (K.O, A.F., C.B., G.P., A.R., L.F., P.D.B.)
| | - Luca Foppoli
- Arrhythmology Unit, San Raffaele Hospital, Milan, Italy (K.O, A.F., C.B., G.P., A.R., L.F., P.D.B.)
| | - Federico Calore
- Abbott Medical Italy, Sesto San Giovanni, Milano, Italy (F.C)
| | - Paolo Della Bella
- Arrhythmology Unit, San Raffaele Hospital, Milan, Italy (K.O, A.F., C.B., G.P., A.R., L.F., P.D.B.)
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