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Özkan U, Budak M, Gürdoğan M, Öztürk G, Yildiz M, Taylan G, Altay S, Yalta K. KCNQ1 Polymorphism in the Context of Ischemic Cardiomyopathy: A Potential Key to Decision-Making for Device Implantation. Clin Cardiol 2025; 48:e70148. [PMID: 40365780 PMCID: PMC12076121 DOI: 10.1002/clc.70148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2025] [Revised: 03/27/2025] [Accepted: 04/28/2025] [Indexed: 05/15/2025] Open
Abstract
BACKGROUND Ventricular tachyarrhythmia (VTA) in ischemic cardiomyopathy (ICM) is a life-threatening condition influenced by genetic factors and electrical remodeling. This study investigated the association between KCNQ1 gene polymorphisms (rs2237892 and rs2237895) and the development of VTA in ICM patients to improve risk stratification and guide device implantation decisions. METHODS This single-center study included 213 ICM patients with implantable cardioverter-defibrillators (ICD) for primary prevention of VTA. Patients were divided into arrhythmia and control groups based on device interrogation findings. Genetic analysis for rs2237892 and rs2237895 polymorphisms was performed using real-time polymerase chain reaction (PCR). Clinical, electrocardiographic, and laboratory parameters were analyzed. Correlation and logistic regression analyses evaluated the association between KCNQ1 polymorphisms and VTA risk. RESULTS The arrhythmia group demonstrated significantly higher QT dispersion, frontal QRS-T angle, and T-wave peak-to-end interval compared to the control group. The TT genotype of rs2237892 and the AC genotype of rs2237895 were significantly associated with increased VTA risk (p < 0.001). Multivariate analysis confirmed these genotypes as independent predictors of VTA. No significant differences in other clinical or laboratory risk factors were observed. CONCLUSIONS KCNQ1 gene polymorphisms (rs2237892 and rs2237895) are strongly associated with VTA in ICM patients, suggesting a potential role as biomarkers for risk stratification. These findings may assist in tailoring ICD implantation decisions and improving patient outcomes.
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Affiliation(s)
- Uğur Özkan
- Department of Cardiology, School of MedicineTrakya UniversityTürkiye
| | - Metin Budak
- Department of Biophysics, Faculty of MedicineTrakya UniversityTürkiye
| | - Muhammet Gürdoğan
- Department of Cardiology, School of MedicineTrakya UniversityTürkiye
| | - Gülnur Öztürk
- Department of Physiotherapy and Rehabilitation, Faculty of Health SciencesTrakya UniversityTürkiye
| | - Mustafa Yildiz
- Department of Biophysics, Faculty of MedicineTrakya UniversityTürkiye
| | - Gökay Taylan
- Department of Cardiology, School of MedicineTrakya UniversityTürkiye
| | - Servet Altay
- Department of Cardiology, School of MedicineTrakya UniversityTürkiye
| | - Kenan Yalta
- Department of Cardiology, School of MedicineTrakya UniversityTürkiye
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2
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Zeppenfeld K, Rademaker R, Al-Ahmad A, Carbucicchio C, De Chillou C, Cvek J, Ebert M, Ho G, Kautzner J, Lambiase P, Merino JL, Lloyd M, Misra S, Pruvot E, Sapp J, Schiappacasse L, Sramko M, Stevenson WG, Zei PC. Patient selection, ventricular tachycardia substrate delineation, and data transfer for stereotactic arrhythmia radioablation: a clinical consensus statement of the European Heart Rhythm Association of the European Society of Cardiology and the Heart Rhythm Society. Europace 2025; 27:euae214. [PMID: 39177652 PMCID: PMC12041921 DOI: 10.1093/europace/euae214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2024] [Accepted: 08/05/2024] [Indexed: 08/24/2024] Open
Abstract
Stereotactic arrhythmia radioablation (STAR) is a novel, non-invasive, and promising treatment option for ventricular arrhythmias (VAs). It has been applied in highly selected patients mainly as bailout procedure, when (multiple) catheter ablations, together with anti-arrhythmic drugs, were unable to control the VAs. Despite the increasing clinical use, there is still limited knowledge of the acute and long-term response of normal and diseased myocardium to STAR. Acute toxicity appeared to be reasonably low, but potential late adverse effects may be underreported. Among published studies, the provided methodological information is often limited, and patient selection, target volume definition, methods for determination and transfer of target volume, and techniques for treatment planning and execution differ across studies, hampering the pooling of data and comparison across studies. In addition, STAR requires close and new collaboration between clinical electrophysiologists and radiation oncologists, which is facilitated by shared knowledge in each collaborator's area of expertise and a common language. This clinical consensus statement provides uniform definition of cardiac target volumes. It aims to provide advice in patient selection for STAR including aetiology-specific aspects and advice in optimal cardiac target volume identification based on available evidence. Safety concerns and the advice for acute and long-term monitoring including the importance of standardized reporting and follow-up are covered by this document. Areas of uncertainty are listed, which require high-quality, reliable pre-clinical and clinical evidence before the expansion of STAR beyond clinical scenarios in which proven therapies are ineffective or unavailable.
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Affiliation(s)
- Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Robert Rademaker
- Department of Cardiology, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, The Netherlands
| | - Amin Al-Ahmad
- Electrophysiology, Texas Cardiac Arrhythmia Institute, Austin, TX, USA
| | | | - Christian De Chillou
- CHU de Nancy, Cardiology, Institut Lorrain du Coeur et des Vaisseaux, Vandoeuvre Les Nancy, France
| | - Jakub Cvek
- Radiation Oncology, University of Ostrava, Ostrava, Czech Republic
| | - Micaela Ebert
- Electrophysiology, Heart Center Leipzig, Leipzig, Germany
| | - Gordon Ho
- Division of Cardiology, Section of Cardiac Electrophysiology, University of California San Diego, La Jolla, CA, USA
| | - Josef Kautzner
- Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Pier Lambiase
- Cardiology Department, University College London, London, UK
| | | | - Michael Lloyd
- Emory Electrophysiology, Electrophysiology Lab Director, EUH, Emory University Hospital, Atlanta, GA, USA
| | - Satish Misra
- Atrium Health Sanger Heart Vascular Institute Kenilworth, Charlotte, NC, USA
| | - Etienne Pruvot
- Department of Cardiology, Lausanne University Hospital, CHUV, Lausanne, Switzerland
| | - John Sapp
- QEII Health Sciences Center, Halifax Infirmary Site, Halifax, NS, Canada
| | - Luis Schiappacasse
- Department of Cardiology, Service de Radio-Oncologie, Lausanne University Hospital, CHUV, Lausanne, Switzerland
| | - Marek Sramko
- Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | | | - Paul C Zei
- Professor of Medicine, Cardiac Electrophysiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Kawaji T, Hayashi T, Nishimura T, Nagashima K. 3D mapping quest: How far can we see with recent advances in 3D mapping? J Cardiol 2025; 85:204-212. [PMID: 39626851 DOI: 10.1016/j.jjcc.2024.11.010] [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: 09/25/2024] [Revised: 11/20/2024] [Accepted: 11/27/2024] [Indexed: 12/19/2024]
Abstract
Recent advances in three-dimensional (3D) ultra-high-density mapping systems have uncovered previously unknown mechanisms underlying various arrhythmias. This clinical review, titled "3D Mapping Quest," focuses on the recently uncovered mechanisms of four types of arrhythmias. (1) To elucidate the precise mechanisms underlying atrial fibrillation (AF), ultra-high-density mapping with adequate spatial and temporal resolution is essential. Various mapping systems have been employed to investigate the chaotic activation during AF. The question remains: Is the AF driver characterized by focal activation or rotational activation? A novel mapping strategy is expected to provide the answer. (2) In atrioventricular nodal reentrant tachycardia (AVNRTs), 3D mapping revealed that the pivot point of activation at the lower end of a functional block line extending vertically downward from the His-bundle area, or a fractionated potential observed during AVNRT, can be targeted for slow pathway ablation. Either approach may prevent unnecessary radiofrequency applications while maintaining the success rate. (3) In premature ventricular contractions originating from the left ventricular summit, 3D mapping has enabled precise identification of the optimal endocardial ablation sites. By performing long-duration ablation at these optimal endocardial sites, the ablation outcomes have improved. (4) In scar-related reentrant ventricular tachycardia (VT), substrate mapping focusing on wavefront discontinuity has allowed for the identification of specific ablation targets within the broad scar. High-density VT activation mapping has revealed the complexity of the circuit structure, such as the 3D VT circuit. The VT circuit delineation on the cardiac surface is conceptualized as a cross-section of a hyperboloid model. Thus, it is anticipated that integrating histological and electrophysiological insights with advanced ultra-high-density mapping technologies will further facilitate a comprehensive understanding of the mechanisms.
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Affiliation(s)
- Tetsuma Kawaji
- Department of Cardiology, Mitsubishi Kyoto Hospital, Kyoto, Japan; Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tatsuya Hayashi
- Division of Cardiovascular Medicine, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Takuro Nishimura
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Koichi Nagashima
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan.
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Ciaccio EJ, Hsia HH, Saluja DS, Garan H, Coromilas J, Yarmohammadi H, Biviano AB, Peters NS. Ventricular tachycardia substrate mapping: What's been done and what needs to be done. Heart Rhythm 2025:S1547-5271(25)00204-8. [PMID: 39988104 DOI: 10.1016/j.hrthm.2025.02.034] [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: 12/03/2024] [Revised: 01/31/2025] [Accepted: 02/10/2025] [Indexed: 02/25/2025]
Abstract
Substrate mapping is an important component of electrophysiological (EP) study for the treatment of reentrant ventricular tachycardia (VT). It is used to detect characteristics of the electrical circuit and, in particular, the location and properties of the central common pathway, aka the isthmus, where multiple circuit loops can coincide. Typically, reentrant circuits are single or double loop, but as the common pathway size increases, 4-loop patterns may emerge, consisting of 2 parallel isthmuses or a single isthmus with 4 loops. Arrhythmogenic substrate contains a mixture of scar, calcification, and fibrofatty regions blended with viable ventricular myocytes, which can slow conduction. It is identified in the EP laboratory in part by the presence of low-amplitude electrograms and a zone of uniform slow conduction resulting from a sparsity of remaining viable myocytes and molecular-level remodeling. The electrograms recorded near isthmus boundaries frequently exhibit an abnormal morphology, such as fractionation and late or split deflections, due to the separation of muscle fiber bundles by fibroadipose tissue or calcification, and due to other conduction impediments such as source-sink mismatch, wherein topographic changes to the viable myocardial structure occur. Substrate mapping facilitates the identification of arrhythmogenic regions during sinus rhythm, whereas inducible VT with periods of ongoing reentry, when recordable, can be used for further assessment. Substrate modeling augments substrate mapping by seeking to predict electrogram morphology and mapped features and properties to be encountered during EP study based on an accurate depiction of arrhythmogenic tissue. Herein, we elaborate on the details of VT substrate mapping and modeling to the present time.
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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.
| | - Henry H Hsia
- Cardiac Electrophysiology and Arrhythmia Service, University of California San Francisco, San Francisco, California
| | - Deepak S Saluja
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Hasan Garan
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - James Coromilas
- Department of Medicine, Division of Cardiovascular Disease and Hypertension, Rutgers University, New Brunswick, New Jersey
| | - Hirad Yarmohammadi
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Angelo B Biviano
- Department of Medicine, Division of Cardiology, 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
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Redondo‐Rodríguez A, Ramos‐Prada A, Quintanilla JG, Calvo D, Sánchez‐González J, Enríquez‐Vázquez D, Marina‐Breysse M, Alfonso‐Almazán JM, González‐Ferrer JJ, Cañadas‐Godoy V, Salgado‐Aranda R, Morillo CA, Pérez‐Villacastín J, Pérez‐Castellano N, Filgueiras‐Rama D. Dispersion of Activation in Single-Beat Global Maps During Programmed Ventricular Stimulation Identifies Infarct-Related Ventricular Tachycardia Isthmus Sites. J Am Heart Assoc 2024; 13:e038441. [PMID: 39575703 PMCID: PMC11681573 DOI: 10.1161/jaha.124.038441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2024] [Accepted: 10/15/2024] [Indexed: 01/18/2025]
Abstract
BACKGROUND Electrophysiological characterization of ventricular tachycardia (VT) isthmus sites is complex and time-consuming. We aimed at developing and validating a global mapping strategy during programmed ventricular stimulation (PVS) to reveal the underlying electrophysiological properties of the infarct-related substrate and to enable identification of highly heterogeneous activation sites associated with protected VT isthmus sites. METHODS AND RESULTS Experimental study that included 22 pigs with established myocardial infarction undergoing in vivo characterization of the anatomical and functional myocardial substrate associated with potential arrhythmogenicity. High-density sequential activation maps during ventricular pacing and VT were compared with single-beat maps using a 64-pole basket catheter positioned in the left ventricle. Further analyses were performed using a novel local activation time-dispersion score to identify regional activation time heterogeneities on both baseline drive pacing and each of the extrastimuli of the PVS protocol. Basket catheter splines covered a median of 81.2% of the endocardial surface of the left ventricle. Basket-catheter-derived single-beat activation maps (N=16) during pacing showed a linear relationship with high-density sequential activation maps. Induction of ventricular arrhythmias was associated with higher local activation time-dispersion score values on single-beat global maps during PVS (N=6, 46 arrhythmia induction attempts). Single-beat-derived local activation time-dispersion score maps during successive coupled extrastimuli of the PVS showed a progressive increase in the predictive performance to identify monomorphic VT isthmus sites within the scar region (area under the curve = 0.779 in S2, area under the curve = 0.859 in S4; N=7). CONCLUSIONS Sixty-four-pole-derived single-beat local activation time-dispersion score global maps during PVS identify infarct-related endocardial regions with highly heterogeneous activation times that are associated with protected VT isthmus sites.
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Affiliation(s)
- Andrés Redondo‐Rodríguez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC)Novel Arrhythmogenic Mechanisms ProgramMadridSpain
| | - Alba Ramos‐Prada
- Centro Nacional de Investigaciones Cardiovasculares (CNIC)Novel Arrhythmogenic Mechanisms ProgramMadridSpain
- Fundación Interhospitalaria para la Investigación CardiovascularMadridSpain
| | - Jorge G. Quintanilla
- Centro Nacional de Investigaciones Cardiovasculares (CNIC)Novel Arrhythmogenic Mechanisms ProgramMadridSpain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV)MadridSpain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC)Cardiovascular InstituteMadridSpain
| | - David Calvo
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV)MadridSpain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC)Cardiovascular InstituteMadridSpain
| | | | - Daniel Enríquez‐Vázquez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV)MadridSpain
- Complexo Hospitalario Universitario A Coruña. Servicio de Cardiología, Instituto de Investigación Biomédica A Coruña (INIBIC)A CoruñaSpain
| | - Manuel Marina‐Breysse
- Centro Nacional de Investigaciones Cardiovasculares (CNIC)Novel Arrhythmogenic Mechanisms ProgramMadridSpain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV)MadridSpain
| | - Jose Manuel Alfonso‐Almazán
- Centro Nacional de Investigaciones Cardiovasculares (CNIC)Novel Arrhythmogenic Mechanisms ProgramMadridSpain
| | - Juan José González‐Ferrer
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV)MadridSpain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC)Cardiovascular InstituteMadridSpain
| | - Victoria Cañadas‐Godoy
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV)MadridSpain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC)Cardiovascular InstituteMadridSpain
| | - Ricardo Salgado‐Aranda
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV)MadridSpain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC)Cardiovascular InstituteMadridSpain
| | - Carlos A. Morillo
- Centro Nacional de Investigaciones Cardiovasculares (CNIC)Novel Arrhythmogenic Mechanisms ProgramMadridSpain
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of MedicineUniversity of CalgaryCalgaryAlbertaCanada
| | - Julián Pérez‐Villacastín
- Fundación Interhospitalaria para la Investigación CardiovascularMadridSpain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV)MadridSpain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC)Cardiovascular InstituteMadridSpain
| | - Nicasio Pérez‐Castellano
- Fundación Interhospitalaria para la Investigación CardiovascularMadridSpain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV)MadridSpain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC)Cardiovascular InstituteMadridSpain
| | - David Filgueiras‐Rama
- Centro Nacional de Investigaciones Cardiovasculares (CNIC)Novel Arrhythmogenic Mechanisms ProgramMadridSpain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV)MadridSpain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC)Cardiovascular InstituteMadridSpain
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Stevenson WG, Richardson TD, Kanagasundram AN, Tandri H. State of the Art: Mapping Strategies to Guide Ablation in Ischemic Heart Disease. JACC Clin Electrophysiol 2024; 10:2744-2761. [PMID: 39520431 DOI: 10.1016/j.jacep.2024.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Revised: 09/06/2024] [Accepted: 09/12/2024] [Indexed: 11/16/2024]
Abstract
Catheter ablation to prevent ventricular tachycardia (VT) that emerges late after a myocardial infarction aims to interrupt the re-entry substrate. Interruption of potential channels and regions of slow conduction that can be identified during stable sinus or paced rhythm is often effective and a number of substrate markers for guiding this approach have been described. While there is substantial agreement with different markers in some patients, the different markers select different regions for ablation in others. Mapping during VT to identify critical re-entry circuit isthmuses is likely more specific, and most useful when VT is incessant or frequent during the procedure or when sinus rhythm substrate ablation fails. Both approaches are often combined. These methods for identifying and characterizing post-infarct-related arrhythmia substrate and the re-entry circuits are reviewed.
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Affiliation(s)
- William G Stevenson
- Cardiac Electrophysiology Section, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - Travis D Richardson
- Cardiac Electrophysiology Section, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Arvindh N Kanagasundram
- Cardiac Electrophysiology Section, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Harikrishna Tandri
- Cardiac Electrophysiology Section, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Hayashi T, Denham N, Nettlefold C, Kakarla J, Anderson R, Bhaskaran A, Massé S, Downar E, Nanthakumar K. Spontaneous termination of ventricular tachycardia in the human heart. J Cardiovasc Electrophysiol 2024; 35:2161-2172. [PMID: 39279414 DOI: 10.1111/jce.16421] [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: 04/16/2024] [Revised: 08/11/2024] [Accepted: 08/19/2024] [Indexed: 09/18/2024]
Abstract
INTRODUCTION Understanding the spatiotemporal location of the spontaneous termination of ventricular tachycardia (VT) may provide new insights for ablation. To test the hypothesis that spontaneous VT termination most frequently occurs at the VT exit due to source-sink mismatch and to characterize electrophysiological properties of the sites termination during VT and with extra-stimulus technique. METHODS Retrospective analysis of intraoperative mapping studies of nine patients with ischemic cardiopathy or repaired tetralogy of Fallot. Simultaneous endocardial and epicardial mapping was performed in both ventricles using a custom mapping array during VT. Electrogram (EGM) characteristics before and at the moment of termination were analyzed including: cycle length oscillations, EGM heterogeneity and a variation in the systolic/diastolic path. The decrements to extra stimulus were analysed for termination sites and other diastolic sites. RESULTS Nine VTs in seven patients demonstrated spontaneous VT termination. Seven VTs (77.8%) spontaneously terminated in the final third of the systolic interval, one (11.1%) in early diastole and one (11.1%) in mid diastole. Cycle length oscillations (prolongation, shortening, and no change) were seen in equal frequency. Four VTs (44.4%) showed alternans in the local EGM at the site of termination and this was more prevalent than alternans at other sites in the diastolic pathway (p < .001). Only one-third of VTs showed a change in activation pattern before termination. There was no difference based on etiology. During substrate characterization with extra-stimulus pacing, sites of spontaneous termination showed greater decrement than other sites of the VT circuit during pacing (43.5 ± 14.5 ms vs. 31.2 ± 31.2 ms; p = .003). CONCLUSION The entrance zone rather than the exit is the commonest site for the spontaneous termination of VT in the human heart. These sites tend to demonstrate EGM alternans during VT and greater decrement during extrastimulus pacing. These findings may help guide future studies into improving the success of VT ablation.
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Affiliation(s)
- Takahiro Hayashi
- Hull Family Cardiac Fibrillation Management Laboratory, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Nathan Denham
- Hull Family Cardiac Fibrillation Management Laboratory, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Chloe Nettlefold
- Hull Family Cardiac Fibrillation Management Laboratory, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Jayant Kakarla
- Hull Family Cardiac Fibrillation Management Laboratory, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Robert Anderson
- Hull Family Cardiac Fibrillation Management Laboratory, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Abhishek Bhaskaran
- Hull Family Cardiac Fibrillation Management Laboratory, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Stéphane Massé
- Hull Family Cardiac Fibrillation Management Laboratory, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Eugene Downar
- Hull Family Cardiac Fibrillation Management Laboratory, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Kumaraswamy Nanthakumar
- Hull Family Cardiac Fibrillation Management Laboratory, Division of Cardiology, Toronto General Hospital, University Health Network, Toronto, ON, Canada
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8
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Fu Z, Dong R, Zheng H, Wang Z, Cao B, Bai J, Ma M, Song Z, Pan F, Xia L, Wu Y, Zhou S, Deng D. Progress of Conductivity and Conduction Velocity Measured in Human and Animal Hearts. Rev Cardiovasc Med 2024; 25:364. [PMID: 39484125 PMCID: PMC11522836 DOI: 10.31083/j.rcm2510364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 05/19/2024] [Accepted: 06/11/2024] [Indexed: 11/03/2024] Open
Abstract
Cardiac conduction velocity (CV) is a critical electrophysiological characteristic of the myocardium, representing the speed at which electrical pulses propagate through cardiac tissue. It can be delineated into longitudinal, transverse, and normal components in the myocardium. The CV and its anisotropy ratio are crucial to both normal electrical conduction and myocardial contraction, as well as pathological conditions where it increases the risk of conduction block and reentry. This comprehensive review synthesizes longitudinal and transverse CV values from clinical and experimental studies of human infarct hearts, including findings from the isthmus and outer loop, alongside data derived from animal models. Additionally, we explore the anisotropic ratio of conductivities assessed through both animal and computational models. The review culminates with a synthesis of scientific evidence that guides the selection of CV and its corresponding conductivity in cardiac modeling, particularly emphasizing its application in patient-specific cardiac arrhythmia modeling.
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Affiliation(s)
- Zhenyin Fu
- College of Biomedical Engineering & Instrument Science, Zhejiang University, 310058 Hangzhou, Zhejiang, China
| | - Ruiqing Dong
- Department of Cardiology, Dushu Lake Hospital Affiliated to Soochow University, 215000 Suzhou, Jiangsu, China
| | - Huanyong Zheng
- School of Biomedical Engineering, Dalian University of Technology, 116024 Dalian, Liaoning, China
| | - Zefeng Wang
- Department of Cardiology, Beijing Anzhen Hospital Affiliated to Capital Medical University, 100029 Beijing, China
| | - Boyang Cao
- College of Biomedical Engineering & Instrument Science, Zhejiang University, 310058 Hangzhou, Zhejiang, China
| | - Jinghui Bai
- Department of General Medicine, Liaoning Cancer Hospital of Dalian University of Technology, 116024 Liaoning, China
| | - Mingxia Ma
- Department of General Medicine, Liaoning Cancer Hospital of Dalian University of Technology, 116024 Liaoning, China
| | - Zhanchun Song
- Department of Cardiology, Fushun Central Hospital, 113006 Liaoning, China
| | - Fuzhi Pan
- Department of General Medicine, Liaoning Cancer Hospital of Dalian University of Technology, 116024 Liaoning, China
| | - Ling Xia
- College of Biomedical Engineering & Instrument Science, Zhejiang University, 310058 Hangzhou, Zhejiang, China
- Research Center for Healthcare Data Science, Zhejiang Lab, 310058 Hangzhou, Zhejiang, China
| | - Yongquan Wu
- Department of Cardiology, Beijing Anzhen Hospital Affiliated to Capital Medical University, 100029 Beijing, China
| | - Shijie Zhou
- Department of Chemical, Paper and Biomedical Engineering, Miami University, Oxford, OH 45056, USA
| | - Dongdong Deng
- School of Biomedical Engineering, Dalian University of Technology, 116024 Dalian, Liaoning, China
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Sung E, Kyranakis S, Daimee UA, Engels M, Prakosa A, Zhou S, Nazarian S, Zimmerman SL, Chrispin J, Trayanova NA. Evaluation of a deep learning-enabled automated computational heart modelling workflow for personalized assessment of ventricular arrhythmias. J Physiol 2024; 602:4625-4644. [PMID: 37060278 DOI: 10.1113/jp284125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 04/12/2023] [Indexed: 04/16/2023] Open
Abstract
Personalized, image-based computational heart modelling is a powerful technology that can be used to improve patient-specific arrhythmia risk stratification and ventricular tachycardia (VT) ablation targeting. However, most state-of-the-art methods still require manual interactions by expert users. The goal of this study is to evaluate the feasibility of an automated, deep learning-based workflow for reconstructing personalized computational electrophysiological heart models to guide patient-specific treatment of VT. Contrast-enhanced computed tomography (CE-CT) images with expert ventricular myocardium segmentations were acquired from 111 patients across five cohorts from three different institutions. A deep convolutional neural network (CNN) for segmenting left ventricular myocardium from CE-CT was developed, trained and evaluated. From both CNN-based and expert segmentations in a subset of patients, personalized electrophysiological heart models were reconstructed and rapid pacing was used to induce VTs. CNN-based and expert segmentations were more concordant in the middle myocardium than in the heart's base or apex. Wavefront propagation during pacing was similar between CNN-based and original heart models. Between most sets of heart models, VT inducibility was the same, the number of induced VTs was strongly correlated, and VT circuits co-localized. Our results demonstrate that personalized computational heart models reconstructed from deep learning-based segmentations even with a small training set size can predict similar VT inducibility and circuit locations as those from expertly-derived heart models. Hence, a user-independent, automated framework for simulating arrhythmias in personalized heart models could feasibly be used in clinical settings to aid VT risk stratification and guide VT ablation therapy. KEY POINTS: Personalized electrophysiological heart modelling can aid in patient-specific ventricular tachycardia (VT) risk stratification and VT ablation targeting. Current state-of-the-art, image-based heart models for VT prediction require expert-dependent, manual interactions that may not be accessible across clinical settings. In this study, we develop an automated, deep learning-based workflow for reconstructing personalized heart models capable of simulating arrhythmias and compare its predictions with that of expert-generated heart models. The number and location of VTs was similar between heart models generated from the deep learning-based workflow and expert-generated heart models. These results demonstrate the feasibility of using an automated computational heart modelling workflow to aid in VT therapeutics and has implications for generalizing personalized computational heart technology to a broad range of clinical centres.
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Affiliation(s)
- Eric Sung
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA
| | - Stephen Kyranakis
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA
| | - Usama A Daimee
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Marc Engels
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Adityo Prakosa
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA
| | - Shijie Zhou
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA
| | - Saman Nazarian
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Stefan L Zimmerman
- Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jonathan Chrispin
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Natalia A Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA
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10
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Darden D, Lakkireddy D. Diving deeper: Essential role of advanced ventricular tachycardia ablation techniques in hypertrophic cardiomyopathy. Indian Pacing Electrophysiol J 2024; 24:14-15. [PMID: 38242287 PMCID: PMC10927976 DOI: 10.1016/j.ipej.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024] Open
Affiliation(s)
- Douglas Darden
- Kansas City Heart Rhythm Institute, Overland Park, KS, USA
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11
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Ciaccio EJ, Coromilas J, Wan EY, Yarmohammadi H, Saluja DS, Peters NS, Garan H, Biviano AB. Correlation relationships of the reentrant ventricular tachycardia circuit. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 241:107764. [PMID: 37597351 DOI: 10.1016/j.cmpb.2023.107764] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 07/01/2023] [Accepted: 08/12/2023] [Indexed: 08/21/2023]
Abstract
INTRODUCTION A quantitative analysis of the components of reentrant ventricular tachycardia (VT) circuitry could improve understanding of its onset and perpetuation. METHOD In 19 canine experiments, the left anterior descending coronary artery was ligated to generate a subepicardial infarct. The border zone resided at the epicardial surface of the anterior left ventricle and was mapped 3-5 days postinfarction with a 196-312 bipolar multielectrode array. Monomorphic VT was inducible by extrastimulation. Activation maps revealed an epicardial double-loop reentrant circuit and isthmus, causing VT. Several circuit parameters were analyzed: the coupling interval for VT induction, VT cycle length, the lateral isthmus boundary (LIB) lengths, and isthmus width and angle. RESULTS The extrastimulus interval for VT induction and the VT cycle length were strongly correlated (p < 0.001). Both the extrastimulus interval and VT cycle length were correlated to the shortest LIB (p < 0.005). A derivation was developed to suggest that when conduction block at the shorter LIB is functional, the VT cycle length may depend on the local refractory period and the delay from wavefront pivot around the LIB. Isthmus width and angle were uncorrelated to other parameters. CONCLUSIONS The shorter LIB is correlated to VT cycle length, hence its circuit loop may drive reentrant VT. The extrastimulation interval, VT cycle length, and shorter LIB are intertwined, and may depend upon the local refractory period. Isthmus width and angle are less correlated, perhaps being more related to electrical discontinuity caused by alterations in infarct shape at depth.
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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, 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, USA
| | - Hirad Yarmohammadi
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Deepak S Saluja
- Department of Medicine - Division of Cardiology, 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, USA
| | - Angelo B Biviano
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY, USA
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12
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Tonko JB, Sporton S, Sawhney V, Dhinoja M. Mapping the unmappable-Rapid high-density contact mapping in hemodynamically unstable ventricular tachycardia using a novel star-shaped multipolar catheter. HeartRhythm Case Rep 2023; 9:749-754. [PMID: 38047195 PMCID: PMC10691944 DOI: 10.1016/j.hrcr.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Affiliation(s)
- Johanna B. Tonko
- St Bartholomew’s Hospital, London, United Kingdom
- Institute for Cardiovascular Science, University College London, London, United Kingdom
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13
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Tampakis K, Pastromas S, Sykiotis A, Kampanarou S, Kourgiannidis G, Pyrpiri C, Bousoula M, Rozakis D, Andrikopoulos G. Real-time cardiovascular magnetic resonance-guided radiofrequency ablation: A comprehensive review. World J Cardiol 2023; 15:415-426. [PMID: 37900261 PMCID: PMC10600785 DOI: 10.4330/wjc.v15.i9.415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/10/2023] [Accepted: 08/31/2023] [Indexed: 09/21/2023] Open
Abstract
Cardiac magnetic resonance (CMR) imaging could enable major advantages when guiding in real-time cardiac electrophysiology procedures offering high-resolution anatomy, arrhythmia substrate, and ablation lesion visualization in the absence of ionizing radiation. Over the last decade, technologies and platforms for performing electrophysiology procedures in a CMR environment have been developed. However, performing procedures outside the conventional fluoroscopic laboratory posed technical, practical and safety concerns. The development of magnetic resonance imaging compatible ablation systems, the recording of high-quality electrograms despite significant electromagnetic interference and reliable methods for catheter visualization and lesion assessment are the main limiting factors. The first human reports, in order to establish a procedural workflow, have rationally focused on the relatively simple typical atrial flutter ablation and have shown that CMR-guided cavotricuspid isthmus ablation represents a valid alternative to conventional ablation. Potential expansion to other more complex arrhythmias, especially ventricular tachycardia and atrial fibrillation, would be of essential impact, taking into consideration the widespread use of substrate-based strategies. Importantly, all limitations need to be solved before application of CMR-guided ablation in a broad clinical setting.
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Affiliation(s)
- Konstantinos Tampakis
- Department of Pacing & Electrophysiology, Henry Dunant Hospital Center, Athens 11526, Greece.
| | - Sokratis Pastromas
- Department of Pacing & Electrophysiology, Henry Dunant Hospital Center, Athens 11526, Greece
| | - Alexandros Sykiotis
- Department of Pacing & Electrophysiology, Henry Dunant Hospital Center, Athens 11526, Greece
| | | | - Georgios Kourgiannidis
- Department of Pacing & Electrophysiology, Henry Dunant Hospital Center, Athens 11526, Greece
| | - Chrysa Pyrpiri
- Department of Radiology, Henry Dunant Hospital Center, Athens 11526, Greece
| | - Maria Bousoula
- Department of Anesthesiology, Henry Dunant Hospital Center, Athens 11526, Greece
| | - Dimitrios Rozakis
- Department of Anesthesiology, Henry Dunant Hospital Center, Athens 11526, Greece
| | - George Andrikopoulos
- Department of Pacing & Electrophysiology, Henry Dunant Hospital Center, Athens 11526, Greece
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14
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Nitta T, Sakamoto SI, Murata H, Suzuki K, Yamada N, Iwasaki Y, Ishii Y. Surgery for ventricular tachycardia originating from the left ventricular summit. Eur J Cardiothorac Surg 2023; 64:ezad323. [PMID: 37725388 DOI: 10.1093/ejcts/ezad323] [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: 03/16/2023] [Revised: 06/28/2023] [Accepted: 09/15/2023] [Indexed: 09/21/2023] Open
Abstract
OBJECTIVES Ventricular tachycardia (VT) originating from the left ventricular summit region, the most superior region of the left ventricle surrounded by the major coronary arteries and veins, is frequently refractory to pharmacological therapies and endocardial and epicardial catheter ablation. METHODS Eleven patients with an age from 31 to 79 (median 56) years old, underwent map-guided surgery for left ventricular summit VT. All patients had undergone 1-5 unsuccessful sessions of catheter ablation for incessant VT, preoperatively. Five patients had suffered VT storm and 1 had a history of cardiopulmonary resuscitation. Four patients had implanted with a defibrillator. Epicardium to endocardium transmural cryothermia was applied at the VT origin determined by intraoperative epicardial mapping with electro-anatomical mapping system. Harmonic scalpel was used to remove the epicardial fat and cryothermia was applied directly to the myocardium, avoiding thermal or mechanical injuries to the coronary vessels. Additional endocardial cryothermia at the VT origin was performed by a cryoprobe introduced into the left ventricular cavity through an aortotomy. RESULTS There was no surgical mortality or long-term mortality related to VT during a median follow-up period of 60 months (interquartile range: 34-82). Five-year freedom from preoperatively documented left ventricular summit VT and non-documented VT was 91% and 73%, respectively. All the patients with postoperative VT underwent successful catheter ablation. Other patients were free from VT during the follow-up period. CONCLUSIONS Epicardial to endocardial transmural cryothermia at the VT origin guided by intraoperative electro-anatomical mapping with a close collaboration with electrophysiologists was crucial in successful surgery for left ventricular summit VT.
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Affiliation(s)
- Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | | | | | - Kenji Suzuki
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Naoki Yamada
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
| | - Yuki Iwasaki
- Department of Cardiology, Nippon Medical School, Tokyo, Japan
| | - Yosuke Ishii
- Department of Cardiovascular Surgery, Nippon Medical School, Tokyo, Japan
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15
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Wilhelm TI, Lewalter T, Fischer J, Reiser J, Werner J, Baumgartner C, Gleirscher L, Hoppmann P, Kupatt C, Tiemann K, Jilek C. Electroanatomical Conduction Characteristics of Pig Myocardial Tissue Derived from High-Density Mapping. J Clin Med 2023; 12:5598. [PMID: 37685665 PMCID: PMC10488835 DOI: 10.3390/jcm12175598] [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: 05/25/2023] [Revised: 08/19/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Ultra-high-density mapping systems allow more precise measurement of the heart chambers at corresponding conduction velocities (CVs) and voltage amplitudes (VAs). Our aim for this study was to define and compare a basic value set for unipolar CV and VA in all four heart chambers and their separate walls in healthy, juvenile porcine hearts using ultra-high-density mapping. METHODS We used the Rhythmia Mapping System to create electroanatomical maps of four pig hearts in sinus rhythm. CVs and VAs were calculated for chambers and wall segments with overlapping circular areas (radius of 5 mm). RESULTS We analysed 21 maps with a resolution of 1.4 points/mm2. CVs were highest in the left atrium (LA), followed by the left ventricle (LV), right ventricle (RV), and right atrium (RA). As for VA, LV was highest, followed by RV, LA, and RA. The left chambers had a higher overall CV and VA than the right. Within the chambers, CV varied more in the right than in the left chambers, and VA varied in the ventricles but not in the atria. There was a slightly positive correlation between CVs and VAs at velocity values of <1.5 m/s. CONCLUSIONS In healthy porcine hearts, the left chambers showed higher VAs and CVs than the right. CV differs mainly within the right chambers and VA differs only within the ventricles. A slightly positive linear correlation was found between slow CVs and low VAs.
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Affiliation(s)
- Theresa Isabelle Wilhelm
- Peter-Osypka Heart Centre Munich, Internistisches Klinikum München Süd, 81379 Munich, Germany (T.L.)
- Medical Graduate Center, School of Medicine, Technical University of Munich, 81675 Munich, Germany
| | - Thorsten Lewalter
- Peter-Osypka Heart Centre Munich, Internistisches Klinikum München Süd, 81379 Munich, Germany (T.L.)
| | - Johannes Fischer
- Center for Preclinical Research, University Hospital Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Judith Reiser
- Center for Preclinical Research, University Hospital Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Julia Werner
- Center for Preclinical Research, University Hospital Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Christine Baumgartner
- Center for Preclinical Research, University Hospital Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Lukas Gleirscher
- Peter-Osypka Heart Centre Munich, Internistisches Klinikum München Süd, 81379 Munich, Germany (T.L.)
| | - Petra Hoppmann
- Department of Internal Medicine I, University Hospital Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Christian Kupatt
- Department of Internal Medicine I, University Hospital Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Klaus Tiemann
- Peter-Osypka Heart Centre Munich, Internistisches Klinikum München Süd, 81379 Munich, Germany (T.L.)
- Department of Internal Medicine I, University Hospital Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
| | - Clemens Jilek
- Peter-Osypka Heart Centre Munich, Internistisches Klinikum München Süd, 81379 Munich, Germany (T.L.)
- Department of Internal Medicine I, University Hospital Rechts der Isar, Technical University of Munich, 81675 Munich, Germany
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Natale A, Zeppenfeld K, Della Bella P, Liu X, Sabbag A, Santangeli P, Sommer P, Sticherling C, Zhang X, Di Biase L. Twenty-five years of catheter ablation of ventricular tachycardia: a look back and a look forward. Europace 2023; 25:euad225. [PMID: 37622589 PMCID: PMC10451002 DOI: 10.1093/europace/euad225] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/14/2023] [Indexed: 08/26/2023] Open
Abstract
This article will discuss the past, present, and future of ventricular tachycardia ablation and the continuing contribution of the Europace journal as the platform for publication of milestone research papers in this field of ventricular tachycardia ablation.
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Affiliation(s)
- Andrea Natale
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, 3000 N. I-35, Suite 720, Austin, TX 78705, USA
| | - Katja Zeppenfeld
- Department of Cardiology, Willem Einthoven Center of Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands
| | - Paolo Della Bella
- Department of Cardiac Electrophysiology and Arrhythmology, San Raffaele University Hospital, Milan, Italy
| | - Xu Liu
- Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Avi Sabbag
- Sheba Medical Center, Tel HaShomer, Israel and the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Philipp Sommer
- Heart and Diabetes Center NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
| | | | - Xiaodong Zhang
- Montefiore Health System, Einstein Medical School, New York, USA
| | - Luigi Di Biase
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, 3000 N. I-35, Suite 720, Austin, TX 78705, USA
- Montefiore Health System, Einstein Medical School, New York, USA
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17
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Amoni M, Vermoortele D, Ekhteraei-Tousi S, Doñate Puertas R, Gilbert G, Youness M, Thienpont B, Willems R, Roderick HL, Claus P, Sipido KR. Heterogeneity of Repolarization and Cell-Cell Variability of Cardiomyocyte Remodeling Within the Myocardial Infarction Border Zone Contribute to Arrhythmia Susceptibility. Circ Arrhythm Electrophysiol 2023; 16:e011677. [PMID: 37128895 PMCID: PMC10187631 DOI: 10.1161/circep.122.011677] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 04/07/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND After myocardial infarction, the infarct border zone (BZ) is the dominant source of life-threatening arrhythmias, where fibrosis and abnormal repolarization create a substrate for reentry. We examined whether repolarization abnormalities are heterogeneous within the BZ in vivo and could be related to heterogeneous cardiomyocyte remodeling. METHODS Myocardial infarction was induced in domestic pigs by 120-minute ischemia followed by reperfusion. After 1 month, remodeling was assessed by magnetic resonance imaging, and electroanatomical mapping was performed to determine the spatial distribution of activation-recovery intervals. Cardiomyocytes were isolated and tissue samples collected from the BZ and remote regions. Optical recording allowed assessment of action potential duration (di-8-ANEPPS, stimulation at 1 Hz, 37 °C) of large cardiomyocyte populations while gene expression in cardiomyocytes was determined by single nuclear RNA sequencing. RESULTS In vivo, activation-recovery intervals in the BZ tended to be longer than in remote with increased spatial heterogeneity evidenced by a greater local SD (3.5±1.3 ms versus remote: 2.0±0.5 ms, P=0.036, npigs=5). Increased activation-recovery interval heterogeneity correlated with enhanced arrhythmia susceptibility. Cellular population studies (ncells=635-862 cells per region) demonstrated greater heterogeneity of action potential duration in the BZ (SD, 105.9±17.0 ms versus remote: 73.9±8.6 ms; P=0.001; npigs=6), which correlated with heterogeneity of activation-recovery interval in vivo. Cell-cell gene expression heterogeneity in the BZ was evidenced by increased Euclidean distances between nuclei of the BZ (12.1 [9.2-15.0] versus 10.6 [7.5-11.6] in remote; P<0.0001). Differentially expressed genes characterizing BZ cardiomyocyte remodeling included hypertrophy-related and ion channel-related genes with high cell-cell variability of expression. These gene expression changes were driven by stress-responsive TFs (transcription factors). In addition, heterogeneity of left ventricular wall thickness was greater in the BZ than in remote. CONCLUSIONS Heterogeneous cardiomyocyte remodeling in the BZ is driven by uniquely altered gene expression, related to heterogeneity in the local microenvironment, and translates to heterogeneous repolarization and arrhythmia vulnerability in vivo.
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Affiliation(s)
- Matthew Amoni
- Department of Cardiovascular Sciences, Experimental Cardiology (M.A., S.E.-T., R.D.P., G.G., M.Y., R.W., H.L.R., K.R.S.), KU Leuven, Belgium
- Division of Cardiology, University Hospitals, Leuven, Belgium (M.A., R.W.)
| | - Dylan Vermoortele
- Imaging and Cardiovascular Dynamics, Department of Cardiovascular Sciences (D.V., P.C.), KU Leuven, Belgium
| | - Samaneh Ekhteraei-Tousi
- Department of Cardiovascular Sciences, Experimental Cardiology (M.A., S.E.-T., R.D.P., G.G., M.Y., R.W., H.L.R., K.R.S.), KU Leuven, Belgium
| | - Rosa Doñate Puertas
- Department of Cardiovascular Sciences, Experimental Cardiology (M.A., S.E.-T., R.D.P., G.G., M.Y., R.W., H.L.R., K.R.S.), KU Leuven, Belgium
| | - Guillaume Gilbert
- Department of Cardiovascular Sciences, Experimental Cardiology (M.A., S.E.-T., R.D.P., G.G., M.Y., R.W., H.L.R., K.R.S.), KU Leuven, Belgium
| | - Mohamad Youness
- Department of Cardiovascular Sciences, Experimental Cardiology (M.A., S.E.-T., R.D.P., G.G., M.Y., R.W., H.L.R., K.R.S.), KU Leuven, Belgium
| | - Bernard Thienpont
- Laboratory for Functional Epigenetics, Department of Human Genetics (B.T.), KU Leuven, Belgium
| | - Rik Willems
- Department of Cardiovascular Sciences, Experimental Cardiology (M.A., S.E.-T., R.D.P., G.G., M.Y., R.W., H.L.R., K.R.S.), KU Leuven, Belgium
- Division of Cardiology, University Hospitals, Leuven, Belgium (M.A., R.W.)
| | - H. Llewelyn Roderick
- Department of Cardiovascular Sciences, Experimental Cardiology (M.A., S.E.-T., R.D.P., G.G., M.Y., R.W., H.L.R., K.R.S.), KU Leuven, Belgium
| | - Piet Claus
- Imaging and Cardiovascular Dynamics, Department of Cardiovascular Sciences (D.V., P.C.), KU Leuven, Belgium
| | - Karin R. Sipido
- Department of Cardiovascular Sciences, Experimental Cardiology (M.A., S.E.-T., R.D.P., G.G., M.Y., R.W., H.L.R., K.R.S.), KU Leuven, Belgium
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Artificial Intelligence as a Diagnostic Tool in Non-Invasive Imaging in the Assessment of Coronary Artery Disease. Med Sci (Basel) 2023; 11:medsci11010020. [PMID: 36976528 PMCID: PMC10053913 DOI: 10.3390/medsci11010020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 02/20/2023] [Accepted: 02/22/2023] [Indexed: 03/02/2023] Open
Abstract
Coronary artery disease (CAD) remains a leading cause of mortality and morbidity worldwide, and it is associated with considerable economic burden. In an ageing, multimorbid population, it has become increasingly important to develop reliable, consistent, low-risk, non-invasive means of diagnosing CAD. The evolution of multiple cardiac modalities in this field has addressed this dilemma to a large extent, not only in providing information regarding anatomical disease, as is the case with coronary computed tomography angiography (CCTA), but also in contributing critical details about functional assessment, for instance, using stress cardiac magnetic resonance (S-CMR). The field of artificial intelligence (AI) is developing at an astounding pace, especially in healthcare. In healthcare, key milestones have been achieved using AI and machine learning (ML) in various clinical settings, from smartwatches detecting arrhythmias to retinal image analysis and skin cancer prediction. In recent times, we have seen an emerging interest in developing AI-based technology in the field of cardiovascular imaging, as it is felt that ML methods have potential to overcome some limitations of current risk models by applying computer algorithms to large databases with multidimensional variables, thus enabling the inclusion of complex relationships to predict outcomes. In this paper, we review the current literature on the various applications of AI in the assessment of CAD, with a focus on multimodality imaging, followed by a discussion on future perspectives and critical challenges that this field is likely to encounter as it continues to evolve in cardiology.
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19
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Hu W, Zhou D, Ding X, Yang G, Liu H, Wang Z, Chen H, Ju W, Li M, Zhang F, Yang J, Han J, Wu X, Qiu Z, Zheng L, Chen M. Arrhythmogenesis of surgical atrial incisions and lesions in Maze procedure: insights from high-resolution mapping of atrial tachycardias. Europace 2023; 25:137-145. [PMID: 35851635 PMCID: PMC10112846 DOI: 10.1093/europace/euac102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 05/25/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Atrial tachycardias (ATs) frequently develop after a surgical Maze procedure. We aimed to elucidate the electrophysiologic mechanisms and their arrhythmogenic substrates of these ATs. METHODS AND RESULTS We retrospectively reviewed 20 patients (14 females, mean age of 55.5 ± 8.6 years) with post-Maze ATs who underwent high-resolution mapping at three institutions. The slow conduction areas, reentry circuits, voltage signals, complex electrograms, and their correlation with the surgical incisions and lesions placed in the surgical Maze procedures were analyzed. Thirty-six ATs with a mean cycle length of 260.0 ± 67.6 ms were mapped in these patients. Among them, 22 (61.1%) were anatomical macro-reentrant ATs (AMAT), 12 (33.3%) non-AMATs (localized ATs), and 2 (5.6%) focal ATs, respectively. Epicardial conduction bridges were observed in 6/20 (30.0%) patients and 7/36 (19.4%) ATs. Different arrhythmogenic substrates were identified in these ATs, including slow conduction regions within the previous lesion areas or between the incisions and anatomical structures, the prolonged activation pathways caused by the short lesions connecting the tricuspid annulus, and the circuits around the long incisions and/or lesions. CONCLUSIONS Reentry is the main mechanism of the post-Maze ATs. The pro-arrhythmic substrates are most likely caused by surgical incisions and lesions. The slow conduction regions and the protected channels yielded from these areas are the major arrhythmogenic factors.
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Affiliation(s)
- Wei Hu
- Cardiology Department, Tong Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Dongchen Zhou
- Cardiology Department, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Xiangwei Ding
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,School of Biomedical Engineering and Informatics, Nanjing Medical University, Nanjing, China
| | - Gang Yang
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hailei Liu
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zidun Wang
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hongwu Chen
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weizu Ju
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Mingfang Li
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Fengxiang Zhang
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jian Yang
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jie Han
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xianhao Wu
- Cardiology Department, Tong Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhaohui Qiu
- Cardiology Department, Tong Ren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liangrong Zheng
- Cardiology Department, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Minglong Chen
- Cardiology Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.,Cardiology Department, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
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20
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Transcoronary electrophysiological parameters in patients undergoing elective and acute coronary intervention. PLoS One 2023; 18:e0281374. [PMID: 36745641 PMCID: PMC9901776 DOI: 10.1371/journal.pone.0281374] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 01/20/2023] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Percutaneous coronary intervention is performed routinely in the management of myocardial infarction with obstructive coronary disease, but intervention to arteries supplying nonviable myocardium may be harmful. It is important therefore to establish myocardial viability, and there is an unmet need in current clinical practice for real time viability assessment to aid in decision making. Transcoronary pacing to assess myocardial electrophysiological parameters may be a novel viability assessment technique which could be used in this regard. METHODS Coronary intervention was carried out according to standard departmental procedure with standard equipment. An exchange length coronary guidewire was passed into both target and reference coronary vessels and an over-the-wire balloon or microcatheter was used to insulate the guidewire and allow electrophysiological parameters to be assessed. Readings were obtained from all major epicardial vessels and substantial branches. At each position, an intracoronary electrocardiogram was recorded, and R wave amplitude was measured. Transcoronary pacing was then performed to establish threshold and impedance for each myocardial segment. A viability cardiac MRI scan was performed for each patient. A standard segmental model was used to determine viability in each segment using an 'infarct score' based on degree of late gadolinium enhancement. Studies were reported blinded to the electrical parameters obtained from the coronary guidewire. The primary outcome was the relationship between pacing threshold and myocardial segment infarct score. Secondary outcomes included the relationship between segmental infarct score and R wave height, and between segmental infarct score and pacing impedance. Data were collected on the feasibility of studying the coronary segments as well as safety. RESULTS Sixty-five patients presenting with stable coronary artery disease or acute coronary syndromes to Leeds General Infirmary between September 2019 and August 2021 were included in the study. Electrophysiological parameters from segments with an infarct score of zero were obtained, with wide variances seen, with no significant difference in impedance or threshold in any territory. There was a significant difference in sensitivity for segments in the right coronary artery territory for both elective and acute patients. This likely relates to reduced myocardial mass in these territories. No significant association between infarct score and sensitivity, impedance or threshold were seen. CONCLUSION This study has established intracoronary electrophysiological parameters in both normal myocardium and areas of myocardial scar. No reliable association was seen between impedance, threshold or R wave amplitude and degree of myocardial viability, contrasting with prior findings from our group and others. More work is therefore required to fully understand the role of transcoronary pacing in this setting.
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21
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Vlachos K, Letsas KP, Srinivasan NT, Frontera A, Efremidis M, Dragasis S, Martin CA, Martin R, Nakashima T, Bazoukis G, Kitamura T, Mililis P, Saplaouras A, Georgopoulos S, Sofoulis S, Kariki O, Koskina S, Takigawa M, Sacher F, Jais P, Santangeli P. The value of functional substrate mapping in ventricular tachycardia ablation. Heart Rhythm O2 2023; 4:134-146. [PMID: 36873315 PMCID: PMC9975018 DOI: 10.1016/j.hroo.2022.10.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
In the setting of structural heart disease, ventricular tachycardia (VT) is typically associated with a re-entrant mechanism. In patients with hemodynamically tolerated VTs, activation and entrainment mapping remain the gold standard for the identification of the critical parts of the circuit. However, this is rarely accomplished, as most VTs are not hemodynamically tolerated to permit mapping during tachycardia. Other limitations include noninducibility of arrhythmia or nonsustained VT. This has led to the development of substrate mapping techniques during sinus rhythm, eliminating the need for prolonged periods of mapping during tachycardia. Recurrence rates following VT ablation are high; therefore, new mapping techniques for substrate characterization are required. Advances in catheter technology and especially multielectrode mapping of abnormal electrograms has increased the ability to identify the mechanism of scar-related VT. Several substrate-guided approaches have been developed to overcome this, including scar homogenization and late potential mapping. Dynamic substrate changes are mainly identified within regions of myocardial scar and can be identified as local abnormal ventricular activities. Furthermore, mapping strategies incorporating ventricular extrastimulation, including from different directions and coupling intervals, have been shown to increase the accuracy of substrate mapping. The implementation of extrastimulus substrate mapping and automated annotation require less extensive ablation and would make VT ablation procedures less cumbersome and accessible to more patients.
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Affiliation(s)
- Konstantinos Vlachos
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- Electrophysiology Department, Onassis Cardiac Surgery Center, Athens, Greece
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | | | - Neil T. Srinivasan
- Department of Cardiac Electrophysiology, Essex Cardiothoracic Centre, Basildon, United Kingdom
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Antonio Frontera
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - Michael Efremidis
- Electrophysiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Stelios Dragasis
- Electrophysiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Claire A. Martin
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus
| | - Ruaridh Martin
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - Takashi Nakashima
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - George Bazoukis
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus
- Department of Cardiology, Larnaca General Hospital, Larnaca, Cyprus
| | - Takeshi Kitamura
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - Panagiotis Mililis
- Laboratory of Cardiac Electrophysiology, General Hospital of Athens Evangelismos, Athens, Greece
| | | | - Stamatios Georgopoulos
- Laboratory of Cardiac Electrophysiology, General Hospital of Athens Evangelismos, Athens, Greece
| | - Stamatios Sofoulis
- Electrophysiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Ourania Kariki
- Electrophysiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Stavroula Koskina
- Electrophysiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Masateru Takigawa
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - Frédéric Sacher
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - Pierre Jais
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - Pasquale Santangeli
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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22
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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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23
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Campos FO, Shiferaw Y, Whitaker J, Plank G, Bishop MJ. Subthreshold delayed afterdepolarizations provide an important arrhythmogenic substrate in the border zone of infarcted hearts. Heart Rhythm 2023; 20:299-306. [PMID: 36343889 DOI: 10.1016/j.hrthm.2022.10.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Fernando O Campos
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom.
| | - Yohannes Shiferaw
- Department of Physics, University of California, Los Angeles, California
| | - John Whitaker
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Gernot Plank
- Gottfried Schatz Research Center, Division of Biophysics, Medical University of Graz, Graz, Austria
| | - Martin J Bishop
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
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24
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Pandozi C, Mariani MV, Chimenti C, Maestrini V, Filomena D, Magnocavallo M, Straito M, Piro A, Russo M, Galeazzi M, Ficili S, Colivicchi F, Severino P, Mancone M, Fedele F, Lavalle C. The scar: the wind in the perfect storm-insights into the mysterious living tissue originating ventricular arrhythmias. J Interv Card Electrophysiol 2023; 66:27-38. [PMID: 35072829 PMCID: PMC9931863 DOI: 10.1007/s10840-021-01104-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 12/27/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Arrhythmic death is very common among patients with structural heart disease, and it is estimated that in European countries, 1 per 1000 inhabitants yearly dies for sudden cardiac death (SCD), mainly as a result of ventricular arrhythmias (VA). The scar is the result of cardiac remodelling process that occurs in several cardiomyopathies, both ischemic and non-ischemic, and is considered the perfect substrate for re-entrant and non-re-entrant arrhythmias. METHODS Our aim was to review published evidence on the histological and electrophysiological properties of myocardial scar and to review the central role of cardiac magnetic resonance (CMR) in assessing ventricular arrhythmias substrate and its potential implication in risk stratification of SCD. RESULTS Scarring process affects both structural and electrical myocardial properties and paves the background for enhanced arrhythmogenicity. Non-uniform anisotropic conduction, gap junctions remodelling, source to sink mismatch and refractoriness dispersion are some of the underlining mechanisms contributing to arrhythmic potential of the scar. All these mechanisms lead to the initiation and maintenance of VA. CMR has a crucial role in the evaluation of patients suffering from VA, as it is considered the gold standard imaging test for scar characterization. Mounting evidences support the use of CMR not only for the definition of gross scar features, as size, localization and transmurality, but also for the identification of possible conducting channels suitable of discrete ablation. Moreover, several studies call out the CMR-based scar characterization as a stratification tool useful in selecting patients at risk of SCD and amenable to implantable cardioverter-defibrillator (ICD) implantation. CONCLUSIONS Scar represents the substrate of ventricular arrhythmias. CMR, defining scar presence and its features, may be a useful tool for guiding ablation procedures and for identifying patients at risk of SCD amenable to ICD therapy.
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Affiliation(s)
- C. Pandozi
- grid.416357.2Department of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - Marco Valerio Mariani
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - C. Chimenti
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - V. Maestrini
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - D. Filomena
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - M. Magnocavallo
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - M. Straito
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - A. Piro
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - M. Russo
- grid.416357.2Department of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - M. Galeazzi
- grid.416357.2Department of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - S. Ficili
- ASP, Ragusa Maggiore Hospital, Modica, Italy
| | - F. Colivicchi
- grid.416357.2Department of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - P. Severino
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - M. Mancone
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - F. Fedele
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - C. Lavalle
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
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25
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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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26
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Cardiac fibrosis in oncologic therapies. CURRENT OPINION IN PHYSIOLOGY 2022; 29. [DOI: 10.1016/j.cophys.2022.100575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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27
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Hawson J, Van Nieuwenhuyse E, Van Den Abeele R, Al-Kaisey A, Anderson RD, Chieng D, Segan L, Watts T, Campbell T, Hendrickx S, Morton J, McLellan A, Kistler P, Lee A, Gerstenfeld EP, Hsia HH, Voskoboinik A, Pathik B, Kumar S, Kalman J, Lee G, Vandersickel N. Directed Graph Mapping for Ventricular Tachycardia: A Comparison to Established Mapping Techniques. JACC Clin Electrophysiol 2022:S2405-500X(22)00723-X. [PMID: 36752465 DOI: 10.1016/j.jacep.2022.08.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 08/04/2022] [Accepted: 08/15/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Understanding underlying mechanism(s) and identifying critical circuit components are fundamental to successful ventricular tachycardia (VT) ablation. Directed graph mapping (DGM) offers a novel technique to identify the mechanism and critical components of a VT circuit. OBJECTIVES This study sought to evaluate the accuracy of DGM in VT ablation compared with traditional mapping techniques and a commercially available automated conduction velocity mapping (ACVM) tool. METHODS Patients with structural heart disease who had undergone a VT ablation with entrainment-proven critical isthmus and a high-density electroanatomical activation map were included. Traditional mapping (TM) consisted of a combination of local activation time and entrainment mapping and was considered the gold standard for determining the VT mechanism, circuit, and isthmus location. The same local activation time values were then processed using DGM and a commercially available ACVM (Coherent Mapping, Biosense Webster) tool. The aim of this study was to compare TM vs DGM and ACVM in their ability to identify the VT mechanism, characterize the VT circuit, and locate the critical isthmus. RESULTS Thirty-five cases were identified. TM classified the VT mechanism as focal in 7 patients and re-entrant in 28 patients. TM classified 11 VTs as single-loop re-entry, 15 as dual-loop re-entry, 1 as complex, and 1 case was indeterminant. The overall agreement between DGM and TM for determining VT mechanism and circuit type was strong (kappa value = 0.79; P < 0.01), as was the agreement between ACVM and TM (kappa value = 0.66; P < 0.01). Both DGM and ACVM identified the putative VT isthmus in 25 (89%) of the re-entrant cases. Focal activation was correctly identified by both techniques in all cases. CONCLUSIONS DGM is a rapid automated algorithm that has a strong level of agreement with TM for manually re-annotated VT maps.
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Affiliation(s)
- Joshua Hawson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | | | | | - Ahmed Al-Kaisey
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Robert D Anderson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - David Chieng
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Louise Segan
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Troy Watts
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Timothy Campbell
- Western Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Sander Hendrickx
- Department of Physics and Astronomy, Ghent University, Ghent, Belgium
| | - Joseph Morton
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Alexander McLellan
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Peter Kistler
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Adam Lee
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Edward P Gerstenfeld
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Henry H Hsia
- Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | | | - Bhupesh Pathik
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Saurabh Kumar
- Western Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia; Department of Cardiology, Westmead Hospital and Westmead Applied Research Centre, Westmead, New South Wales, Australia
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia.
| | - Nele Vandersickel
- Department of Physics and Astronomy, Ghent University, Ghent, Belgium
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28
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Adeliño R, Martínez-Falguera D, Curiel C, Teis A, Marsal R, Rodríguez-Leor O, Prat-Vidal C, Fadeuilhe E, Aranyó J, Revuelta-López E, Sarrias A, Bazan V, Andrés-Cordón JF, Roura S, Villuendas R, Lupón J, Bayes-Genis A, Gálvez-Montón C, Bisbal F. Electrophysiological effects of adipose graft transposition procedure (AGTP) on the post-myocardial infarction scar: A multimodal characterization of arrhythmogenic substrate. Front Cardiovasc Med 2022; 9:983001. [PMID: 36204562 PMCID: PMC9530287 DOI: 10.3389/fcvm.2022.983001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To assess the arrhythmic safety profile of the adipose graft transposition procedure (AGTP) and its electrophysiological effects on post-myocardial infarction (MI) scar. Background Myocardial repair is a promising treatment for patients with MI. The AGTP is a cardiac reparative therapy that reduces infarct size and improves cardiac function. The impact of AGTP on arrhythmogenesis has not been addressed. Methods MI was induced in 20 swine. Contrast-enhanced magnetic resonance (ce-MRI), electrophysiological study (EPS), and left-ventricular endocardial high-density mapping were performed 15 days post-MI. Animals were randomized 1:1 to AGTP or sham-surgery group and monitored with ECG-Holter. Repeat EPS, endocardial mapping, and ce-MRI were performed 30 days post-intervention. Myocardial SERCA2, Connexin-43 (Cx43), Ryanodine receptor-2 (RyR2), and cardiac troponin-I (cTnI) gene and protein expression were evaluated. Results The AGTP group showed a significant reduction of the total infarct scar, border zone and dense scar mass by ce-MRI (p = 0.04), and a decreased total scar and border zone area in bipolar voltage mapping (p < 0.001). AGTP treatment significantly reduced the area of very-slow conduction velocity (<0.2 m/s) (p = 0.002), the number of deceleration zones (p = 0.029), and the area of fractionated electrograms (p = 0.005). No differences were detected in number of induced or spontaneous ventricular arrhythmias at EPS and Holter-monitoring. SERCA2, Cx43, and RyR2 gene expression were decreased in the infarct core of AGTP-treated animals (p = 0.021, p = 0.018, p = 0.051, respectively). Conclusion AGTP is a safe reparative therapy in terms of arrhythmic risk and provides additional protective effect against adverse electrophysiological remodeling in ischemic heart disease.
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Affiliation(s)
- Raquel Adeliño
- ICREC Research Program, Germans Trias i Pujol Research Institute (IGTP), Barcelona, Spain
| | - Daina Martínez-Falguera
- ICREC Research Program, Germans Trias i Pujol Research Institute (IGTP), Barcelona, Spain
- Faculty of Medicine, University of Barcelona, Barcelona, Spain
| | - Carolina Curiel
- Boston Scientific Department, Barcelona Delegation, Barcelona, Spain
| | - Albert Teis
- ICREC Research Program, Germans Trias i Pujol Research Institute (IGTP), Barcelona, Spain
- Heart Institute (iCOR), Germans Trias i Pujol University Hospital, Barcelona, Spain
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain
| | - Roger Marsal
- Boston Scientific Department, Barcelona Delegation, Barcelona, Spain
| | - Oriol Rodríguez-Leor
- Heart Institute (iCOR), Germans Trias i Pujol University Hospital, Barcelona, Spain
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain
| | - Cristina Prat-Vidal
- ICREC Research Program, Germans Trias i Pujol Research Institute (IGTP), Barcelona, Spain
| | - Edgar Fadeuilhe
- Heart Institute (iCOR), Germans Trias i Pujol University Hospital, Barcelona, Spain
| | - Júlia Aranyó
- Heart Institute (iCOR), Germans Trias i Pujol University Hospital, Barcelona, Spain
| | - Elena Revuelta-López
- ICREC Research Program, Germans Trias i Pujol Research Institute (IGTP), Barcelona, Spain
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain
| | - Axel Sarrias
- Heart Institute (iCOR), Germans Trias i Pujol University Hospital, Barcelona, Spain
| | - Víctor Bazan
- Heart Institute (iCOR), Germans Trias i Pujol University Hospital, Barcelona, Spain
| | | | - Santiago Roura
- ICREC Research Program, Germans Trias i Pujol Research Institute (IGTP), Barcelona, Spain
- Heart Institute (iCOR), Germans Trias i Pujol University Hospital, Barcelona, Spain
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain
- Faculty of Medicine, University of Vic-Central University of Catalonia (UVic-UCC), Vic, Spain
| | - Roger Villuendas
- Heart Institute (iCOR), Germans Trias i Pujol University Hospital, Barcelona, Spain
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain
| | - Josep Lupón
- Heart Institute (iCOR), Germans Trias i Pujol University Hospital, Barcelona, Spain
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain
- Department of Medicine, Can Ruti Campus, Autonomous University of Barcelona, Barcelona, Spain
| | - Antoni Bayes-Genis
- ICREC Research Program, Germans Trias i Pujol Research Institute (IGTP), Barcelona, Spain
- Heart Institute (iCOR), Germans Trias i Pujol University Hospital, Barcelona, Spain
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain
- Department of Medicine, Can Ruti Campus, Autonomous University of Barcelona, Barcelona, Spain
| | - Carolina Gálvez-Montón
- ICREC Research Program, Germans Trias i Pujol Research Institute (IGTP), Barcelona, Spain
- Heart Institute (iCOR), Germans Trias i Pujol University Hospital, Barcelona, Spain
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain
- *Correspondence: Carolina Gálvez-Montón,
| | - Felipe Bisbal
- ICREC Research Program, Germans Trias i Pujol Research Institute (IGTP), Barcelona, Spain
- Heart Institute (iCOR), Germans Trias i Pujol University Hospital, Barcelona, Spain
- CIBER Cardiovascular, Instituto de Salud Carlos III, Madrid, Spain
- *Correspondence: Carolina Gálvez-Montón,
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Ueda A, Katsume Y, Miwa Y, Mohri T, Tashiro M, Nonoguchi N, Hoshida K, Togashi I, Sato T, Soejima K. Temporal and Spatial Pacemap Parameters for Identification of Cardiac Surfaces with Critical Sites for Ventricular Tachycardia. J Cardiovasc Electrophysiol 2022; 33:1791-1800. [PMID: 35748391 DOI: 10.1111/jce.15611] [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: 02/25/2022] [Revised: 06/07/2022] [Accepted: 06/22/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Multi-surface pacemapping may help identify the surface of interest in scar-related ventricular tachycardia. This study aimed to investigate the performance of pacemap parameters for detecting critical sites through multi-surface mapping. METHODS AND RESULTS In 26 patients who underwent scar-related ventricular tachycardia ablation, pacemap parameters including a matching score, the difference between the longest and shortest stimulus-QRS intervals (Δs-QRS), and the distance between the good pacemap sites were measured. The parameters were compared between surfaces with and without critical sites and ablation outcomes. A total of 941 pacemaps at 56 surfaces targeting 35 ventricular tachycardias were analyzed. A greater Δs-QRS (40 vs. 8 ms, P<0.001) and longer distance between two good pacemap sites (24 vs. 13 mm, P<0.001) were observed on the surfaces with critical sites. A similar trend was seen in multi-surface pacemapping for the same ventricular tachycardias (52 vs 18 ms in Δs-QRS, P=0.021; 37 vs. 12 mm in distance, P=0.019), although the best pacemap scores were comparable (94 vs. 87, P=0.295). The Δs-QRS >20 ms and the distance >19 mm showed high positive likelihood ratios (19.8 and 6.1, respectively) for discriminating the surface harboring the critical site. Ablation of ventricular tachycardias fulfilling these parameters was successful on the surfaces, but without the required multi-surface ablation. CONCLUSION Temporal (Δs-QRS) and spatial (distance) parameters for good pacemap match sites were excellent markers for detecting the surface harboring critical sites in scar-related ventricular tachycardia. A multi-surface pacemapping can successfully identify the surface of interest. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Akiko Ueda
- Division of Advanced Arrhythmia Management, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-0004, Japan
| | - Yumi Katsume
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-0004, Japan
| | - Yosuke Miwa
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-0004, Japan
| | - Takato Mohri
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-0004, Japan
| | - Mika Tashiro
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-0004, Japan
| | - Noriko Nonoguchi
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-0004, Japan
| | - Kyoko Hoshida
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-0004, Japan
| | - Ikuko Togashi
- Division of Advanced Arrhythmia Management, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-0004, Japan
| | - Toshiaki Sato
- Division of Advanced Arrhythmia Management, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-0004, Japan
| | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University Hospital, 6-20-2 Shinkawa, Mitaka, Tokyo, 181-0004, Japan
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30
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Guenancia C, Supple G, Sellal JM, Magnin-Poull I, Benali K, Hammache N, Echivard M, Marchlinski F, de Chillou C. How to use pace mapping for ventricular tachycardia ablation in post-infarct patients. J Cardiovasc Electrophysiol 2022; 33:1801-1809. [PMID: 35665562 PMCID: PMC9543459 DOI: 10.1111/jce.15586] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 04/15/2022] [Accepted: 05/03/2022] [Indexed: 11/27/2022]
Abstract
We aim to describe the technical aspects of pace mapping (PM), as well as the two typical patterns of pacing correlation maps during ventricular tachycardia (VT) ablation. The first main pattern is focal, with a gradual and eccentric decrease of the QRS correlation from the area with the best PM correlation. This focal pattern may be associated with two clinical situations: (1) with some endocardial points showing a good correlation compared to VT morphology: true endocardial exit of VT or endocardial breakthrough of either an intramural or an epicardial circuit; (2) without any endocardial points showing a good correlation compared to VT morphology: the VT may originate from the other ventricle, but the presence of an intramural or an epicardial circuit should be considered in patients with a structural heart disease. The second pattern is the presence of PM points exhibiting a good correlation close to other PM points showing a poor correlation compared to VT morphology: this abrupt change in paced QRS morphology over a short distance indicates divergence of activation wavefronts between these sites and suggests the presence of a slow conduction channel: the VT isthmus.
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Affiliation(s)
- Charles Guenancia
- Cardiology Department, University Hospital, Dijon, France.,PEC 2 EA 7460, University of Burgundy and Franche-Comté, Dijon, France.,Département de Cardiologie, Centre Hospitalier Universitaire (CHU de Nancy), Vandœuvre lès-Nancy, France.,INSERM-IADI U1254, Vandœuvre lès-Nancy, France
| | - Gregory Supple
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jean-Marc Sellal
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.,Département de Cardiologie, Centre Hospitalier Universitaire (CHU de Nancy), Vandœuvre lès-Nancy, France
| | - Isabelle Magnin-Poull
- Département de Cardiologie, Centre Hospitalier Universitaire (CHU de Nancy), Vandœuvre lès-Nancy, France
| | - Karim Benali
- Département de Cardiologie, Centre Hospitalier Universitaire (CHU de Nancy), Vandœuvre lès-Nancy, France.,INSERM-IADI U1254, Vandœuvre lès-Nancy, France
| | - Nefissa Hammache
- Département de Cardiologie, Centre Hospitalier Universitaire (CHU de Nancy), Vandœuvre lès-Nancy, France.,INSERM-IADI U1254, Vandœuvre lès-Nancy, France
| | - Mathieu Echivard
- Département de Cardiologie, Centre Hospitalier Universitaire (CHU de Nancy), Vandœuvre lès-Nancy, France
| | - Francis Marchlinski
- Division of Cardiovascular Medicine, Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Christian de Chillou
- Département de Cardiologie, Centre Hospitalier Universitaire (CHU de Nancy), Vandœuvre lès-Nancy, France.,INSERM-IADI U1254, Vandœuvre lès-Nancy, France
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31
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Iannaccone M, Nombela-Franco L, Gallone G, Annone U, Di Marco A, Giannini F, Ayoub M, Sardone A, Amat-Santos I, Fernandez-Lozano I, Barbero U, Dusi V, Toselli M, Petretta A, de Salvia A, Boccuzzi G, Colangelo S, Anguera I, D'Ascenzo F, Colombo A, De Ferrari GM, Escaned J, Garbo R, Mashayekhi K. Impact of successful chronic coronary total occlusion recanalization on recurrence of ventricular arrhythmias in implantable cardioverter-defibrillator recipients for ischemic cardiomyopathy (VACTO PCI study). CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 43:104-111. [DOI: 10.1016/j.carrev.2022.03.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/22/2022] [Accepted: 03/28/2022] [Indexed: 12/11/2022]
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32
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Arsenos P, Gatzoulis KA, Tsiachris D, Dilaveris P, Sideris S, Sotiropoulos I, Archontakis S, Antoniou CK, Kordalis A, Skiadas I, Toutouzas K, Vlachopoulos C, Tousoulis D, Tsioufis K. Arrhythmic risk stratification in ischemic, non-ischemic and hypertrophic cardiomyopathy: A two-step multifactorial, electrophysiology study inclusive approach. World J Cardiol 2022; 14:139-151. [PMID: 35432775 PMCID: PMC8968455 DOI: 10.4330/wjc.v14.i3.139] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 10/28/2021] [Accepted: 02/23/2022] [Indexed: 02/06/2023] Open
Abstract
Annual arrhythmic sudden cardiac death ranges from 0.6% to 4% in ischemic cardiomyopathy (ICM), 1% to 2% in non-ischemic cardiomyopathy (NICM), and 1% in hypertrophic cardiomyopathy (HCM). Towards a more effective arrhythmic risk stratification (ARS) we hereby present a two-step ARS with the usage of seven non-invasive risk factors: Late potentials presence (≥ 2/3 positive criteria), premature ventricular contractions (≥ 30/h), non-sustained ventricular tachycardia (≥ 1episode/24 h), abnormal heart rate turbulence (onset ≥ 0% and slope ≤ 2.5 ms) and reduced deceleration capacity (≤ 4.5 ms), abnormal T wave alternans (≥ 65μV), decreased heart rate variability (SDNN < 70ms), and prolonged QTc interval (> 440 ms in males and > 450 ms in females) which reflect the arrhythmogenic mechanisms for the selection of the intermediate arrhythmic risk patients in the first step. In the second step, these intermediate-risk patients undergo a programmed ventricular stimulation (PVS) for the detection of inducible, truly high-risk ICM and NICM patients, who will benefit from an implantable cardioverter defibrillator. For HCM patients, we also suggest the incorporation of the PVS either for the low HCM Risk-score patients or for the patients with one traditional risk factor in order to improve the inadequate sensitivity of the former and the low specificity of the latter.
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Affiliation(s)
- Petros Arsenos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
| | - Konstantinos A Gatzoulis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece.
| | | | - Polychronis Dilaveris
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
| | - Skevos Sideris
- Department of Cardiology, Hippokration Hospital, Athens 11527, Attika, Greece
| | - Ilias Sotiropoulos
- Department of Cardiology, Hippokration Hospital, Athens 11527, Attika, Greece
| | | | | | - Athanasios Kordalis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
| | - Ioannis Skiadas
- Fifth Department of Cardiology, Hygeia Hospital, Marousi 15123, Attika, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
| | - Charalambos Vlachopoulos
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, National and Kapodistrian University of Athens, Hippokration Hospital, Athens 11527, Attika, Greece
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33
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Kao PH, Chung FP, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Chao TF, Liao JN, Lin CY, Chang TY, Kuo L, Wu CI, Liu CM, Liu SH, Cheng WH, Lin L, Ton AKN, Hsu CY, Chhay C, Chen SA. Application of Ensite TM LiveView Function for Identification of Scar-related Ventricular Tachycardia Isthmus. J Cardiovasc Electrophysiol 2022; 33:1223-1233. [PMID: 35304796 DOI: 10.1111/jce.15455] [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: 01/10/2022] [Revised: 02/24/2022] [Accepted: 03/10/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Dynamic display of real-time wavefront activation pattern may facilitate the recognition of reentrant circuits, particularly the diastolic path of ventricular tachycardia (VT). OBJECTIVE We aimed to evaluate the feasibility of LiveView Dynamic Display for mapping the critical isthmus of scar-related reentrant VT. METHODS Patients with mappable scar-related reentrant VT were selected. The characteristics of the underlying substrates and VT circuits were assessed using HD grid multi-electrode catheter. The VT isthmuses were identified based on the activation map, entrainment, and ablation results. The accuracy of the LiveView findings in detecting potential VT isthmus was assessed. RESULTS We studied 18 scar-related reentrant VTs in 10 patients (median age: 59.5 years, 100% male) including 6 and 4 patients with ischemic and non-ischemic cardiomyopathy, respectively. The median VT cycle length was 426 ms (interquartile range: 386-466 ms). Among 590 regional mapping displays, 92.0% of the VT isthmus sites were identified by LiveView Dynamic Display. The accuracy of LiveView for isthmus identification was 84%, with positive and negative predictive values of 54.8% and 97.8%, respectively. The area with abnormal electrograms was negatively correlated with the accuracy of LiveView Dynamic Display (r = -0.506, p = 0.027). The median time interval to identify a VT isthmus using LiveView was significantly shorter than that using conventional activation maps (50.5 [29.8-120] vs. 219 [157.5-400.8] s, p = 0.015). CONCLUSION This study demonstrated the feasibility of LiveView Dynamic Display in identifying the critical isthmus of scar-related VT with modest accuracy. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Pei-Heng Kao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan
| | - Fa-Po Chung
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Lin Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Li-Wei Lo
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-Feng Hu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ta-Chuan Tuan
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tze-Fan Chao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jo-Nan Liao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chin-Yu Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ting-Yung Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ling Kuo
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-I Wu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chih-Min Liu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shin-Huei Liu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Han Cheng
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Linda Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - An Khanh-Nu Ton
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chu-Yu Hsu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chheng Chhay
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Ann Chen
- Department of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Cardiovascular center, Taichung Veterans General Hospital, Taichung, Taiwan
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Cetin M, Ornek E, Bastug S, Kara M, Deveci B, Korkmaz A, Ozeke O, Cay S, Ozcan F, Topaloglu S, Aras D. An Incessant Tachycardia with Alternating QRS Complexes: What Is the Mechanism? J Innov Card Rhythm Manag 2022; 13:4900-4904. [PMID: 35251760 PMCID: PMC8887927 DOI: 10.19102/icrm.2022.130203] [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: 07/16/2021] [Accepted: 08/02/2021] [Indexed: 11/15/2022] Open
Abstract
We present a patient with ischemic cardiomyopathy who had ventricular tachycardia (VT) with QRS morphology alternans. The electrophysiological findings, in this case, supported the occurrence of antegrade activation of the proximal His–Purkinje system during VT, with the ultimate electrocardiogram morphology dependent on fusion from intramyocardial and His–Purkinje activations.
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Affiliation(s)
- Mustafa Cetin
- Department of Cardiology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Ender Ornek
- Department of Cardiology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Serdal Bastug
- Department of Cardiology, Ankara Yıldırım Beyazıt University School of Medicine, Ankara City Hospital, Ankara, Turkey
| | - Meryem Kara
- Department of Cardiology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Bulent Deveci
- Department of Cardiology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Ahmet Korkmaz
- Department of Cardiology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Ozcan Ozeke
- Department of Cardiology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Serkan Cay
- Department of Cardiology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Firat Ozcan
- Department of Cardiology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Serkan Topaloglu
- Department of Cardiology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Dursun Aras
- Department of Cardiology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
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35
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Armbruster AL, Campbell KB, Kahanda MG, Cuculich PS. The role of inflammation in the pathogenesis and treatment of arrhythmias. Pharmacotherapy 2022; 42:250-262. [PMID: 35098555 DOI: 10.1002/phar.2663] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 11/30/2021] [Accepted: 12/03/2021] [Indexed: 12/20/2022]
Abstract
The pathogenesis of arrhythmias is complex and multifactorial. The role of inflammation in the pathogenesis of both atrial and ventricular arrhythmias (VA) has been explored. However, developing successful pharmacotherapy regimens based on those pathways has proven more of a challenge. This narrative review provides an overview of five common arrhythmias impacted by inflammation, including atrial fibrillation (AF), myocardial infarction, arrhythmogenic cardiomyopathy, cardiac sarcoidosis, and QT prolongation, and the potential role for anti-inflammatory therapy in their management. We identified arrhythmias and arrhythmogenic disease states with the most evidence linking pathogenesis to inflammation and conducted comprehensive searches of United States National Library of Medicine MEDLINE® and PubMed databases. Although a variety of agents have been studied for the management of AF, primarily in an effort to reduce postoperative AF following cardiac surgery, no standard anti-inflammatory agents are used in clinical practice at this time. Although inflammation following myocardial infarction may contribute to the development of VA, there is no clear benefit with the use of anti-inflammatory agents at this time. Similarly, although inflammation is clearly linked to the development of arrhythmias in arrhythmogenic cardiomyopathy, data demonstrating a benefit with anti-inflammatory agents are limited. Cardiac sarcoidosis, an infiltrative disease eliciting an immune response, is primarily treated by immunosuppressive therapy and steroids, despite a lack of primary literature to support such regimens. In this case, anti-inflammatory agents are frequently used in clinical practice. The pathophysiology of arrhythmias is complex, and inflammation likely plays a role in both onset and duration, however, for most arrhythmias the role of pharmacotherapy targeting inflammation remains unclear.
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Affiliation(s)
- Anastasia L Armbruster
- St. Louis College of Pharmacy, University of Health Sciences and Pharmacy in St. Louis, St. Louis, Missouri, USA
| | | | - Milan G Kahanda
- Cardiovascular Division, Department of Internal Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Phillip S Cuculich
- Cardiovascular Division, Department of Internal Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
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Heterogeneous repolarization creates ventricular tachycardia circuits in healed myocardial infarction scar. Nat Commun 2022; 13:830. [PMID: 35149693 PMCID: PMC8837660 DOI: 10.1038/s41467-022-28418-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 01/14/2022] [Indexed: 11/30/2022] Open
Abstract
Arrhythmias originating in scarred ventricular myocardium are a major cause of death, but the underlying mechanism allowing these rhythms to exist remains unknown. This gap in knowledge critically limits identification of at-risk patients and treatment once arrhythmias become manifest. Here we show that potassium voltage-gated channel subfamily E regulatory subunits 3 and 4 (KCNE3, KCNE4) are uniquely upregulated at arrhythmia sites within scarred myocardium. Ventricular arrhythmias occur in areas with a distinctive cardiomyocyte repolarization pattern, where myocyte tracts with short repolarization times connect to myocytes tracts with long repolarization times. We found this unique pattern of repolarization heterogeneity only in ventricular arrhythmia circuits. In contrast, conduction abnormalities were ubiquitous within scar. These repolarization heterogeneities are consistent with known functional effects of KCNE3 and KCNE4 on the slow delayed-rectifier potassium current. We observed repolarization heterogeneity using conventional cardiac electrophysiologic techniques that could potentially translate to identification of at-risk patients. The neutralization of the repolarization heterogeneities could represent a potential strategy for the elimination of ventricular arrhythmia circuits. Ventricular arrhythmias after heart attack are a leading cause of death. Here the authors show, in a porcine model, that KCNE3 and KCNE4 upregulation and a unique pattern of repolarization heterogeneity in the scar facilitate reentrant ventricular tachycardia.
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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: 36] [Impact Index Per Article: 12.0] [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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Kahle AK, Jungen C, Alken FA, Scherschel K, Willems S, Pürerfellner H, Chen S, Eckardt L, Meyer C. Management of ventricular tachycardia in patients with ischaemic cardiomyopathy: contemporary armamentarium. Europace 2021; 24:538-551. [PMID: 34967892 DOI: 10.1093/europace/euab274] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Indexed: 01/10/2023] Open
Abstract
Worldwide, ∼4 million people die from sudden cardiac death every year caused in more than half of the cases by ischaemic cardiomyopathy (ICM). Prevention of sudden cardiac death after myocardial infarction by implantation of a cardioverter-defibrillator (ICD) is the most common, even though not curative, therapy to date. Optimized ICD programming should be strived for in order to decrease the incidence of ICD interventions. Catheter ablation reduces the recurrence of ventricular tachycardias (VTs) and is an important adjunct to sole ICD-based treatment or pharmacological antiarrhythmic therapy in patients with ICM, as conclusively demonstrated by seven randomized controlled trials (RCTs) in the last two decades. However, none of the conducted trials was powered to reveal a survival benefit for ablated patients as compared to controls. Whereas thorough consideration of an early approach is necessary following two recent RCTs (PAUSE-SCD, BERLIN VT), catheter ablation is particularly recommended in patients with recurrent VT after ICD therapy. In this context, novel, pathophysiologically driven ablation strategies referring to deep morphological and functional substrate phenotyping based on high-resolution mapping and three-dimensional visualization of scars appear promising. Emerging concepts like sympathetic cardiac denervation as well as radioablation might expand the therapeutical armamentarium especially in patients with therapy-refractory VT. Randomized controlled trials are warranted and on the way to investigate how these translate into improved patient outcome. This review summarizes therapeutic strategies currently available for the prevention of VT recurrences, the optimal timing of applicability, and highlights future perspectives after a PAUSE in BERLIN.
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Affiliation(s)
- Ann-Kathrin Kahle
- Division of Cardiology, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217 Düsseldorf, Germany.,Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Medical Faculty, Universitätsstrasse 1, 40225 Düsseldorf, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany
| | - Christiane Jungen
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany.,Clinic for Cardiology, University Heart & Vascular Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.,Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Fares-Alexander Alken
- Division of Cardiology, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217 Düsseldorf, Germany.,Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Medical Faculty, Universitätsstrasse 1, 40225 Düsseldorf, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany
| | - Katharina Scherschel
- Division of Cardiology, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217 Düsseldorf, Germany.,Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Medical Faculty, Universitätsstrasse 1, 40225 Düsseldorf, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany
| | - Stephan Willems
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany.,Department of Cardiology and Internal Intensive Care Medicine, Asklepios Hospital St. Georg, Lohmühlenstrasse 5, 20099 Hamburg, Germany
| | - Helmut Pürerfellner
- Department of Electrophysiology, Academic Teaching Hospital, Ordensklinikum Linz Elisabethinen, Fadingerstraße 1, 4020 Linz, Austria
| | - Shaojie Chen
- Cardioangiologisches Centrum Bethanien (CCB), Frankfurt Academy For Arrhythmias (FAFA), Kardiologie, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Wilhelm-Epstein Straße 4, 60431 Frankfurt am Main, Germany
| | - Lars Eckardt
- Department for Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Christian Meyer
- Division of Cardiology, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217 Düsseldorf, Germany.,Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Medical Faculty, Universitätsstrasse 1, 40225 Düsseldorf, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany
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Tong L, Zhao C, Fu Z, Dong R, Wu Z, Wang Z, Zhang N, Wang X, Cao B, Sun Y, Zheng D, Xia L, Deng D. Preliminary Study: Learning the Impact of Simulation Time on Reentry Location and Morphology Induced by Personalized Cardiac Modeling. Front Physiol 2021; 12:733500. [PMID: 35002750 PMCID: PMC8739986 DOI: 10.3389/fphys.2021.733500] [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] [Received: 06/30/2021] [Accepted: 11/30/2021] [Indexed: 11/13/2022] Open
Abstract
Personalized cardiac modeling is widely used for studying the mechanisms of cardiac arrythmias. Due to the high demanding of computational resource of modeling, the arrhythmias induced in the models are usually simulated for just a few seconds. In clinic, it is common that arrhythmias last for more than several minutes and the morphologies of reentries are not always stable, so it is not clear that whether the simulation of arrythmias for just a few seconds is long enough to match the arrhythmias detected in patients. This study aimed to observe how long simulation of the induced arrhythmias in the personalized cardiac models is sufficient to match the arrhythmias detected in patients. A total of 5 contrast enhanced MRI datasets of patient hearts with myocardial infarction were used in this study. Then, a classification method based on Gaussian mixture model was used to detect the infarct tissue. For each reentry, 3 s and 10 s were simulated. The characteristics of each reentry simulated for different duration were studied. Reentries were induced in all 5 ventricular models and sustained reentries were induced at 39 stimulation sites in the model. By analyzing the simulation results, we found that 41% of the sustained reentries in the 3 s simulation group terminated in the longer simulation groups (10 s). The second finding in our simulation was that only 23.1% of the sustained reentries in the 3 s simulation did not change location and morphology in the extended 10 s simulation. The third finding was that 35.9% reentries were stable in the 3 s simulation and should be extended for the simulation time. The fourth finding was that the simulation results in 10 s simulation matched better with the clinical measurements than the 3 s simulation. It was shown that 10 s simulation was sufficient to make simulation results stable. The findings of this study not only improve the simulation accuracy, but also reduce the unnecessary simulation time to achieve the optimal use of computer resources to improve the simulation efficiency and shorten the simulation time to meet the time node requirements of clinical operation on patients.
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Affiliation(s)
- Lv Tong
- School of Biomedical Engineering, Dalian University of Technology, Dalian, China
| | - Caiming Zhao
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhenyin Fu
- College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Ruiqing Dong
- Department of Cardiology, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
| | - Zhenghong Wu
- College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Zefeng Wang
- Department of Cardiology, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing, China
| | - Nan Zhang
- Department of Radiology, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing, China
| | - Xinlu Wang
- Department of Cardiology, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing, China
| | - Boyang Cao
- School of Biomedical Engineering, Dalian University of Technology, Dalian, China
| | - Yutong Sun
- School of Biomedical Engineering, Dalian University of Technology, Dalian, China
| | - Dingchang Zheng
- Research Centre for Intelligent Healthcare, Faculty of Health and Life Science, Coventry University, Coventry, United Kingdom
| | - Ling Xia
- College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Dongdong Deng
- School of Biomedical Engineering, Dalian University of Technology, Dalian, China
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Limitations and Pitfalls of Substrate Mapping for Ventricular Tachycardia. JACC Clin Electrophysiol 2021; 7:542-560. [PMID: 33888275 DOI: 10.1016/j.jacep.2021.02.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/08/2021] [Accepted: 02/08/2021] [Indexed: 12/11/2022]
Abstract
The fundamental hypothesis of substrate mapping for scar-mediated ventricular tachycardia is that surrogates of the isthmus can be identified and targeted with ablation during sinus rhythm. These surrogates include electrocardiographic indications for electric discontinuity such as fractionation, split, late, and long potentials, also evident as sites displaying activation slowing. However, ablation strategies targeting these surrogates during sinus rhythm have resulted in unacceptably high rates of clinical failures, promoting the idea that a more widespread ablation may be required. High-resolution mapping technologies provide an opportunity to examine the substrate at greater detail; however, their use has not yet translated into improved clinical outcomes. This may be related to ongoing efforts to examine the same surrogates at higher resolution instead of using high-resolution technologies for discovering new and potentially more specific surrogates. This article reviews common limitations and pitfalls of substrate mapping and discusses new opportunities for high-resolution mapping to increase the accuracy of substrate mapping: 1) multielectrode mapping catheters provide an opportunity to rapidly examine the substrate during electrophysiological conditions that more closely simulate ventricular tachycardia by means of activation from different directions and coupling intervals; 2) electrogram annotation methods based on the maximal negative derivative of the extracellular potential or maximal voltage are often inaccurate in nonuniform anisotropic tissue. The use of multielectrode catheters may improve the accuracy of electrogram annotation by using spatiotemporal dispersion of single-beat acquisitions and a localized indifferent reference; and 3) resetting and entrainment remain important methods for studying re-entry for and guiding ablation.
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High density mapping guided partial antral ablation for a pulmonary vein isolation. Sci Rep 2021; 11:16563. [PMID: 34400711 PMCID: PMC8367962 DOI: 10.1038/s41598-021-96004-4] [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: 04/11/2021] [Accepted: 07/23/2021] [Indexed: 11/12/2022] Open
Abstract
The muscular discontinuities at the pulmonary vein (PV)–left atrial (LA) junction are known. The high-density mapping may help to find the muscular discontinuity. This study evaluated the efficacy of a partial antral ablation for a pulmonary vein (PV) isolation using high density (HD) mapping. A total of 60 drug-refractory atrial fibrillation (AF) patients undergoing catheter ablation were enrolled. The detailed activation mapping of each PV and LA junction was performed using an HD mapping system, and each PV segment’s activation pattern was classified into a “directly-activated from the LA” or “passively-activated from an adjacent PV segment” pattern. The antral ablations were performed at the directly-activated PV segments only when the PV had “passively-activated segments”. If the PV did not contain passively-activated segments, a circumferential antral ablation was performed on those PVs. A “successful partial antral ablation” was designated if the electrical isolation of targeted PV was achieved by ablation at the directly-activated segments only. If the isolation was not achieved even though all directly-activated segments were ablated, a “failed partial antral ablation” was designated, and then a circumferential ablation was performed. Among 240 PVs, passively-activated segments were observed in 140 (58.3%) PVs. Both inferior PVs had more passively-activated segments than superior PVs, and the posteroinferior segments had the highest proportion of passive activation. The overall rate of successful partial antral ablation was 85%. The atrial tachyarrhythmia recurrence was observed in 10 patients (16.7%) at 1-year. HD mapping allowed the evaluation of the detailed activation patterns of the PVs, and passively-activated segments may represent muscular discontinuity. Partial antral ablation of directly-activated antral segments only was feasible and effective for a PVI.
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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: 9] [Impact Index Per Article: 2.3] [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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Varma N. Perimitral ventricular tachycardia associated with remote inferior myocardial infarction. J Cardiovasc Electrophysiol 2021; 32:2228-2237. [PMID: 34191359 DOI: 10.1111/jce.15143] [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: 03/06/2021] [Revised: 05/31/2021] [Accepted: 06/18/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Circuits underlying ventricular tachycardias (VTs) accompanying remote inferior myocardial infarction (IMI) are regarded to be located in the scar. Rotation around the mitral annulus (MA) had also been postulated. We tested whether entrainment mapping could confirm whether MA rotation in VTs post-IMI represented a "driving circuit." METHODS Three patients with IMI (male, left ventricular ejection fraction range 13%-40%) with hemodynamically tolerated VT (cycle length 365-690 ms) were studied with activation and entrainment mapping of the MA. RESULTS Patients showed QRS morphologies reported for VTs following IMI: LBBB (left bundle branch block) pattern and/or right bundle pattern. Entrainment revealed the entire MA perimeter constituted the circuit, that is, macroreentry (path length greater than 13 cm in one case). Areas showing prolonged fractionated electrograms (accounting for over 50% of tachycardia cycle length) demonstrated concealed entrainment indicative of slow conduction through (and not around) the scar. Concealed entrainment was observed along the MA, with similar stimulus-QRS intervals when pacing during normal sinus rhythm. Radiofrequency ablation of the inferior isthmus from scar to MA (epicardially in one case) abolished tachycardia. In follow-up, two patients had no VT recurrence and maintained NYHA Class 1 functional status during several years of follow-up. The other patient continued to deteriorate with rapidly progressive HF, had recurrent VT within 3 months, proceeding to transplant within 9 months. Our findings confirm a single-loop perimitral circuit, which is largely (if not exclusively) protected by anatomical barriers. This differs from the established "figure-of-8" VT model. CONCLUSION Single-loop macroreentrant mitral annular circuits may underlie some VTs following inferior wall infarcts.
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Affiliation(s)
- Niraj Varma
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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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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Nishimura T, Upadhyay GA, Aziz ZA, Beaser AD, Shatz DY, Nayak HM, Tung R. Double loop ventricular tachycardia activation patterns with single loop mechanisms: Asymmetric entrainment responses during "pseudo-figure-of-eight" reentry. Heart Rhythm 2021; 18:1548-1556. [PMID: 33965607 DOI: 10.1016/j.hrthm.2021.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/19/2021] [Accepted: 05/03/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The classical paradigm of scar-related reentrant ventricular tachycardia (VT) features a circuit with a double loop figure-of-eight (F8) activation pattern. OBJECTIVE The purpose of this study was to interrogate VT circuits with F8 activation patterns by entrainment mapping to differentiate an active loop from a passive loop. METHODS Sixty VT circuits with >90% of tachycardia cycle length delineated in high resolution were retrospectively analyzed in 55 patients (nonischemic 49%). A pseudo-F8 VT circuit was defined as a double loop activation pattern driven by a single loop mechanism with a passive loop that yields a long postpacing interval (postpacing interval - tachycardia cycle length ≥ 30 ms). RESULTS Single loop activation patterns were observed in 33% (n = 20). Of 40 circuits with F8 patterns by activation mapping, 20 were studied with entrainment mapping, where a passive loop was identified by a long postpacing interval in 50%. In 6 circuits where entrainment mapping was performed from both outer loop regions, all demonstrated asymmetric responses to entrainment, confirming a single loop mechanism. Entrainment from both lateral margins of the common pathway (n = 7) demonstrated an asymmetric response in 29%. In all pseudo-F8 circuits (n = 10), the shorter loop functioned as the active loop and ablation targeting the active loop side of the isthmus resulted in VT termination with a single radiofrequency application. CONCLUSION In a selected cohort, single loop mechanisms are more prevalent than double loop reentry in reentrant human VT. Half of VT circuits with double loop activation patterns can be demonstrated to be sustained by a single active loop mechanism by entrainment mapping. Ablation targeting the shorter active loop resulted in rapid termination during radiofrequency application.
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Affiliation(s)
- Takuro Nishimura
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Gaurav A Upadhyay
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Zaid A Aziz
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Andrew D Beaser
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Dalise Y Shatz
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Hemal M Nayak
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Roderick Tung
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois.
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Papageorgiou N, Srinivasan NT. Dynamic High-density Functional Substrate Mapping Improves Outcomes in Ischaemic Ventricular Tachycardia Ablation: Sense Protocol Functional Substrate Mapping and Other Functional Mapping Techniques. Arrhythm Electrophysiol Rev 2021; 10:38-44. [PMID: 33936742 PMCID: PMC8076974 DOI: 10.15420/aer.2020.28] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Post-infarct-related ventricular tachycardia (VT) occurs due to reentry over surviving fibres within ventricular scar tissue. The mapping and ablation of patients in VT remains a challenge when VT is poorly tolerated and in cases in which VT is non-sustained or not inducible. Conventional substrate mapping techniques are limited by the ambiguity of substrate characterisation methods and the variety of mapping tools, which may record signals differently based on their bipolar spacing and electrode size. Real world data suggest that outcomes from VT ablation remain poor in terms of freedom from recurrent therapy using conventional techniques. Functional substrate mapping techniques, such as single extrastimulus protocol mapping, identify regions of unmasked delayed potentials, which, by nature of their dynamic and functional components, may play a critical role in sustaining VT. These methods may improve substrate mapping of VT, potentially making ablation safer and more reproducible, and thereby improving the outcomes. Further large-scale studies are needed.
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Affiliation(s)
- Nikolaos Papageorgiou
- Department of Cardiac Electrophysiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Neil T Srinivasan
- Department of Cardiac Electrophysiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK.,Institute of Cardiovascular Science, University College London, London, UK.,Department of Cardiac Electrophysiology, Essex Cardiothoracic Centre, Basildon, UK
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Yamabe H, Kajiyama K, Soejima T, Fukami Y, Haraguchi K, Okonogi T, Hirai K, Fukuoka R, Orita Y, Umeji K, Koga H, Kawasaki T. Comparison of the catheter ablation outcome in patients between targeting the entrance and exit of the reentry circuit in verapamil-sensitive atrial tachycardia originating from the atrioventricular-node vicinity. Heart Vessels 2021; 36:1201-1211. [PMID: 33512600 DOI: 10.1007/s00380-021-01791-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 01/15/2021] [Indexed: 10/22/2022]
Abstract
Verapamil-sensitive atrial tachycardia originating from the atrioventricular node vicinity (AVN-AT) can be eliminated with radiofrequency energy (RF) deliveries targeting either the entrance or exit of its reentry circuit. However, the outcome of these different approaches has not been clarified well. Thus, we compared the catheter ablation outcome targeting the entrance of reentry circuit, identified by the entrainment method (Ent-Group; 21 patients) with that targeting the earliest atrial activation site (EAAS) during AT (Exit-Group; 16 patients). There was no significant difference in the tachycardia cycle length (441.4 ± 87.4 vs. 392.8 ± 64.8 ms, p = 0.0704) or distance from the His bundle (HB) site to the EAAS (6.5 ± 2.0 vs. 7.6 ± 1.8 mm, p = 0.0822) between the Ent- and Exit-Groups. However, distance from the successful ablation site to the HB site in the Ent-Group was significantly longer than that in the Exit-Group (13.4 ± 3.1 vs. 7.6 ± 1.8 mm, p < 0.0001), resulting in more frequent transient atrioventricular block episodes in the Exit-Group than Ent-Group (31.3 vs. 0%, p < 0.01). Initial ATs (AT1s) were terminated in all patients in both Groups. However, ATs accompanied by shifting in the EAAS (AT2) were induced more frequently in the Exit-Group than Ent-Group (50.0 vs. 14.3%, p < 0.02) after eliminating AT1. RF deliveries to the EAAS eliminated all AT2s. The number of RF deliveries was greater in the Exit-Group than Ent-Group (6.9 ± 3.3 vs. 3.9 ± 1.6, p < 0.001). In conclusion, RF ablation targeting the entrance sites can avoid AVN injury and is superior in reducing the number of RF deliveries and occurrence of different ATs than targeting the exit sites in the AVN-AT.
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Affiliation(s)
- Hiroshige Yamabe
- Department of Cardiology, Cardiovascular Center, Shin-Koga Hospital, 120, Tenjin-cho, Kurume City, Fukuoka, 830-8577, Japan.
| | - Kimihiro Kajiyama
- Department of Cardiology, Cardiovascular Center, Shin-Koga Hospital, 120, Tenjin-cho, Kurume City, Fukuoka, 830-8577, Japan
| | - Toshiya Soejima
- Department of Cardiology, Cardiovascular Center, Shin-Koga Hospital, 120, Tenjin-cho, Kurume City, Fukuoka, 830-8577, Japan
| | - Yurie Fukami
- Department of Cardiology, Cardiovascular Center, Shin-Koga Hospital, 120, Tenjin-cho, Kurume City, Fukuoka, 830-8577, Japan
| | - Kazuki Haraguchi
- Department of Cardiology, Cardiovascular Center, Shin-Koga Hospital, 120, Tenjin-cho, Kurume City, Fukuoka, 830-8577, Japan
| | - Taichi Okonogi
- Department of Cardiology, Cardiovascular Center, Shin-Koga Hospital, 120, Tenjin-cho, Kurume City, Fukuoka, 830-8577, Japan
| | - Keisuke Hirai
- Department of Cardiology, Cardiovascular Center, Shin-Koga Hospital, 120, Tenjin-cho, Kurume City, Fukuoka, 830-8577, Japan
| | - Ryota Fukuoka
- Department of Cardiology, Cardiovascular Center, Shin-Koga Hospital, 120, Tenjin-cho, Kurume City, Fukuoka, 830-8577, Japan
| | - Yoshiya Orita
- Department of Cardiology, Cardiovascular Center, Shin-Koga Hospital, 120, Tenjin-cho, Kurume City, Fukuoka, 830-8577, Japan
| | - Kyoko Umeji
- Department of Cardiology, Cardiovascular Center, Shin-Koga Hospital, 120, Tenjin-cho, Kurume City, Fukuoka, 830-8577, Japan
| | - Hisashi Koga
- Department of Cardiology, Cardiovascular Center, Shin-Koga Hospital, 120, Tenjin-cho, Kurume City, Fukuoka, 830-8577, Japan
| | - Tomohiro Kawasaki
- Department of Cardiology, Cardiovascular Center, Shin-Koga Hospital, 120, Tenjin-cho, Kurume City, Fukuoka, 830-8577, Japan
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Campos FO, Orini M, Arnold R, Whitaker J, O'Neill M, Razavi R, Plank G, Hanson B, Porter B, Rinaldi CA, Gill J, Lambiase PD, Taggart P, Bishop MJ. Assessing the ability of substrate mapping techniques to guide ventricular tachycardia ablation using computational modelling. Comput Biol Med 2021; 130:104214. [PMID: 33476992 DOI: 10.1016/j.compbiomed.2021.104214] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 01/05/2021] [Accepted: 01/05/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Identification of targets for ablation of post-infarction ventricular tachycardias (VTs) remains challenging, often requiring arrhythmia induction to delineate the reentrant circuit. This carries a risk for the patient and may not be feasible. Substrate mapping has emerged as a safer strategy to uncover arrhythmogenic regions. However, VT recurrence remains common. GOAL To use computer simulations to assess the ability of different substrate mapping approaches to identify VT exit sites. METHODS A 3D computational model of the porcine post-infarction heart was constructed to simulate VT and paced rhythm. Electroanatomical maps were constructed based on endocardial electrogram features and the reentry vulnerability index (RVI - a metric combining activation (AT) and repolarization timings to identify tissue susceptibility to reentry). Since scar transmurality in our model was not homogeneous, parameters derived from all signals (including dense scar regions) were used in the analysis. Potential ablation targets obtained from each electroanatomical map during pacing were compared to the exit site detected during VT mapping. RESULTS Simulation data showed that voltage cut-offs applied to bipolar electrograms could delineate the scar, but not the VT circuit. Electrogram fractionation had the highest correlation with scar transmurality. The RVI identified regions closest to VT exit site but was outperformed by AT gradients combined with voltage cut-offs. The performance of all metrics was affected by pacing location. CONCLUSIONS Substrate mapping could provide information about the infarct, but the directional dependency on activation should be considered. Activation-repolarization metrics have utility in safely identifying VT targets, even with non-transmural scars.
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Affiliation(s)
- Fernando O Campos
- School of Biomedical Engineering and Imaging Sciences, Rayne Institute, 4th Floor, Lambeth Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom.
| | - Michele Orini
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Electrophysiology Department, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Robert Arnold
- Gottfried Schatz Research Center (for Cell Signaling, Metabolism and Aging), Division of Biophysics, Graz, Austria
| | - John Whitaker
- School of Biomedical Engineering and Imaging Sciences, Rayne Institute, 4th Floor, Lambeth Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom
| | - Mark O'Neill
- School of Biomedical Engineering and Imaging Sciences, Rayne Institute, 4th Floor, Lambeth Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom
| | - Reza Razavi
- School of Biomedical Engineering and Imaging Sciences, Rayne Institute, 4th Floor, Lambeth Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom
| | - Gernot Plank
- Gottfried Schatz Research Center (for Cell Signaling, Metabolism and Aging), Division of Biophysics, Graz, Austria
| | - Ben Hanson
- Department of Mechanical Engineering, University College London, London, United Kingdom
| | - Bradley Porter
- School of Biomedical Engineering and Imaging Sciences, Rayne Institute, 4th Floor, Lambeth Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom; Department of Cardiology, Guys and St Thomas' NHS Trust, London, United Kingdom
| | | | - Jaswinder Gill
- School of Biomedical Engineering and Imaging Sciences, Rayne Institute, 4th Floor, Lambeth Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom; Department of Cardiology, Guys and St Thomas' NHS Trust, London, United Kingdom
| | - Pier D Lambiase
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Electrophysiology Department, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Peter Taggart
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Electrophysiology Department, Barts Heart Centre, St Bartholomew's Hospital, London, United Kingdom
| | - Martin J Bishop
- School of Biomedical Engineering and Imaging Sciences, Rayne Institute, 4th Floor, Lambeth Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom
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49
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Ishidoya Y, Ranjan R. Novel Approaches to Risk Assessment for Ventricular Tachycardia Induction and Therapy. CURRENT CARDIOVASCULAR RISK REPORTS 2021. [DOI: 10.1007/s12170-020-00666-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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50
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Crinion D, Neira V, Al Hamad N, de Leon A, Bakker D, Korogyi A, Abdollah H, Glover B, Simpson C, Baranchuk A, Chacko S, Enriquez A, Redfearn D. Close-coupled pacing to identify the "functional" substrate of ventricular tachycardia: Long-term outcomes of the paced electrogram feature analysis technique. Heart Rhythm 2020; 18:723-731. [PMID: 33378703 DOI: 10.1016/j.hrthm.2020.12.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 12/09/2020] [Accepted: 12/22/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The conduction delay and block that compose the critical isthmus of macroreentrant ventricular tachycardia (VT) is partly "functional" in that they only occur at faster cycle lengths. Close-coupled pacing stresses the myocardium's conduction capacity and may reveal late potentials (LPs) and fractionation. Interest has emerged in targeting this functional substrate. OBJECTIVE The purpose of this study was to assess the feasibility and efficacy of a functional substrate VT ablation strategy. METHODS Patients with scar-related VT undergoing their first ablation were recruited. A closely coupled extrastimulus (ventricular effective refractory period + 30 ms) was delivered at the right ventricular apex while mapping with a high-density catheter. Sites of functional impaired conduction exhibited increased electrogram duration due to LPs/fractionation. The time to last deflection was annotated on an electroanatomic map, readily identifying ablation targets. RESULTS A total of 40 patients were recruited (34 [85%] ischemic). Median procedure duration was 330 minutes (interquartile range [IQR] 300-369), and ablation time was 49.4 minutes (IQR 33.8-48.3). Median functional substrate area was 41.9 cm2 (IQR 22.1-73.9). It was similarly distributed across bipolar voltage zones. Noninducibility was achieved in 34 of 40 patients (85%). Median follow-up was 711 days (IQR 255.5-972.8), during which 35 of 39 patients (89.7%) did not have VT recurrence, and 3 of 39 (7.5%) died. Antiarrhythmic drugs were continued in 53.8% (21/39). CONCLUSION Functional substrate ablation resulted in high rates of noninducibility and freedom from VT. Mapping times were increased considerably. Our findings add to the encouraging trend reported by related techniques. Randomized multicenter trials are warranted to assess this next phase of VT ablation.
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Affiliation(s)
- Derek Crinion
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | - Victor Neira
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | - Nasser Al Hamad
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | - Ana de Leon
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | - David Bakker
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | | | - Hoshiar Abdollah
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | - Ben Glover
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | - Christopher Simpson
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | - Adrian Baranchuk
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | - Sanoj Chacko
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | - Andres Enriquez
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | - Damian Redfearn
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada.
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