Electroanatomical mapping
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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.
- MeSH
- antiarytmika terapeutické užití MeSH
- diagnostické zobrazování metody MeSH
- dospělí MeSH
- echokardiografie metody MeSH
- fibrilace síní patologie terapie MeSH
- katetrizační ablace metody MeSH
- koronární nemoc patologie MeSH
- lidé MeSH
- výběr pacientů MeSH
- Check Tag
- dospělí MeSH
- lidé MeSH
- mužské pohlaví MeSH
- ženské pohlaví MeSH
BACKGROUND: Electroanatomical voltage mapping (EAVM) has been compared with late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR), which cannot delineate diffuse fibrosis. T1-mapping CMR overcomes the limitations of LGE-CMR, but it has not been directly compared against EAVM. OBJECTIVES: This study aims to assess the relationship between left ventricular (LV) endocardial voltage obtained by EAVM and extracellular volume (ECV) obtained by T1 mapping. METHODS: The study investigated patients who underwent endocardial EAVM for ventricular arrhythmias (CARTO 3, Biosense Webster) together with preprocedural contrast-enhanced T1 mapping (Ingenia 3T, Philips Healthcare). After image integration, EAVM datapoints were projected onto LGE-CMR and ECV-encoded images. Average values of unipolar voltage (UV), bipolar voltage (BV), LGE transmurality, and ECV were merged from corresponding cardiac segments (6 per slice) and pooled for analysis. RESULTS: The analysis included data from 628 segments from 18 patients (57 ± 13 years of age, 17% females, LV ejection fraction 48% ± 14%, nonischemic/ischemic cardiomyopathy/controls: 8/6/4 patients). Based on the 95th and 5th percentile values obtained from the controls, ECV >33%, BV <2.9 mV, and UV <6.7 mV were considered abnormal. There was a significant inverse association between voltage and ECV, but only in segments with abnormal ECV. Increased ECV could predict abnormal BV and UV with acceptable accuracy (area under the curve of 0.78 [95% CI: 0.74-0.83] and 0.84 [95% CI: 0.79-0.88]). CONCLUSIONS: This study found a significant inverse relationship between LV endocardial voltage and ECV. Real-time integration of T1 mapping may guide catheter mapping and may allow identification of areas of diffuse fibrosis potentially related to ventricular arrhythmias.
AIMS: To analyse and optimize the interobserver agreement for gross target volume (GTV) delineation on cardiac computed tomography (CCT) based on electroanatomical mapping (EAM) data acquired to guide radiotherapy for ventricular tachycardia (VT). METHODS AND RESULTS: Electroanatomical mapping data were exported and merged with the segmented CCT using manual registration by two observers. A GTV was created by both observers for predefined left ventricular (LV) areas based on preselected endocardial EAM points indicating a two-dimensional (2D) surface area of interest. The influence of (interobserver) registration accuracy and availability of EAM data on the final GTV and 2D surface location within each LV area was evaluated. The median distance between the CCT and EAM after registration was 2.7 mm, 95th percentile 6.2 mm for observer #1 and 3.0 mm, 95th percentile 7.6 mm for observer #2 (P = 0.9). Created GTVs were significantly different (8 vs. 19 mL) with lowest GTV overlap (35%) for lateral wall target areas. Similarly, the highest shift between 2D surfaces was observed for the septal LV (6.4 mm). The optimal surface registration accuracy (2.6 mm) and interobserver agreement (Δ interobserver EAM surface registration 1.3 mm) was achieved if at least three cardiac chambers were mapped, including high-quality endocardial LV EAM. CONCLUSION: Detailed EAM of at least three chambers allows for accurate co-registration of EAM data with CCT and high interobserver agreement to guide radiotherapy of VT. However, the substrate location should be taken in consideration when creating a treatment volume margin.
- MeSH
- komorová tachykardie * diagnostické zobrazování radioterapie MeSH
- lidé MeSH
- srdeční komory diagnostické zobrazování MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
Recurrent ventricular tachycardia (VT) is an important cause of mortality and morbidity late after myocardial infarction. With frequent use of implantable cardioverter-defibrillators, these VTs are often poorly defined and not tolerated for mapping, factors previously viewed as relative contraindications to ablation. This observational multicenter study assessed the outcome of VT ablation with a saline-irrigated catheter combined with an electroanatomic mapping system. METHODS AND RESULTS: Two hundred thirty-one patients (median LV ejection fraction, 0.25; heart failure in 62%) with recurrent episodes of monomorphic VT (median, 11 in the preceding 6 months) caused by prior myocardial infarction were enrolled. All inducible monomorphic VTs with a rate approximating or slower than any spontaneous VTs were targeted for ablation guided by electroanatomic mapping during sinus rhythm and/or VT. Patients were not excluded for multiple VTs (median, 3 per patient) or unmappable VT (present in 69% of patients). Ablation abolished all inducible VTs in 49% of patients. The primary end point of freedom from recurrent incessant VT or intermittent VT after 6 months of follow-up was achieved for 123 patients (53%). In 142 patients with implantable cardioverter-defibrillators before and after ablation for intermittent VT who survived 6 months, VT episodes were reduced from a median of 11.5 to 0 (P<0.0001). The 1-year mortality rate was 18%, with 72.5% of deaths attributed to ventricular arrhythmias or heart failure. The procedure mortality rate was 3%, with no strokes. CONCLUSIONS: Catheter ablation is a reasonable option to reduce episodes of recurrent VT in patients with prior myocardial infarction, even when multiple and/or unmappable VTs are present. This population remains at high risk for death, warranting surveillance and further study.
- MeSH
- financování organizované MeSH
- infarkt myokardu chirurgie komplikace mortalita MeSH
- katetrizační ablace metody mortalita přístrojové vybavení MeSH
- komorová tachykardie etiologie chirurgie mortalita MeSH
- lidé středního věku MeSH
- lidé MeSH
- mapování potenciálů tělesného povrchu metody přístrojové vybavení MeSH
- míra přežití MeSH
- následné studie MeSH
- peroperační monitorování metody přístrojové vybavení MeSH
- senioři MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
OBJECTIVES: This study sought to investigate the value of electroanatomical voltage mapping (EAVM) to distinguish cardiac sarcoidosis (CS) from arrhythmogenic right ventricular cardiomyopathy (ARVC) in patients with ventricular tachycardia from the right ventricle (RV). BACKGROUND: CS can mimic ARVC. Because scar in ARVC is predominantly subepicardial, this study hypothesized that the relative sizes of endocardial low bipolar voltage (BV) to low unipolar voltage (UV) areas may distinguish CS from ARVC. METHODS: Patients with CS affecting the RV (n = 14), patients with gene-positive ARVC (n = 13), and a reference group of patients without structural heart disease (n = 9) who underwent RV endocardial EAVM were included. RV region-specific BV and UV cutoffs were derived from control subjects. In CS and ARVC, segmental involvement was determined and low-voltage areas were measured, using <1.5 mV for BV and <3.9 mV, <4.4 mV, and <5.5 mV for UV. The ratio between low BV and low UV area was calculated generating 3 parameters: Ratio3.9, Ratio4.4 and Ratio5.5, respectively. RESULTS: In control subjects, BV and UV varied significantly among RV regions. The basal septum was involved in 71% of CS patients and in none of ARVC patients. Ratio5.5 discriminated CS from ARVC the best. An algorithm including Ratio5.5 ≥0.45 and basal septal involvement identified CS with 93% sensitivity and 85% specificity. This was validated in a separate population (CS [n = 6], ARVC [n = 10]) with 100% sensitivity and 100% specificity. CONCLUSIONS: EAVM provides detailed information about scar characteristics and scar distribution in the RV. An algorithm combining Ratio5.5 (area BV <1.5 mV/area UV <5.5 mV) and bipolar basal septal involvement allows accurate diagnosis of (isolated) CS in patients presenting with monomorphic ventricular tachycardia from the RV.
- MeSH
- arytmogenní dysplazie pravé komory * diagnóza MeSH
- elektrofyziologické techniky kardiologické MeSH
- elektrokardiografie MeSH
- komorová tachykardie * diagnóza MeSH
- lidé MeSH
- sarkoidóza * komplikace diagnóza MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
Prezentujeme kazuistiku mladého muže s incesantní idiopatickou komorovu extrasystolií vycházející z levého aortálního Valsalvova sinu. Lokalizace ektopického ložiska a jeho anatomický vztah ke kmeni levé věnčité tepny byly stanoveny pomocí elektroanatomického mapování a angiografických vyšetření. Nebolestivá a bezpečná destrukce ložiska ablací byla provedena pomocí kryoenergie.
A case of a young man with incessant idiopathic ventricular premature beats originating from the left aortic sinus of Valsalva is presented. Localization of the ectopic focus and its anatomic relation to the left main coronary artery was identified using electroanatomic mapping and angiography. Painless and safe destruction of the ectopic focus was completed with cryoablation.
- MeSH
- angiografie metody využití MeSH
- dospělí MeSH
- katetrizační ablace metody přístrojové vybavení využití MeSH
- komorové extrasystoly diagnóza etiologie terapie MeSH
- kryochirurgie metody přístrojové vybavení využití MeSH
- lidé MeSH
- mapování potenciálů tělesného povrchu metody využití MeSH
- Valsalvův sinus patofyziologie patologie MeSH
- Check Tag
- dospělí MeSH
- lidé MeSH
- mužské pohlaví MeSH
- Publikační typ
- kazuistiky MeSH
BACKGROUND: Left atrial (LA) enlargement has been identified as a predictor of worse clinical outcome after catheter ablation for atrial fibrillation (AF). We investigated the correspondence of LA size parameters assessed by echocardiography, CT and 3D electroanatomical mapping in patients with AF treated by catheter ablation. METHODS: We analyzed echocardiographic LA volume measurements by disc summation method (LAVDISC), computed tomography (LAVCT) and 3D electroanatomical mapping (LAVCARTO) in 100 pts. (71% males; aged 63 ± 8 years; paroxysmal AF in 55% of patients). RESULTS: Mean LAVDISC was 83 ± 25 ml (median: 115; IQR: 98-140 ml), mean LAVCT was 120 ± 34 ml (median: 115; IQR: 98-140 ml) and mean LAVCARTO was 123 ± 36 ml (median: 118; IQR: 99-132 ml). Pearson's correlation coefficient between LAVDISC a LAVCT was 0.6 (p < 0.0001) and between LAVCARTO and LAVCT was 0.79 (p < 0.0001). There was a significant difference between the two correlation coefficients (p < 0.004). The absolute difference between LAVCARTO and LAVCT (3.5 (95% CI -42 - 43) ml) was significantly lower (p < 0.0001) as compared to LAVDISC and LAVCT (- 39 (95% CI -102 - 24) ml). In opposite to LAVDISC, the bias between LAV obtained by CT and CARTO did not differentiate according to presence of spherical remodeling (1.7 ± 28 vs. vs. 5.1 ± 31 ml). Only presence of sinus rhythm was significant and independent covariate of the difference between CARTO and CT-derived LAVs by multivariate regression analysis. CONCLUSIONS: Even though LA volumes evaluated by 3D-electroanatomical mapping have quite good accuracy, the precision is low. For volumes estimated by echocardiography, both precision and accuracy are low.
- MeSH
- echokardiografie metody MeSH
- fibrilace síní diagnostické zobrazování chirurgie MeSH
- katetrizační ablace MeSH
- lidé středního věku MeSH
- lidé MeSH
- počítačová rentgenová tomografie metody MeSH
- regresní analýza MeSH
- remodelace síní MeSH
- senioři MeSH
- senzitivita a specificita MeSH
- srdeční síně diagnostické zobrazování MeSH
- zobrazování trojrozměrné metody MeSH
- Check Tag
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- práce podpořená grantem MeSH
