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Francia P, Falasconi G, Penela D, Viveros D, Alderete J, Saglietto A, Bellido AF, Martí-Almor J, Franco-Ocaña P, Soto-Iglesias D, Zaraket F, Turturiello D, Berruezo A. Scar architecture affects the electrophysiological characteristics of induced ventricular arrhythmias in hypertrophic cardiomyopathy. Europace 2024; 26:euae050. [PMID: 38375690 PMCID: PMC10914403 DOI: 10.1093/europace/euae050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 02/09/2024] [Indexed: 02/21/2024] Open
Abstract
AIMS Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) detects myocardial scarring, a risk factor for ventricular arrhythmias (VAs) in hypertrophic cardiomyopathy (HCM). The LGE-CMR distinguishes core, borderzone (BZ) fibrosis, and BZ channels, crucial components of re-entry circuits. We studied how scar architecture affects inducibility and electrophysiological traits of VA in HCM. METHODS AND RESULTS We correlated scar composition with programmed ventricular stimulation-inducible VA features using LGE intensity maps. Thirty consecutive patients were enrolled. Thirteen (43%) were non-inducible, 6 (20%) had inducible non-sustained, and 11 (37%) had inducible sustained mono (MMVT)- or polymorphic VT/VF (PVT/VF). Of 17 induced VA, 13 (76%) were MMVT that either ended spontaneously, persisted as sustained monomorphic, or degenerated into PVT/VF. Twenty-seven patients (90%) had LGE. Of these, 17 (57%) had non-sustained or sustained inducible VA. Scar mass significantly increased (P = 0.002) from non-inducible to inducible non-sustained and sustained VA patients in both the BZ and core components. Borderzone channels were found in 23%, 67%, and 91% of non-inducible, inducible non-sustained, and inducible sustained VA patients (P = 0.003). All 13 patients induced with MMVT or monomorphic-initiated PVT/VF had LGE. The origin of 10/13 of these VTs matched scar location, with 8/10 of these LGE regions showing BZ channels. During follow-up (20 months, interquartile range: 7-37), one patient with BZ channels and inducible PVT had an ICD shock for VF. CONCLUSION Scar architecture determines inducibility and electrophysiological traits of VA in HCM. Larger studies should explore the role of complex LGE patterns in refining risk assessment in HCM patients.
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Affiliation(s)
- Pietro Francia
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
- Cardiology Unit, Department of Clinical and Molecular Medicine, Sant’Andrea Hospital, University Sapienza, Rome, Italy
| | - Giulio Falasconi
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
- IRCCS Humanitas Research Hospital, Cardiovascular Department, Milan, Italy
| | - Diego Penela
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
- IRCCS Humanitas Research Hospital, Cardiovascular Department, Milan, Italy
| | - Daniel Viveros
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| | - José Alderete
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| | - Andrea Saglietto
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
- Division of Cardiology, Cardiovascular and Thoracic Department, ‘Citta della Salute e della Scienza Hospital, Turin, Italy
| | - Aldo Francisco Bellido
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| | - Julio Martí-Almor
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| | - Paula Franco-Ocaña
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| | - David Soto-Iglesias
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| | - Fatima Zaraket
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| | - Dario Turturiello
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
| | - Antonio Berruezo
- Arrhythmia Department, Teknon Heart Institute, Teknon Medical Center, C/Vilana 12, 08022 Barcelona, Spain
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Subramanian M, Atreya AR, Yalagudri SD, Shekar PV, Saggu DK, Narasimhan C. Catheter Ablation for Ventricular Arrhythmias in Hypertrophic Cardiomyopathy. Card Electrophysiol Clin 2022; 14:693-699. [PMID: 36396186 DOI: 10.1016/j.ccep.2022.08.005] [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
Implantable cardioverter-defibrillators are the mainstay of therapy for prevention of sudden cardiac death in high-risk patients with hypertrophic cardiomyopathy (HCM). Catheter ablation is a useful option for patients with recurrent, drug refractory monomorphic ventricular tachycardia (VT), and device therapy. Compared with other nonischemic substrates, there are limited data on the role and outcomes of catheter ablation in HCM. The challenges of VT ablation in HCM patients include deep intramural and epicardial substrates, suboptimal power delivery, and higher recurrence due to progression of disease. Patient selection, using cardiac MRI scar localization, and optimizing ablation techniques can improve outcomes in these patients.
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Affiliation(s)
- Muthiah Subramanian
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Mindspace Road, Gachibowli, Hyderabad 500032, India
| | - Auras R Atreya
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Mindspace Road, Gachibowli, Hyderabad 500032, India; Division of Cardiovascular Medicine, Electrophysiology Section, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sachin D Yalagudri
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Mindspace Road, Gachibowli, Hyderabad 500032, India
| | - P Vijay Shekar
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Mindspace Road, Gachibowli, Hyderabad 500032, India
| | - Daljeet Kaur Saggu
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Mindspace Road, Gachibowli, Hyderabad 500032, India
| | - Calambur Narasimhan
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Mindspace Road, Gachibowli, Hyderabad 500032, India.
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Haq KT, Rogovoy NM, Thomas JA, Hamilton C, Lutz KJ, Wirth A, Bender AB, German DM, Przybylowicz R, van Dam P, Dewland TA, Dalouk K, Stecker E, Nazer B, Jessel PM, MacMurdy KS, Zarraga IGE, Beitinjaneh B, Henrikson CA, Raitt M, Fuss C, Ferencik M, Tereshchenko LG. Adaptive Cardiac Resynchronization Therapy Effect on Electrical Dyssynchrony (aCRT-ELSYNC): A randomized controlled trial. Heart Rhythm O2 2021; 2:374-381. [PMID: 34430943 PMCID: PMC8369305 DOI: 10.1016/j.hroo.2021.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Adaptive cardiac resynchronization therapy (aCRT) is known to have clinical benefits over conventional CRT, but the mechanisms are unclear. OBJECTIVE Compare effects of aCRT and conventional CRT on electrical dyssynchrony. METHODS A prospective, double-blind, 1:1 parallel-group assignment randomized controlled trial in patients receiving CRT for routine clinical indications. Participants underwent cardiac computed tomography and 128-electrode body surface mapping. The primary outcome was change in electrical dyssynchrony measured on the epicardial surface using noninvasive electrocardiographic imaging before and 6 months post-CRT. Ventricular electrical uncoupling (VEU) was calculated as the difference between the mean left ventricular (LV) and right ventricular (RV) activation times. An electrical dyssynchrony index (EDI) was computed as the standard deviation of local epicardial activation times. RESULTS We randomized 27 participants (aged 64 ± 12 years; 34% female; 53% ischemic cardiomyopathy; LV ejection fraction 28% ± 8%; QRS duration 155 ± 21 ms; typical left bundle branch block [LBBB] in 13%) to conventional CRT (n = 15) vs aCRT (n = 12). In atypical LBBB (n = 11; 41%) with S waves in V5-V6, conduction block occurred in the anterior RV, as opposed to the interventricular groove in strict LBBB. As compared to baseline, VEU reduced post-CRT in the aCRT (median reduction 18.9 [interquartile range 4.3-29.2 ms; P = .034]), but not in the conventional CRT (21.4 [-30.0 to 49.9 ms; P = .525]) group. There were no differences in the degree of change in VEU and EDI indices between treatment groups. CONCLUSION The effect of aCRT and conventional CRT on electrical dyssynchrony is largely similar, but only aCRT harmoniously reduced interventricular dyssynchrony by reducing RV uncoupling.
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Affiliation(s)
- Kazi T. Haq
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Nichole M. Rogovoy
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Jason A. Thomas
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
- University of Washington, Seattle, Washington
| | - Christopher Hamilton
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Katherine J. Lutz
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Ashley Wirth
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Aron B. Bender
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
- University of California Los Angeles, Los Angeles, California
| | - David M. German
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Ryle Przybylowicz
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | | | - Thomas A. Dewland
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
- University of California San Francisco, San Francisco, California
| | - Khidir Dalouk
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
- VA Portland Health Care System, Portland, Oregon
| | - Eric Stecker
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Babak Nazer
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Peter M. Jessel
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
- VA Portland Health Care System, Portland, Oregon
| | - Karen S. MacMurdy
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
- VA Portland Health Care System, Portland, Oregon
| | - Ignatius Gerardo E. Zarraga
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
- VA Portland Health Care System, Portland, Oregon
| | - Bassel Beitinjaneh
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Charles A. Henrikson
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Merritt Raitt
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
- VA Portland Health Care System, Portland, Oregon
| | - Cristina Fuss
- Department of Diagnostic Radiology, Oregon Health & Science University, Portland, Oregon
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
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