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Parreira L, Marinheiro R, Carmo P, Chambel D, Mesquita D, Amador P, Marques L, Mancelos S, Reis RP, Adragao P. Validation of an electrocardiographic marker of low voltage areas in the right ventricular outflow tract in patients with idiopathic ventricular arrhythmias. J Cardiovasc Electrophysiol 2022; 33:2322-2334. [PMID: 35971685 DOI: 10.1111/jce.15654] [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: 05/03/2022] [Revised: 07/11/2022] [Accepted: 08/07/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Previous studies have reported the presence of subtle abnormalities in the right ventricular outflow tract (RVOT) in patients with apparently normal hearts and ventricular arrhythmias (VAs) from the RVOT, including the presence of low voltage areas (LVAs). This LVAs seem to be associated with the presence of ST-segment elevation in V1 or V2 leads at the level of the 2nd intercostal space (ICS). OBJECTIVE Our aim was to validate an electrocardiographic marker of LVAs in the RVOT in patients with idiopathic outflow tract VAs. METHODS A total of 120 patients were studied, 84 patients referred for ablation of idiopathic VAs with an inferior axis by the same operator, and a control group of 36 patients without VAs. Structural heart disease including arrhythmogenic right ventricular cardiomyopathy was ruled out in all patients. An electrocardiogram was performed with V1-V2 at the 2nd ICS, and ST-segment elevation ≥1 mm and T-wave inversion beyond V1 were assessed. Bipolar voltage map of the RVOT was performed in sinus rhythm (0.5-1.5 mV color display). Areas with electrograms <1.5 mV were considered LVAs, and their presence was assessed. We compared three groups, VAs from the RVOT (n = 66), VAs from the LVOT (n = 18) and Control group (n = 36). ST-elevation, T-wave inversion and left versus right side of the VAs were tested as predictors of LVAs, respective odds ratio (ORs) (95% confidence interval [CI]) and p values, were calculated with univariate logist regression. Variables with a p < .005 were included in the multivariate analysis. RESULTS ST-segment elevation, T-wave inversion and LVAs were present in the RVOT group, LVOT group and Control group as follows: (62%, 17%, and 6%, p < .0001), (33%, 29%, and 0%, p = .001) and (62%, 25%, and 14%, p < .0001). The ST-segment elevation, T-wave inversion and right-sided VAs were all predictors of LVAs, respective unadjusted ORs (95% CI), p values were, 32.31 (11.33-92.13), p < .0001, 4.137 (1.615-10.60), p = .003 and 8.200 (3.309-20.32), p < .0001. After adjustment, the only independent predictor of LVAs was the ST-segment elevation, with an adjusted OR (95% CI) of 20.94 (6.787-64.61), p < .0001. CONCLUSION LVAs were frequently present in patients with idiopathic VAs. ST-segment elevation was the only independent predictor of their presence.
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Affiliation(s)
- Leonor Parreira
- Cardiology Department, Luz Hospital Lisbon, Lisboa, Portugal.,Cardiology Department, Setubal Hospital Centre, Setubal, Portugal
| | - Rita Marinheiro
- Cardiology Department, Setubal Hospital Centre, Setubal, Portugal
| | - Pedro Carmo
- Cardiology Department, Luz Hospital Lisbon, Lisboa, Portugal
| | - Duarte Chambel
- Cardiology Department, Setubal Hospital Centre, Setubal, Portugal
| | - Dinis Mesquita
- Cardiology Department, Setubal Hospital Centre, Setubal, Portugal
| | - Pedro Amador
- Cardiology Department, Setubal Hospital Centre, Setubal, Portugal
| | - Lia Marques
- Cardiology Department, Setubal Hospital Centre, Setubal, Portugal
| | - Sofia Mancelos
- Cardiology Department, Luz Hospital Lisbon, Lisboa, Portugal
| | | | - Pedro Adragao
- Cardiology Department, Luz Hospital Lisbon, Lisboa, Portugal
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Parreira L, Carmo P, Marinheiro R, Chambel D, Mesquita D, Amador P, Pinho J, Marques L, Reis RP, Adragao P. A simplified approach to radiofrequency catheter ablation of idiopathic ventricular outflow tract premature ventricular contractions. J Cardiovasc Electrophysiol 2022; 33:2308-2321. [PMID: 35938385 DOI: 10.1111/jce.15652] [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: 06/24/2022] [Revised: 07/14/2022] [Accepted: 08/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Frequently, low voltage areas (LVAs) and diastolic potentials (DPs) are present at ablation site in sinus rhythm in patients with idiopathic premature ventricular contractions (PVCs). OBJECTIVE Validate these findings as substrate for PVCs and evaluate the feasibility of a simplified substrate approach based on LVAs and DPs for ablation of idiopathic outflow tract PVCs, in patients with a low PVC burden during the procedure. METHODS Prospective single-arm clinical trial at two centers with comparison with a historical group, matched to age and gender. The study group consisted of consecutive patients referred for ablation of frequent idiopathic PVCs with inferior axis, that presented with less than 2 PVCs/min in first 5 minutes of the procedure. The ablation was based on fast mapping of the RVOT in sinus rhythm looking for LVAs and DPs, defined as isolated small amplitude potentials occurring after the T wave of the surface ECG. The area with LVAs and DPs was tagged, and a simplified activation mapping of the PVCs was done in that area. The procedure time, success rate and recurrence rate were compared with the historical group in whom ablation was performed based on activation and pace mapping only. A validation group without PVCs was also studied to assess the prevalence of LVAs and DPs in the general population. RESULTS The study (n=38), historical (n=38) and validation (n=38) groups did not differ in relation to age or gender. Prevalence of LVAs and DPs was significantly higher in the study group in comparison with the validation group, respectively, 71% vs 11%, p<0.0001 and 87% vs 8%, p<0.0001. Procedure time was significantly lower in the study group when comparing to the historical group, 130 (100-164) vs 183 (160-203) min, p<0.0001 and the success rate was significantly higher, 90% vs 64%, p=0.013. The recurrence rate in patients with a successful ablation was not significantly different between both groups, Log-Rank=0.125. CONCLUSION Prevalence of LVAs and DPs was significantly higher in the study group than in the validation group. The proposed approach proved to be feasible, faster and more efficient than the historical approach. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Leonor Parreira
- Setubal Hospital Centre, R. Camilo Castelo Branco 175, 2910-549, Setubal.,Luz Hospital Lisbon, Av. Lusiada 100, 1500-650, Lisboa
| | - Pedro Carmo
- Luz Hospital Lisbon, Av. Lusiada 100, 1500-650, Lisboa
| | - Rita Marinheiro
- Setubal Hospital Centre, R. Camilo Castelo Branco 175, 2910-549, Setubal
| | - Duarte Chambel
- Setubal Hospital Centre, R. Camilo Castelo Branco 175, 2910-549, Setubal
| | - Dinis Mesquita
- Setubal Hospital Centre, R. Camilo Castelo Branco 175, 2910-549, Setubal
| | - Pedro Amador
- Setubal Hospital Centre, R. Camilo Castelo Branco 175, 2910-549, Setubal
| | - Joana Pinho
- Luz Hospital Lisbon, Av. Lusiada 100, 1500-650, Lisboa
| | - Lia Marques
- Setubal Hospital Centre, R. Camilo Castelo Branco 175, 2910-549, Setubal
| | | | - Pedro Adragao
- Luz Hospital Lisbon, Av. Lusiada 100, 1500-650, Lisboa
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Parreira L, Carmo P, Marinheiro R, Mesquita D, Chmelevsky M, Ferreira A, Marques L, Pinho J, Chambel D, Nunes S, Amador P, Gonçalves P, Marques H, Caria R, Adragão P. Assessment of wave front activation duration and speed across the right ventricular outflow tract using electrocardiographic imaging as predictors of the origin of the premature ventricular contractions: A validation study. J Electrocardiol 2022; 73:68-75. [PMID: 35667215 DOI: 10.1016/j.jelectrocard.2022.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/26/2022] [Accepted: 05/11/2022] [Indexed: 12/29/2022]
Abstract
AIMS Evaluate right ventricular outflow tract (RVOT) activation duration (AD) and speed, invasively and with the electrocardiographic imaging (ECGI), as predictors of the origin of the PVCs, validating the ECGI. METHODS 18 consecutive patients, 8 males, median age 55 (35-63) years that underwent ablation of PVCs with inferior axis and had ECGI performed before ablation. Isochronal activation maps of the RVOT in PVC were obtained with the ECGI and invasively. Total RVOT AD was measured as the time between earliest and latest activated region, and propagation speed by measuring the area of the first 10 ms of activation. Cut-off values for AD, activation speed and number of 10 ms isochrones to predict the origin of the PVCs, were obtained with the ROC curve analysis. Agreement between methods was done with Pearson correlation test and Bland-Altman plot. RESULTS PVCs originated from the RVOT in 11 (61%) patients. The stronger predictor of PVC origin was the AD. The median AD in PVCs from RVOT was significantly longer than from outside the RVOT, both with ECGI and invasively, respectively 62 (58-73) vs 37 (33-40) ms, p < 0.0001 and 68 (60-75) vs 35 (29-41) ms, p < 0.0001. Agreement between the two methods was good (r = 0.864, p < 0.0001). The cut-off value of 43 ms for AD measured with ECGI predicted the origin of the PVCs with a sensitivity and specificity of 100%. CONCLUSIONS We found good agreement between ECGI and invasive map. The AD measured with ECGI was the best predictor of the origin of the PVCs.
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Affiliation(s)
- Leonor Parreira
- Hospital Luz Lisbon, Av Lusiada, 1500-650 Lisboa, Portugal; Setubal Hospital Center, R. Camilo Castelo Branco 175, 2910-549 Setúbal, Portugal.
| | - Pedro Carmo
- Hospital Luz Lisbon, Av Lusiada, 1500-650 Lisboa, Portugal
| | - Rita Marinheiro
- Setubal Hospital Center, R. Camilo Castelo Branco 175, 2910-549 Setúbal, Portugal
| | - Dinis Mesquita
- Setubal Hospital Center, R. Camilo Castelo Branco 175, 2910-549 Setúbal, Portugal
| | | | | | - Lia Marques
- Setubal Hospital Center, R. Camilo Castelo Branco 175, 2910-549 Setúbal, Portugal
| | - Joana Pinho
- Hospital Luz Lisbon, Av Lusiada, 1500-650 Lisboa, Portugal
| | - Duarte Chambel
- Setubal Hospital Center, R. Camilo Castelo Branco 175, 2910-549 Setúbal, Portugal
| | - Silvia Nunes
- Hospital Luz Lisbon, Av Lusiada, 1500-650 Lisboa, Portugal
| | - Pedro Amador
- Setubal Hospital Center, R. Camilo Castelo Branco 175, 2910-549 Setúbal, Portugal
| | | | - Hugo Marques
- Hospital Luz Lisbon, Av Lusiada, 1500-650 Lisboa, Portugal
| | - Rui Caria
- Setubal Hospital Center, R. Camilo Castelo Branco 175, 2910-549 Setúbal, Portugal
| | - Pedro Adragão
- Hospital Luz Lisbon, Av Lusiada, 1500-650 Lisboa, Portugal
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Parreira L, Carmo P, Marinheiro R, Mesquita D, Farinha J, Esteves A, Amador P, Ferreira A, Fonseca M, Caria R, Adragao P. Prolonged Right Ventricular Outflow Tract Endocardial Activation Duration and Presence of Deceleration Zones in Patients With Idiopathic Premature Ventricular Contractions. Association With Low Voltage Areas. Front Physiol 2021; 12:699559. [PMID: 34276420 PMCID: PMC8283314 DOI: 10.3389/fphys.2021.699559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/04/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND AND AIMS The wavefront propagation velocity in the myocardium with fibrosis is characterized by the presence of deceleration zones and late activated zones, that are absent in the normal myocardium. Our aim was to study the right ventricular outflow tract (RVOT) endocardial activation duration in sinus rhythm, and assess the presence of deceleration zones, in patients with premature ventricular contractions (PVCs) and in controls. METHODS We studied 29 patients with idiopathic PVCs from the outflow tract, subjected to catheter ablation that had an activation and voltage map of the RVOT in sinus rhythm. A control group of 15 patients without PVCs that underwent ablation of supraventricular arrhythmias was also studied. RVOT endocardial activation duration and number of 10 ms isochrones across the RVOT were assessed. Propagation speed was calculated at the zone with the higher number of isochrones per cm radius. Deceleration zones were defined as zones with >3 isochrones within 1 cm radius. Low voltage areas were defined as areas with local electrogram with amplitude <1.5 mV. RESULTS The two groups did not differ in relation to age, gender or number of points in the map. RVOT endocardial activation duration and number of 10 ms isochrones were higher in the PVC group; 56 (41-66) ms vs. 39 (35-41) ms, p = 0.001 and 5 (4-8) vs. 4 (4-5), p = 0.001. Presence of deceleration zones and low voltage areas were more frequent in the PVC group; 20 (69%) vs. 0 (0%), p < 0.0001 and 21 (72%) vs. 0 (0%), p < 0.0001. The wavefront propagation speed was significantly lower in patients with PVCs than in the control group, 0.35 (0.27-0.40) vs. 0.63 (0.56-0.66) m/s, p < 0.0001. Patients with low voltage areas had longer activation duration 60 (52-67) vs. 36 (32-40) ms, p < 0.0001, more deceleration zones, 20 (95%) vs. 0 (0%), p < 0.0001, and lower wavefront propagation speed, 0.30 (0.26-0.36) vs. 0.54 (0.36-0.66) m/s, p = 0.002, than patients without low voltage areas. CONCLUSION Right ventricular outflow tract endocardial activation duration was longer, propagation speed was lower and deceleration zones were more frequent in patients with PVCs than in controls and were associated with the presence of low voltage areas.
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Affiliation(s)
- Leonor Parreira
- Department of Cardiology, Hospital Centre of Setubal, Setubal, Portugal
- Department of Cardiology, Luz Hospital Lisboa, Lisbon, Portugal
| | - Pedro Carmo
- Department of Cardiology, Luz Hospital Lisboa, Lisbon, Portugal
| | - Rita Marinheiro
- Department of Cardiology, Hospital Centre of Setubal, Setubal, Portugal
| | - Dinis Mesquita
- Department of Cardiology, Hospital Centre of Setubal, Setubal, Portugal
| | - José Farinha
- Department of Cardiology, Hospital Centre of Setubal, Setubal, Portugal
| | - Ana Esteves
- Department of Cardiology, Hospital Centre of Setubal, Setubal, Portugal
| | - Pedro Amador
- Department of Cardiology, Hospital Centre of Setubal, Setubal, Portugal
| | | | - Marta Fonseca
- Department of Cardiology, Hospital Centre of Setubal, Setubal, Portugal
| | - Rui Caria
- Department of Cardiology, Hospital Centre of Setubal, Setubal, Portugal
| | - Pedro Adragao
- Department of Cardiology, Luz Hospital Lisboa, Lisbon, Portugal
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