Ventricular activation mapping
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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
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 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
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 resynchronization therapy (CRT) has become standard therapy for selected patients with congestive heart failure and dyssynchrony of cardiac contraction that is a consequence of electrical dyssynchrony. Intracardiac mapping enables detailed analysis of electrical activation sequences far beyond the standard ECG and allows description of specific activation associated with the benefit of CRT. Intracardiac mapping can also localize the region of the latest ventricular activation and areas of slow conduction, and thus potentially assist in selection of optimal pacing site for CRT. Precise description of electrical activation sequences, and correlation with parameters of mechanical dyssynchrony, may contribute to understanding the principles and mechanisms underlying the effect of CRT.
RATIONALE: Ventricular arrhythmias remain the leading cause of death in patients suffering myocardial ischemia. Myeloperoxidase, a heme enzyme released by polymorphonuclear neutrophils, accumulates within ischemic myocardium and has been linked to adverse left ventricular remodeling. OBJECTIVE: To reveal the role of myeloperoxidase for the development of ventricular arrhythmias. METHODS AND RESULTS: In different murine models of myocardial ischemia, myeloperoxidase deficiency profoundly decreased vulnerability for ventricular tachycardia on programmed right ventricular and burst stimulation and spontaneously as assessed by ECG telemetry after isoproterenol injection. Experiments using CD11b/CD18 integrin-deficient (CD11b(-/-)) mice and intravenous myeloperoxidase infusion revealed that neutrophil infiltration is a prerequisite for myocardial myeloperoxidase accumulation. Ventricles from myeloperoxidase-deficient (Mpo(-/-)) mice showed less pronounced slowing and decreased heterogeneity of electric conduction in the peri-infarct zone than wild-type mice. Expression of the redox-sensitive gap junctional protein Cx43 (Connexin 43) was reduced in the peri-infarct area of wild-type compared with Mpo(-/-) mice. In isolated wild-type cardiomyocytes, Cx43 protein content decreased on myeloperoxidase/H2O2 incubation. Mapping of induced pluripotent stem cell-derived cardiomyocyte networks and in vivo investigations linked Cx43 breakdown to myeloperoxidase-dependent activation of matrix metalloproteinase 7. Moreover, Mpo(-/-) mice showed decreased ventricular postischemic fibrosis reflecting reduced accumulation of myofibroblasts. Ex vivo, myeloperoxidase was demonstrated to induce fibroblast-to-myofibroblast transdifferentiation by activation of p38 mitogen-activated protein kinases resulting in upregulated collagen generation. In support of our experimental findings, baseline myeloperoxidase plasma levels were independently associated with a history of ventricular arrhythmias, sudden cardiac death, or implantable cardioverter-defibrillator implantation in a cohort of 2622 stable patients with an ejection fraction >35% undergoing elective diagnostic cardiac evaluation. CONCLUSIONS: Myeloperoxidase emerges as a crucial mediator of postischemic myocardial remodeling and may evolve as a novel pharmacological target for secondary disease prevention after myocardial ischemia.
- MeSH
- ischemická choroba srdeční metabolismus patologie MeSH
- kardiomyocyty metabolismus patologie MeSH
- kultivované buňky MeSH
- lidé MeSH
- myši inbrední C57BL MeSH
- myši knockoutované MeSH
- myši MeSH
- orgánové kultury - kultivační techniky MeSH
- peroxidasa nedostatek MeSH
- remodelace komor fyziologie MeSH
- srdeční arytmie metabolismus patologie MeSH
- zvířata MeSH
- Check Tag
- lidé MeSH
- mužské pohlaví MeSH
- myši MeSH
- zvířata MeSH
- Publikační typ
- časopisecké články MeSH
PURPOSE: The aim of this proof-of-concept study is to introduce new high-dynamic ECG technique with potential to detect temporal-spatial distribution of ventricular electrical depolarization and to assess the level of ventricular dyssynchrony. METHODS: 5-kHz 12-lead ECG data was collected. The amplitude envelopes of the QRS were computed in an ultra-high frequency band of 500-1000 Hz and were averaged (UHFQRS). UHFQRS V lead maps were compiled, and numerical descriptor identifying ventricular dyssynchrony (UHFDYS) was detected. RESULTS: An electrical UHFQRS maps describe the ventricular dyssynchrony distribution in resolution of milliseconds and correlate with strain rate results obtained by speckle tracking echocardiography. The effect of biventricular stimulation is demonstrated by the UHFQRS morphology and by the UHFDYS descriptor in selected examples. CONCLUSIONS: UHFQRS offers a new and simple technique for assessing electrical activation patterns in ventricular dyssynchrony with a temporal-spatial resolution that cannot be obtained by processing standard surface ECG. The main clinical potential of UHFQRS lies in the identification of differences in electrical activation among CRT candidates and detection of improvements in electrical synchrony in patients with biventricular pacing.
- MeSH
- dospělí MeSH
- dysfunkce levé srdeční komory diagnostické zobrazování terapie MeSH
- echokardiografie trojrozměrná metody MeSH
- elektrokardiografie metody MeSH
- interpretace obrazu počítačem * MeSH
- lidé středního věku MeSH
- lidé MeSH
- remodelace komor fyziologie MeSH
- senioři MeSH
- srdeční resynchronizační terapie metody MeSH
- stupeň závažnosti nemoci MeSH
- výsledek terapie MeSH
- vzorkové studie MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mužské pohlaví MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
