Dataset Information

Electrophysiologic Scar Substrate in Relation to VT: Noninvasive High-Resolution Mapping and Risk Assessment with ECGI.

ABSTRACT: Ischemic cardiomyopathy (ICM) can provide the substrate for ventricular tachycardia (VT).To map noninvasively with high resolution the electrophysiologic (EP) scar substrate, identify its relationship to reentry circuits during VT, and stratify VT risk in ICM patients.Noninvasive high-resolution epicardial mapping with electrocardiographic imaging (ECGI) was performed in 32 ICM patients (17 with clinical VT, 15 without VT). Abnormal scar EP substrate was determined based on electrogram (EGM) amplitude (as percentage of maximal peak-to-peak voltage over the entire ventricular epicardium; total scar [TS] < 30%; dense scar [DS] < 15%), fractionation, and presence of late potentials (LPs). Scar burden was defined as the ratio of the scar size to the total epicardial surface area. The VT activation pattern was mapped and correlated with the EP substrate to identify components of the reentry circuit.Patients with VT had higher scar burden (TS: 51.0 ± 9.3% vs 36.5 ± 5.4%, P < 0.05; DS: 29.5 ± 7.3% vs 16.8 ± 6.8%, P < 0.05) with lower normalized unipolar EGM voltage (TS: 0.107 ± 0.027 vs 0.153 ± 0.031, P < 0.05; DS: 0.073 ± 0.023 vs 0.098 ± 0.026, P < 0.05), greater prevalence of fractionated EGMs (TS: 44.1 ± 10.6% vs 26.8 ± 6.3%, P < 0.05; DS: 50.8 ± 10.8% vs 30.9 ± 7.0%, P < 0.05), and LPs (TS: 26.8 ± 10.7% vs 15.8 ± 5.3, P < 0.05). VTs were mapped in eight patients; the reentry circuits were closely related to the EP substrate.ECGI noninvasively identified scar EP substrate that underlies abnormal conduction in ICM patients. It identified regions within the scar that aligned with critical elements of the reentry circuit during VT. ECGI can potentially be used for VT risk stratification in ICM patients.

SUBMITTER: Zhang J

PROVIDER: S-EPMC4970912 | biostudies-literature | 2016 Aug

REPOSITORIES: biostudies-literature

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Electrophysiologic Scar Substrate in Relation to VT: Noninvasive High-Resolution Mapping and Risk Assessment with ECGI.

Zhang Junjie J Cooper Daniel H DH Desouza Kavit A KA Cuculich Phillip S PS Woodard Pamela K PK Smith Timothy W TW Rudy Yoram Y

Pacing and clinical electrophysiology : PACE 20160606 8

<h4>Background</h4>Ischemic cardiomyopathy (ICM) can provide the substrate for ventricular tachycardia (VT).<h4>Objective</h4>To map noninvasively with high resolution the electrophysiologic (EP) scar substrate, identify its relationship to reentry circuits during VT, and stratify VT risk in ICM patients.<h4>Methods</h4>Noninvasive high-resolution epicardial mapping with electrocardiographic imaging (ECGI) was performed in 32 ICM patients (17 with clinical VT, 15 without VT). Abnormal scar EP su ...[more]

PMID: 27197804

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Project description:BackgroundDynamic functional substrate mapping of scar-related ventricular tachycardia offers better identification of ablation targets with limited ablation lesions. Several functional substrate mapping approaches have been proposed, including decrement-evoked potential (DEEP) mapping. The aim of our study was to compare the short- and long-term efficacy of a DEEP-guided versus a fixed-substrate-guided strategy for the ablation of scar-related ventricular tachycardia (VT).ResultsForty consecutive patients presenting for ablation of scar-related VT were randomized to either DEEP-guided or substrate-guided ablation. Late potentials were tagged and ablated in the non-DEEP group, while those in the DEEP group were subjected to RV extrastimulation after a drive train. Only potentials showing significant delay were ablated. Patients were followed for a median duration of 12 months. Twenty patients were allocated to the DEEP group, while the other 20 were allocated to the non-DEEP group. Twelve patients (60%) in the DEEP group had ischemic cardiomyopathy versus 10 patients (50%) in the non-DEEP group (P-value 0.525). Intraoperatively, the median percentage of points with LPs was 19% in the DEEP group and 20.6% in the non-DEEP group. The procedural time was longer in the DEEP group, approaching but missing statistical significance (P-value 0.059). VT non-inducibility was successfully accomplished in 16 patients (80%) in the DEEP group versus 17 patients (85%) in the non-DEEP group (P value 0.597). After a median follow-up duration of 12 months, the VT recurrence rate was 65% in both groups (P value 0.311), with a dropout rate of 10% in the DEEP group. As for the secondary endpoints, all-cause mortality rates were 20% and 25% in the DEEP and non-DEEP groups, respectively (P-value 0.342).ConclusionsDEEP-assisted ablation of scar-related ventricular tachycardia is a feasible strategy with comparable short- and long-term outcomes to a fixed-substrate-based strategy with more specific ablation targets, albeit relatively longer but non-significant procedural times and higher procedural deaths. The imbalance between the study groups in terms of epicardial versus endocardial mapping, although non-significant, warrants the prudent interpretation of our results. Further large-scale randomized trials are recommended.Trial registrationclinicaltrials.gov, registration number: NCT05086510, registered on 28th September 2021, record https://classic.Clinicaltrialsgov/ct2/show/NCT05086510.

Project description:BackgroundRecent advancements in a 3-dimensional mapping system allow for the assessment of detailed conduction properties during sinus rhythm and thus the establishment of a strategy targeting functionally abnormal regions in scar-related ventricular tachycardia (VT). We hypothesized that a rotational activation pattern (RAP) observed in maps during baseline rhythm was associated with the critical location of VT.MethodsWe retrospectively examined the pattern of wavefront propagation during sinus rhythm in patients with scar-related VT. The prevalence and features of the RAP on critical VT circuits were analyzed. RAP was defined as >90° of inward curvature directly above or at the edge of the slow conductive areas.ResultsForty-five VTs in 37 patients (66±15 years old, 89% male, 27% ischemic heart disease) were evaluated. High-density substrate mapping during sinus rhythm (median, 2524 points) was performed using the CARTO3 system before VT induction. Critical sites for reentry were identified by direct termination by radiofrequency catheter ablation in 21 VTs or by pace mapping in 12 VTs. Among them, RAP was present in 70% of the 33 VTs. Four VTs had no RAP at the critical sites during sinus rhythm, but it became visible in the mappings with different wavefront directions. Six VTs, in which intramural or epicardial isthmus was suspected, were rendered noninducible by radiofrequency catheter ablation to the endocardial surface without RAP. RAP had a sensitivity and specificity of 70% and 89%, respectively, for predicting the elements in the critical zone for VT.ConclusionsThe critical zone of VT appears to correspond to an area characterized by the RAP with slow conduction during sinus rhythm, which facilitates targeting areas specific for reentry. However, this may not be applicable to intramural VT substrates and might be affected by the direction of wavefront propagation to the scar during mapping. Graphic Abstract: A graphic abstract is available for this article.

Dataset Information

Electrophysiologic Scar Substrate in Relation to VT: Noninvasive High-Resolution Mapping and Risk Assessment with ECGI.

Publications

Electrophysiologic Scar Substrate in Relation to VT: Noninvasive High-Resolution Mapping and Risk Assessment with ECGI.

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