Dataset Information

Impact of chronic total coronary occlusion revascularisation on infarct-related myocardial scars responsible for recurrent ventricular tachycardia.

ABSTRACT:

Aims

The aim of this study was to determine whether revascularisation of an infarct-related artery chronic total occlusion (IRA-CTO) has a modulatory effect on myocardial scar composition.

Methods and results

This is a unique, first-time report of three consecutive patients presenting with myocardial scar-related recurrent ventricular tachycardia (rVT) on a background of ischaemic cardiomyopathy. Electro-anatomic mapping of the left ventricular endocardium was performed before and immediately after IRA-CTO percutaneous coronary intervention (PCI) to assess for changes in scar composition and size. There were substantial percentage reductions in the low voltage area of scar compared to baseline after IRA-CTO PCI (Patient 1: -12.8%, Patient 2: -27.0%, and Patient 3: -15.3%). Interval remapping ≥6 months after the index procedure demonstrated extensive net reductions in all areas of myocardial scar (Patient 1: dense scar =-7.5%, border zone scar =-54.9%, low voltage area =-32.7%, and Patient 2: dense scar =-38.6%, border zone scar =-59.6%, low voltage area =-51.7%). Patient 3 declined interval remapping but has remained free of rVT at one-year follow-up.

Conclusions

IRA-CTO PCI may positively modify the size and composition of myocardial scar associated with rVT in the context of ischaemic cardiomyopathy.

SUBMITTER: Myat A

PROVIDER: S-EPMC9725072 | biostudies-literature | 2021 Feb

REPOSITORIES: biostudies-literature

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Publications

Impact of chronic total coronary occlusion revascularisation on infarct-related myocardial scars responsible for recurrent ventricular tachycardia.

Myat Aung A Patel Mihir M Silberbauer John J Hildick-Smith David D

EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology 20210201 14

<h4>Aims</h4>The aim of this study was to determine whether revascularisation of an infarct-related artery chronic total occlusion (IRA-CTO) has a modulatory effect on myocardial scar composition.<h4>Methods and results</h4>This is a unique, first-time report of three consecutive patients presenting with myocardial scar-related recurrent ventricular tachycardia (rVT) on a background of ischaemic cardiomyopathy. Electro-anatomic mapping of the left ventricular endocardium was performed before and ...[more]

PMID: 31270033

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Project description:BackgroundWhether myocardial perfusion grade (MPG) following late recanalization of infarct-related arteries (IRAs) predicts left ventricular (LV) function recovery beyond the acute phase of myocardial infarction (MI) is unknown.Methods and resultsThe Total Occlusion Study of Canada-2 enrolled stable patients with a persistently occluded IRA beyond 24 hours and up to 28 days post-MI. We studied the relationship between the initial MPG and changes in LV function and volume as well as the change in MPG from immediate post-percutaneous coronary intervention (PCI) to 1 year in 139 PCI patients with thrombolysis in myocardial infarction grade 3 epicardial flow post-PCI and with paired values grouped into impaired or good MPG groups (MPG 0/1 or MPG 2/3). MPG 0/1 patients were more likely to have received thrombolytic therapy and to have a left anterior descending IRA. They had lower blood pressure and LV ejection fraction (LVEF) and a higher heart rate and systolic sphericity index at baseline. Changes in the MPG 0/1 and MPG 2/3 groups from baseline to 1 year were LVEF, 3.3±9.0% and 4.8±8.9% (P=0.42); LV end-systolic volume index (LVESVI), -1.1±9.2 and -4.7±12.3 mL/m(2) (P=0.25); LV end-diastolic volume index (LVEDVI), 0.08±19.1 and -2.4±22.2 mL/m(2) (P=0.67); and SDs/chord for infarct zone wall motion index (WMI), 0.38±0.70 and 0.84±1.11 (P=0.01). By covariate-adjusted analysis, post-PCI MPG 0/1 predicted lower WMI (P<0.001), lower LVEF (P<0.001), and higher LVESVI (P<0.01) but not LVEDVI at 1 year. Of the MPG 0/1 patients, 60% were MPG 2 or 3 at 1 year.ConclusionsPreserved MPG is present in a high proportion of patients following late PCI of occluded IRAs post-MI. Poor MPG post-PCI frequently improves MPG over 1 year. MPG graded after IRA recanalization undertaken days to weeks post MI is associated with LV recovery, indicating that MPG determined in the subacute post-MI period remains a marker of viability.Clinical trial registrationURL: http://www.clinicaltrials.gov. Unique identifier: NCT00025766.

Project description:In the chronic stage of myocardial infarction, a significant number of patients develop life-threatening ventricular tachycardias (VT) due to the arrhythmogenic nature of the remodeled myocardium. Radiofrequency ablation (RFA) is a common procedure to isolate reentry pathways across the infarct scar that are responsible for VT. Unfortunately, this strategy show relatively low success rates; up to 50% of patients experience recurrent VT after the procedure. In the last decade, intensive research in the field of computational cardiac electrophysiology (EP) has demonstrated the ability of three-dimensional (3D) cardiac computational models to perform in-silico EP studies. However, the personalization and modeling of certain key components remain challenging, particularly in the case of the infarct border zone (BZ). In this study, we used a clinical dataset from a patient with a history of infarct-related VT to build an image-based 3D ventricular model aimed at computational simulation of cardiac EP, including detailed patient-specific cardiac anatomy and infarct scar geometry. We modeled the BZ in eight different ways by combining the presence or absence of electrical remodeling with four different levels of image-based patchy fibrosis (0, 10, 20, and 30%). A 3D torso model was also constructed to compute the ECG. Patient-specific sinus activation patterns were simulated and validated against the patient's ECG. Subsequently, the pacing protocol used to induce reentrant VTs in the EP laboratory was reproduced in-silico. The clinical VT was induced with different versions of the model and from different pacing points, thus identifying the slow conducting channel responsible for such VT. Finally, the real patient's ECG recorded during VT episodes was used to validate our simulation results and to assess different strategies to model the BZ. Our study showed that reduced conduction velocities and heterogeneity in action potential duration in the BZ are the main factors in promoting reentrant activity. Either electrical remodeling or fibrosis in a degree of at least 30% in the BZ were required to initiate VT. Moreover, this proof-of-concept study confirms the feasibility of developing 3D computational models for cardiac EP able to reproduce cardiac activation in sinus rhythm and during VT, using exclusively non-invasive clinical data.

Dataset Information

Impact of chronic total coronary occlusion revascularisation on infarct-related myocardial scars responsible for recurrent ventricular tachycardia.

Aims

Methods and results

Conclusions

Publications

Impact of chronic total coronary occlusion revascularisation on infarct-related myocardial scars responsible for recurrent ventricular tachycardia.

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