Ventricular activation mapping Dotaz Zobrazit nápovědu
BACKGROUND: The left ventricular (LV) lead local electrogram (EGM) delay from the beginning of the QRS complex (QLV) is considered a strong predictor of response to cardiac resynchronization therapy. We have developed a method for fast epicardial QLV mapping during video-thoracoscopic surgery to guide LV lead placement. METHODS: A three-port, video-thoracoscopic approach was used for LV free wall epicardial mapping and lead implantation. A decapolar electrophysiological catheter was introduced through one port and systematically attached to multiple accessible LV sites. The pacing lead was targeted to the site with maximum QLV. The LV free wall activation pattern was analyzed in 16 pre-specified anatomical segments. RESULTS: We implanted LV leads in 13 patients with LBBB or IVCD. The procedural and mapping times were 142 ± 39 minutes and 20 ± 9 minutes, respectively. A total of 15.0 ± 2.2 LV segments were mappable with variable spatial distribution of QLV-optimum. The QLV ratio (QLV/QRSd) at the optimum segment was significantly higher (by 0.17 ± 0.08, p < 0.00001) as compared to an empirical midventricular lateral segment. The LV lead was implanted at the optimum segment in 11 patients (at an adjacent segment in 2 patients) achieving a QLV ratio of 0.82 ± 0.09 (range 0.63-0.93) and 99.5 ± 0.6% match with intraprocedural mapping. CONCLUSION: Video-thoracoscopic LV lead implantation can be effectively and safely guided by epicardial QLV mapping. This strategy was highly successful in targeting the selected LV segment and resulted in significantly higher QLV ratios compared to an empirical midventricular lateral segment.
- MeSH
- blokáda Tawarova raménka diagnóza patofyziologie terapie MeSH
- časové faktory MeSH
- design vybavení MeSH
- epikardiální mapování * MeSH
- funkce levé komory srdeční MeSH
- hrudní chirurgie video-asistovaná * MeSH
- komorový tlak (srdce) MeSH
- lidé středního věku MeSH
- lidé MeSH
- perikard patofyziologie MeSH
- prediktivní hodnota testů MeSH
- prostředky srdeční resynchronizační terapie * MeSH
- senioři MeSH
- srdeční komory patofyziologie chirurgie MeSH
- srdeční resynchronizační terapie * škodlivé účinky MeSH
- studie proveditelnosti MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- hodnotící studie MeSH
BACKGROUND AND OBJECTIVES: Catheter ablation of ventricular tachycardia (VT) may include induction of VT and localization of VT-exit site. Our aim was to assess localization performance of a novel statistical pace-mapping method and compare it with performance of an electrocardiographic inverse solution. METHODS: Seven patients undergoing ablation of VT (4 with epicardial, 3 with endocardial exit) aided by electroanatomic mapping underwent intraprocedural 120-lead body-surface potential mapping (BSPM). Two approaches to localization of activation origin were tested: (1) A statistical method, based on multiple linear regression (MLR), which required only the conventional 12-lead ECG for a sufficient number of pacing sites with known origin together with patient-specific geometry of the endocardial/epicardial surface obtained by electroanatomic mapping; and (2) a classical deterministic inverse solution for recovering heart-surface potentials, which required BSPM and patient-specific geometry of the heart and torso obtained via computed tomography (CT). RESULTS: For the MLR method, at least 10-15 pacing sites with known coordinates, together with their corresponding 12-lead ECGs, were required to derive reliable patient-specific regression equations, which then enabled accurate localization of ventricular activation with unknown origin. For 4 patients who underwent epicardial mapping, the median of localization error for the MLR was significantly lower than that for the inverse solution (10.6 vs. 27.3 mm, P = 0.034); a similar result held for 3 patients who underwent endocardial mapping (7.7 vs. 17.1 mm, P = 0.017). The pooled localization error for all epicardial and endocardial sites was also significantly smaller for the MLR compared with the inverse solution (P = 0.005). CONCLUSIONS: The novel pace-mapping approach to localizing the origin of ventricular activation offers an easily implementable supplement and/or alternative to the preprocedure inverse solution; its simplicity makes it suitable for real-time applications during clinical catheter-ablation procedures.
- MeSH
- anatomické modely MeSH
- katetrizační ablace metody MeSH
- komorová tachykardie diagnostické zobrazování patofyziologie chirurgie MeSH
- lidé MeSH
- mapování potenciálů tělesného povrchu přístrojové vybavení metody MeSH
- modely kardiovaskulární * MeSH
- zobrazování trojrozměrné přístrojové vybavení metody MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
In stable ventricular tachycardia (VT), activation mapping and entrainment mapping are the most important strategies to describe the reentrant circuit and its critical components. In many patients, however, VT is noninducible or hemodynamically unstable and unmappable. Several technological advances have broadened ablation options in unmappable VTs. Preprocedural imaging and intraprocedural imaging play an important role in location and extent of the substrate. Electroanatomic mapping with several technological improvements allows more precise electrical assessment of the substrate. A combination of imaging and electroanatomic mapping allows substantial modification of arrhythmogenic substrate in sinus rhythm or during device pacing without hemodynamic compromise.
- MeSH
- algoritmy MeSH
- elektrofyziologické techniky kardiologické * MeSH
- elektrokardiografie MeSH
- infarkt myokardu * diagnostické zobrazování patofyziologie chirurgie MeSH
- kardiologické zobrazovací techniky MeSH
- katetrizační ablace * MeSH
- komorová tachykardie * diagnostické zobrazování patofyziologie chirurgie MeSH
- lidé MeSH
- magnetická rezonanční tomografie MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- přehledy MeSH
Incesantní formy komorových tachykardií (KT) po infarktu myokardu (IM) představují závažný terapeutický problém. Pacienti bývají často zajištěni implantovaným kardioverterem – defibrilátorem (ICD) a incesantní charakter arytmie vede obvykle k sérii výbojů, případně není arytmie pro svou pomalou frekvenci detekována. Cílem této studie je popis zkušeností s katetrizační ablací těchto arytmií za použití elektroanatomického mapování. Metody: V souboru 51 pacientů po katetrizační ablaci KT po IM pomocí elektroanatomického mapovacího systému bylo identifikováno 10 nemocných (muži, průměrný věk 65±12 let) s incesantní formou arytmie. U všech sledovaných byla zjištěna těžká poinfarktová dysfunkce levé komory srdeční (EF 23,0 ± 5,4 %). Vzhledem k incesantní formě arytmie bylo provedeno elektroanatomické mapování levé komory při KT a k ozřejmení kritického isthmu okruhu reentry bylo použito metody „entrainment mapping“. Po přerušení běžící KT byla provedena programovaná stimulace komor a v případě indukovatelnosti jiné formy KT bylo pokračováno v mapování při sinusovém rytmu. Byla vytvořena voltážová mapa dutiny levé komory s označením oblasti denzních jizev, pozdních potenciálů a pomalého vedení (integrovaný mapovací postup). Posléze byly provedeny léze napříč zónou exitu dalších KT. Výsledky: Incesantní KT se podařilo odstranit katetrizační ablací ve všech případech. U 7 nemocných bylo na konci výkonu dosaženo kompletního efektu – neindukovatelnosti KT. Průměrné trvání výkonu bylo 186,5 ± 79,7 min při skiaskopickém čase 5,7 ± 2,2 min. Jedinou komplikací bylo u jednoho nemocného krvácení z třísla s rozvojem pseudoaneurysmatu. U pacientů s nevyvolatelnou KT na konci výkonu byla zaznamenána recidiva jiné nebo stejné KT pouze ve 2 případech. U 3 nemocných s indukovatelnou jinou KT na konci výkonu došlo k sporadické recidivě arytmie ve 2 případech. Závěry: Elektroanatomický mapovací systém dovoluje u nemocných s incesantní formou KT rychlou orientaci o kritickém substrátu, podporuje úspěšnou a bezpečnou katetrizační ablaci a zároveň umožňuje díky integrovanému mapovacímu postupu následnou rozsáhlejší modifikaci arytmogenního substrátu. Tím přispívá k snížení výskytu dalších forem KT.
Incessant forms of ventricular tachycardia (VT) represent a significant therapeutic problem. Although the patients are often implanted with an implantable cardioverter-defibrillator (ICD), incessant character of arrhythmia commonly leads to multiple discharges and/or VT is not detected for its slow rate. The aim of this study is to present an experience with catheter ablation of these arrhythmias using electroanatomical mapping. Methods: In a cohort of 51 patients who underwent catheter ablation of postinfarction VT with an electroanatomical mapping system, 10 patients (all men, mean age 65±12 years) had incessant tachycardia. All had significant postinfarction dysfunction of the left ventricle (LVEF 23.0 ± 5.4%). The incessant character of VT enabled electroanatomical activation mapping of the left (or right) ventricle during tachycardia and entrainment mapping was used to identify the critical isthmus for re-entry circuit. After VT termination, programmed ventricular stimulation was performed. Whenever another VT was inducible, electroanatomical mapping was continued in sinus rhythm. The voltage map of the left (right) ventricle was constructed with annotation of scar regions, areas of late potentials and/or slow conduction (the so-called integrated mapping technique). Finally, radiofrequency lesions across the exit zones of VTs were produced. Results: Incessant VT was successfully terminated by catheter ablation in all cases. In 7 patients, the complete effect, i.e. non-inducibility of any VT, has been achieved. On average, the procedure lasted 186.5 ± 79.7 mins with a fluoroscopy time of 5.7 ± 2.2 mins. The only significant complication was groin haemorrhage followed by formation of a pseudoaneurysm of the femoral artery in one patient. In patients with non-inducible VT at the end of the procedure, recurrence of different or the same VT was observed during follow-up in 2 cases. In 3 subjects with persistent inducibility of another VT, only a sporadic recurrence of arrhythmia was recorded in 2 cases. Conclusions: In subjects with incessant VT, the electroanatomical mapping system allows rapid orientation regarding the critical component of the reentrant circuit and supports successful and safe catheter ablation. At the same time, integrated mapping approach enables a substantial modification of the arrhythmogenic substrate, leading to a reduction in other forms of VT.
BACKGROUND: The optimal method to identify the arrhythmogenic substrate of scar-related ventricular tachycardia (VT) is unknown. Sites of activation slowing during sinus rhythm (SR) often colocalize with the VT circuit. However, the utility and limitations of such approach for guiding ablation are unknown. METHODS: We conducted a multicenter study in patients with infarct-related VT. The left ventricular (LV) was mapped during activation from 3 directions: SR (or atrial pacing), right ventricular, and LV pacing at 600 ms. Ablation was applied selectively to the cumulative area of slow activation, defined as the sum of all regions with activation times of ≥40 ms per 10 mm. Hemodynamically tolerated VTs were mapped with activation or entrainment. The primary outcome was a composite of appropriate implanted cardioverter-defibrillator therapies and cardiovascular death. RESULTS: In 85 patients, the LV was mapped during activation from 2.4±0.6 directions. The direction of LV activation influenced the location and magnitude of activation slowing. The spatial overlap of activation slowing between SR and right ventricular pacing was 84.2±7.1%, between SR and LV pacing was 61.4±8.8%, and between right ventricular and LV pacing was 71.3±9.6% (P<0.05 between all comparisons). Mapping during SR identified only 66.2±8.2% of the entire area of activation slowing and 58% critical isthmus sites. Activation from other directions by right ventricular and LV stimulation unmasked an additional 33% of slowly conducting zones and 25% critical isthmus sites. The area of maximal activation slowing often corresponded to the site where the wavefront first interacted with the infarct. During a follow-up period of 3.6 years, the primary end point occurred in 14 out of 85 (16.5%) patients. CONCLUSIONS: The spatial distribution of activation slowing is dependent on the direction of LV activation with the area of maximal slowing corresponding to the site where the wavefront first interacts with the infarct. This data may have implications for VT substrate mapping strategies.
- MeSH
- akční potenciály MeSH
- časové faktory MeSH
- elektrofyziologické techniky kardiologické MeSH
- katetrizační ablace * škodlivé účinky mortalita MeSH
- komorová tachykardie diagnóza mortalita patofyziologie chirurgie MeSH
- lidé středního věku MeSH
- lidé MeSH
- prospektivní studie MeSH
- rizikové faktory MeSH
- senioři MeSH
- srdeční frekvence MeSH
- výsledek terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
- Research Support, N.I.H., Extramural MeSH
- Geografické názvy
- Evropa MeSH
- Korejská republika MeSH
- Spojené státy americké MeSH
Cardiac repolarization is prolonged in diabetes mellitus (DM), however the distribution of repolarization durations in diabetic hearts is unknown. We estimated the ventricular repolarization pattern and its relation to the ECG phenomena in diabetic mice. Potential mapping was performed on the anterior ventricular surface in healthy (n=18) and alloxan-induced diabetic (n=12) mice with the 64-electrode array. Activation times, end of repolarization times, and activation-recovery intervals (ARIs) were recorded along with limb lead ECGs. ARIs were shorter in the left as compared to right ventricular leads (P<0.05). The global dispersion of repolarization, interventricular and apicobasal repolarization gradients were greater in DM than in healthy animals (P<0.03). The increased dispersion of repolarization and apicobasal repolarization gradient in DM correlated with the prolonged QTc and Tpeak-Tend intervals, respectively. The increased ventricular repolarization heterogeneity corresponded to the electrocardiographic markers was demonstrated in DM.
- MeSH
- akční potenciály MeSH
- alloxan farmakologie MeSH
- diabetes mellitus patofyziologie MeSH
- elektrokardiografie MeSH
- experimentální diabetes mellitus patofyziologie MeSH
- myši MeSH
- srdce - funkce komor fyziologie MeSH
- srdeční komory metabolismus MeSH
- zvířata MeSH
- Check Tag
- mužské pohlaví MeSH
- myši MeSH
- ženské pohlaví MeSH
- zvířata MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
BACKGROUND: The presence and extent of ventricular dyssynchrony are currently assessed from the QRS complex morphology and width. However, similar electrocardiography (ECG) pattern may be caused by variable ventricular activation sequence. This may then contribute to interindividually different response to cardiac resynchronization therapy (CRT). METHODS: Electroanatomical mapping and magnetic resonance imaging scan were performed in 11 patients with left bundle branch block (LBBB, QRS 170 ± 14 ms) and heart failure of ischemic (coronary artery disease (CAD), n = 2) and nonischemic (dilated cardiomyopathy (DCM), n = 9) etiology. Ventricular activation sequence was studied during LBBB and final CRT programming. Presence and extent of scarring were analyzed in the 17-segment left-ventricular (LV) model. RESULTS: Regardless of etiology, presence of typical LBBB was associated with diffuse prolongation of impulse conduction with right-to-left activation sequence. Basal lateral wall was constant site of late activation. This activation pattern was present in "true LBBB," but also in LBBB-like pattern (persistent S wave in V5-6) and left axis deviation. Activation started in right vetricular (RV) apex in patients with left axis deviation at RV free wall in normal axis. Individuals with CAD and DCM patient displayed focal scar. Despite that they exhibited typical LBBB and activation sequence mirrored findings in other LBBB individuals. Reverse remodeling (∆LVESV > 15% after 6 months) was evident in 10 patients. CONCLUSIONS: Both typical LBBB and LBBB-like pattern might be associated with constant activation sequence regardless of etiology and scar localization. Activation initiation in RV apex, not LV activation sequence can be surrogate for left axis deviation. CRT caused inter- and intraventricular LV resynchronization without significantly changed RV activation sequence and duration.
- MeSH
- blokáda Tawarova raménka diagnostické zobrazování patofyziologie terapie MeSH
- elektrokardiografie * MeSH
- epikardiální mapování MeSH
- lidé středního věku MeSH
- lidé MeSH
- magnetická rezonanční tomografie MeSH
- senioři MeSH
- srdeční komory diagnostické zobrazování patofyziologie MeSH
- srdeční resynchronizační terapie metody MeSH
- srdeční selhání diagnostické zobrazování patofyziologie terapie MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
Tandem Heart je relativně nově vyvinutý přístroj pro aktivní krátkodobou hemodynamickou podporu pVAD (= percutaneous ventricular assist device). Přístroj - „pumpa" se vřazuje do oběhu v levé síni po její transseptální punkci a zavedení 21F nasávací žil-ní kanyly, krev je vedena do vlastní centrifugální pumpy a vrací se do oběhu 15-17F arteriální kanylou cestou femorální tepny. Hlavní indikací k užití VAD je kardiogenní šok, zvláště tam, kde není adekvátní hemodynamická odpověď na IABK. Fyziologicky jde o 30-50% snížení preloadu levého srdce, a tím i o snížení jeho práce a zvýšení kontrakční schopnosti. Kontraindikací je zejména pravostranné srdeční selhání. Ve srovnání s IABK dochází po zavedení VAD rychleji a výrazněji v řádu desítek minut ke zlepšování hemodynamických parametrů, zejména k poklesu plnícího tlaku a vzestupu minutového výdeje. Na kardiologickém oddělení naší nemocnice jsme v r. 2005 Tandem Heart použili u dvou pacientů. V prvním případě šlo o 51 letého muže v kardiogenním šoku při anteroextenzivním infarktu myokardu. Druhým byl 63 lety muž s těžkou poinfarktovou dysfunkcí levé komory, s implantovaným ICD (kardiovertor-defibrilátor), u kterého došlo při arytmické bouři k těžkému srdečnímu selhání. Zde byl VAD zaveden k zajištění hemodynamiky během elektroanatomického mapování a radiofrekvenční ablace komorové tachykardie.
Tandem Heart is a relatively newly developed device for active short-term hemodynamic support (percutaneous ventricular assist device, pVAD). The device, or "pump", is linked to blood circulation in the left ventricle following a transseptal puncture and introduction of a 21F venous suclion cannula. The blood is guided into the centrifugal pump proper and returns into the circulation through a 15-17F arterial cannula via the femoral artery. The main indication for VAD is cardiogenic shock, particularly in the absence of an adequate hemodynamic response to IABC. Physiologically, left heart preload is reduced by 30-50%, reducing its workload and improving contractility. The main contraindication is right-sided heart failure. Compared to IABC, recovery of haemodynamic parameters, especially drop in filling pressure and increase of heart output, is more rapid and marked after VAD introduction. In 2005, we ušed Tandem Heart in two patients at the cardiology department of our hospital. The first was a 51-year-old male suffering cardiogenic shock during a large anterior wall MI. The second patient was a 63-year-old male with severe post-infarction left ventricular dysfunction with an ICD (Implanted Cardioverter Defibrillator), who experienced severe heart failure during an arrhythmic storm. The VAD was ušed to secure haemodynamics during electroanatomic mapping and radiofrequency ablation of ventricular tachycardia.
