Conduction patterns of idiopathic arrhythmias from the endocardium and epicardium of outflow tracts: New insights with noninvasive electroanatomic mapping

Mountantonakis, Stavros; Vaishnav, Aditi S; Jacobson, Jeremy; Bernstein, Neil E.; Bhasin, Kabir; Coleman, Kristie; Skipitaris, Nicholas

doi:10.1016/j.hrthm.2019.04.026

Cited by 19 publications

(20 citation statements)

References 17 publications

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“…We agree with the above statement, however, we have shown that while the imaging of electrical propagation with NIEAM is poor for the entire cycle length, one can deduct conclusions on the general patterns of activation and determine the order of depolarization of cardiac segments that are anatomically distant. This technique has allowed us to determine the chamber of origin of OTVA based on activation timing of lateral mitral annulus versus basal septum versus lateral tricuspid annulus 12 . Given limitations in spatial and temporal resolution of the current system, we believe that determination of chamber of origin is important first step before attempting to predict the SOO for OTVAs.…”

Section: Discussionmentioning

confidence: 99%

“…We have shown that current signal processing result in noninvasive electroanatomical maps that lack the spatial and temporal resolution to reliably differentiate between the neighboring structures of the outflow tracts when using the earliest arrhythmia breakout. Using NIEAM‐based activation timing of the lateral mitral annulus and basal septum, we have previously proposed a two‐step algorithm that differentiates between RVOT, LVOT, and the epicardial origin with a 100% diagnostic accuracy 12 . This algorithm is proven to be superior to the 12‐lead electrocardiogram (ECG) and has been shown to obviate unnecessary vascular access and eliminate unnecessary mapping and ablation 13 .…”

Section: Introductionmentioning

confidence: 99%

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Surface unipolar electrogram characteristics to predict site of origin of outflow tract arrhythmias using noninvasive mapping

Coleman

Saleh

Makker

et al. 2021

Cardiovasc electrophysiol

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Background Noninvasive electroanatomic mapping (NIEAM) demonstrate patterns of depolarization that are useful in identifying the chamber of origin (COO) in outflow tract ventricular arrhythmias (OTVA). However, its use in predicting exact site of origin (SOO) has not yet been validated. Methods NIEAMs (CardioInsight, Medtronic) from 40 patients (age 62.5 ± 2.6) undergoing ablation for OTVA were reviewed for diagnostic accuracy in predicting the SOO. Earliest arrhythmia breakout and directionality of earliest instantaneous unipolar electrograms (uEGMs) on NIEAMs were evaluated subjectively by two observers for quality and amplitude. Sites with most negative earliest uEGMs on right and left ventricular outflow tracts, as well as epicardial surface were manually identified. Using NIEAM‐based activation timing of the lateral mitral annulus and basal septum COO was identified for each OTVA. Predictions of SOO using NIEAMs was compared with true SOO from invasive study. NIEAMs SOO predictions were compared with subjective 12 lead electrocardiogram (ECG) review by two observers. Results Review of arrhythmia breakout and signal directionality had poor diagnostic value in predicting SOO in OTVA (50.6% and 49.4%, 56.6% and 43.4%, respectively) and underperformed compared with ECG interpretation (59.1% and 80.5%). After excluding uEGMs with poor characteristics, the uEGM with most negative amplitude at the COO was predictive of the true SOO with 96.4% sensitivity and specificity. Conclusion We propose a stepwise approach when interpreting NIEAMs for OTVA where patterns of activation are evaluated first to determine the COO, followed by identification of the site with most negative amplitude instantaneous uEGM to determine SOO.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Surface unipolar electrogram characteristics to predict site of origin of outflow tract arrhythmias using noninvasive mapping

Coleman

Saleh

Makker

et al. 2021

Cardiovasc electrophysiol

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“…However, this theory remains controversial as only the proximal portion of the coronary venous system is encased by myocytes. While the mechanism of arrhythmogenesis remains poorly understood, a better understanding of the electrocardiographic characterization of IVAs that can be terminated from the coronary veins may aid operators' preparation for RFCAs and may also lead to higher success rates and shorter procedural times by obviating the need for a retrograde and/or pericardial approach 14,15 …”

Section: Discussionmentioning

confidence: 99%

“…While the mechanism of arrhythmogenesis remains poorly understood, a better understanding of the electrocardiographic characterization of IVAs that can be terminated from the coronary veins may aid operators' preparation for RFCAs and may also lead to higher success rates and shorter procedural times by obviating the need for a retrograde and/or pericardial approach. 14,15 Many parameters have been published in an effort to characterize epicardial IVAs that may be targeted from the GCV. Multiple studies compared RFCAs that were initially unsuccessful from the endocardium and ultimately successful from the epicardium to (terminal negative deflection of a "w").…”

Section: Discussionmentioning

confidence: 99%

Electrocardiographic localization of ventricular arrhythmias successfully ablated from the distal great cardiac vein

Chang

Gabriels

Vaishnav

et al. 2020

Cardiovasc electrophysiol

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Background: Idiopathic ventricular arrhythmias (IVAs) from the left ventricular (LV) summit may be successfully ablated from the distal great cardiac vein (dGCV). Using a 12-lead electrocardiogram (ECG) to localize IVAs that can be ablated from the dGCV is valuable for ablation planning. Objective: To determine if a "w" wave, a notch in the Q wave in lead I, and other ECG features can identify IVAs that can be successfully ablated from the dGCV. Methods: We reviewed outflow tract premature ventricular contraction (PVC) ablations performed at two centers between September 2010 and June 2018. Successful PVC ablations, in which the PVCs were mapped from the right ventricular outflow tract, coronary cusps, commissures, endocardial LV, and the coronary venous system including the dGCV were included. ECG characteristics were compared between patients with successful ablations in the dGCV and non-dGCV sites. Results: Of the 120 patients (age 56.8 ± 13.8 years, 45% female) that met the inclusion criteria, the dGCV was the successful ablation site in 18 patients (15%). Multivariate analysis with binary logistic regression showed that a "w" in lead I in combination with an early precordial pattern break and a maximum deflection index (MDI) ≥ 0.5 had sensitivity and specificity for a successful ablation in the dGCV of 94.4% and 96.1%, respectively. Conclusion: Combining a "w" wave in lead I with an early precordial pattern break and an MDI ≥ 0.5 is highly sensitive and specific for identifying the dGCV as a successful ablation site for PVCs.

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“…Therefore, tools that allow noninvasive electrocardiographic mapping (ECM) and localization of the clinically relevant VT prior to attempted ablation could be particularly helpful. The CardioInsight Vest (Medtronic, Minneapolis, MN) has previously been successful in identifying the focus of VT prior to invasive electrophysiologic study 7 , 8 ; however, the application of this technology in a patient with an LVAD and the associated electrical interference seen with these devices has not been previously reported.…”

Section: Introductionmentioning

confidence: 99%

Noninvasive electrocardiographic mapping of ventricular tachycardia in a patient with a left ventricular assist device

Rehorn

Koontz

Barnett

et al. 2020

HeartRhythm Case Reports

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Conduction patterns of idiopathic arrhythmias from the endocardium and epicardium of outflow tracts: New insights with noninvasive electroanatomic mapping

Cited by 19 publications

References 17 publications

Surface unipolar electrogram characteristics to predict site of origin of outflow tract arrhythmias using noninvasive mapping

Surface unipolar electrogram characteristics to predict site of origin of outflow tract arrhythmias using noninvasive mapping

Electrocardiographic localization of ventricular arrhythmias successfully ablated from the distal great cardiac vein

Noninvasive electrocardiographic mapping of ventricular tachycardia in a patient with a left ventricular assist device

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