Endocardial Unipolar Voltage Mapping to Detect Epicardial Ventricular Tachycardia Substrate in Patients With Nonischemic Left Ventricular Cardiomyopathy

Hutchinson, Mathew D.; Gerstenfeld, Edward P.; Desjardins, Benoı̂t; Bala, Rupa; Riley, Michael P.; García, Fermin C.; Dixit, Sanjay; Lin, David; Tzou, Wendy S.; Cooper, Joshua M.; Verdino, Ralph J.; Callans, David J.; Marchlinski, Francis E.

doi:10.1161/circep.110.959957

Cited by 358 publications

(230 citation statements)

References 16 publications

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“…The hypothesis was that endocardial areas of scar may show low bipolar voltage but near‐normal unipolar voltage. Unipolar voltage maps include the far‐field electrical activity from the overlying viable myocardium and hence can differentiate thin endocardial scars from thick transmural scars 16, 17. In this study, in the three dogs with large confluent infarcts, endocardial scar areas showed high unipolar voltage (>15 mV) and transmural scar showed lower unipolar voltage (Fig.…”

Section: Discussionmentioning

confidence: 61%

Correlation of Scar in Cardiac MRI and High‐Resolution Contact Mapping of Left Ventricle in a Chronic Infarct Model

Thajudeen

Jackman

Stewart

et al. 2015

Pacing Clinical Electrophis

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BackgroundEndocardial mapping for scars and abnormal electrograms forms the most essential component of ventricular tachycardia ablation. The utility of ultra‐high resolution mapping of ventricular scar was assessed using a multielectrode contact mapping system in a chronic canine infarct model.MethodsChronic infarcts were created in five anesthetized dogs by ligating the left anterior descending coronary artery. Late gadolinium‐enhanced magnetic resonance imaging (LGE MRI) was obtained 4.9 ± 0.9 months after infarction, with three‐dimensional (3D) gadolinium enhancement signal intensity maps at 1‐mm and 5‐mm depths from the endocardium. Ultra‐high resolution electroanatomical maps were created using a novel mapping system (Rhythmia Mapping System, Rhythmia Medical/Boston Scientific, Marlborough, MA, USA) Rhythmia Medical, Boston Scientific, Marlborough, MA, USA with an 8.5F catheter with mini‐basket electrode array (64 tiny electrodes, 2.5‐mm spacing, center‐to‐center).ResultsThe maps contained 7,754 ± 1,960 electrograms per animal with a mean resolution of 2.8 ± 0.6 mm. Low bipolar voltage (<2 mV) correlated closely with scar on the LGE MRI and the 3D signal intensity map (1‐mm depth). The scar areas between the MRI signal intensity map and electroanatomic map matched at 87.7% of sites. Bipolar and unipolar voltages, compared in 592 electrograms from four MRI‐defined scar types (endocardial scar, epicardial scar, mottled transmural scar, and dense transmural scar) as well as normal tissue, were significantly different. A unipolar voltage of <13 mV correlated with transmural extension of scar in MRI. Electrograms exhibiting isolated late potentials (ILPs) were manually annotated and ILP maps were created showing ILP location and timing. ILPs were identified in 203 ± 159 electrograms per dog (within low‐voltage areas) and ILP maps showed gradation in timing of ILPs at different locations in the scar.ConclusionsUltra‐high resolution contact electroanatomical mapping accurately localizes ventricular scar and abnormal myocardial tissue in this chronic canine infarct model. The high fidelity electrograms provided clear identification of the very low amplitude ILPs within the scar tissue and has the potential to quickly identify targets for ablation.

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Section: Discussionmentioning

confidence: 61%

Correlation of Scar in Cardiac MRI and High‐Resolution Contact Mapping of Left Ventricle in a Chronic Infarct Model

Thajudeen

Jackman

Stewart

et al. 2015

Pacing Clinical Electrophis

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“…Remarkably, endocardial voltage mapping of the RV and LV can help in evaluating the extent of epicardial abnormalities with a cutoff value of 5.5 mV and 8.3 mV for the RV and LV, respectively 71, 72. Arrhythmogenic potentials or local abnormal ventricular activity potentials can be adjusted objectively through a novel quantification analysis, such as simultaneous amplitude frequency electrogram transformation (SAFE‐T) maps 73.…”

Section: Management Of Vt In Nicmmentioning

confidence: 99%

Ventricular arrhythmias in nonischemic cardiomyopathy

Chung

Lin

et al. 2018

Journal of Arrhythmia

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Nonischemic cardiomyopathies (NICMs) are composed of variable disease entities, including primary and secondary cardiomyopathies. Determining the etiology of NICM provides pivotal roles of not only the understanding of the individual pathogenesis, but also the clinical management, such as risk stratification, pharmacological treatment, and intervention therapies. Despite the diverse causes of NICM, these cases mostly require clinical attention owing to progressive myocardial injury, resulting in ventricular dysfunction and heart failure. The interaction between the diseased ventricular substrates and systemic/neurophysiological factors contributes to the cornerstones responsible for ventricular arrhythmogenesis and sudden cardiac death (SCD). Prevention of SCD and diminishing ventricular tachyarrhythmias are the important mainstays for the management of NICM patients. Given the understanding of the abnormal ventricular substrates and advancement of navigation systems, radiofrequency catheter ablation (RFCA) has become an adjunctive or alternative strategy for NICM patients who experience drug‐refractory ventricular tachycardias (VTs). Successful ablation can frequently be achieved at the expense of an epicardial intervention. A recent study has proven the survival benefits for NICM patients who are free from recurrent VTs after a successful RFCA, regardless of the New York Heart Association (NYHA) functional class status or left ventricular ejection fraction. Additionally, recent evidence has highlighted the better delineation of a diseased myocardium through the incorporation of cardiovascular magnetic resonance imaging (CMRI) and 3D mapping systems, which can facilitate the identification of critical ventricular arrhythmogenic substrates in NICM patients.

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“…Viability of the interventricular septum (IVS) was defined by averaging the measurements obtained in the septal and basal septal areas. In accordance with previous data on electroanatomical mapping in nonischemic DCM 11, transendocardial delivery of cell suspension was performed with MyoStar injection catheter targeting areas with unipolar voltage ≥8.27 mV and linear shortening <6%. Each patient received 20 injections of 0.3 ml.…”

Section: Methodsmentioning

confidence: 98%

CD34+ Cell Transplantation Improves Right Ventricular Function in Patients with Nonischemic Dilated Cardiomyopathy

Frljak

Jaklič

Zemljic

et al. 2018

Stem Cells Translational Medicine

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We investigated the effects of CD34+ cell therapy on right ventricular (RV) function in patients with nonischemic dilated cardiomyopathy (DCM). We enrolled 60 patients with DCM who were randomized to CD34+ cell therapy (Stem Cells (SC) Group n = 30), or no cell therapy (Controls, n = 30). The SC Group received granulocyte‐colony stimulating factor, and CD34+ cells were collected by apheresis and injected transendocardially. Patients were followed for 6 months. At baseline, the groups did not differ in age, gender, left ventricular ejection fraction, N‐terminal probrain natriuretic peptide, or parameters of RV function. At 6 months, we found a significant improvement in RV function in the SC Group (tricuspid annular plane systolic excursion [TAPSE]: +0.44 ± 0.64 cm, p = .001; peak systolic tissue Doppler velocity of tricuspid annulus [St]: +1.5 ± 2.1 cm/s; p = .001; percent of fractional area change [FAC]: +8.6% ± 5%, p = .01), but not in Controls (TAPSE: −0.07 ± 0.32 cm, p = .40; St: −0.1 ± 1.2 cm/s; p = .44; FAC: −1.2% ± 3.2%, p = .50). On repeat electroanatomical mapping, we found an improvement in interventricular septum viability in 19 of 30 patients from the SC Group; this correlated with the improvements in RV function (13/19 in the improved septum group versus 3/11 in the remaining cohort, p = .029). These results suggest that patients with DCM, changes in RV function correlate with changes of viability of interventricular septum. CD34+ cell therapy appears to be associated with improved right ventricular function in this patient cohort. (Clinical Trial Registration Information: www.clinicaltrials.gov; NCT02248532). Stem Cells Translational Medicine 2018;7:168–172

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Endocardial Unipolar Voltage Mapping to Detect Epicardial Ventricular Tachycardia Substrate in Patients With Nonischemic Left Ventricular Cardiomyopathy

Cited by 358 publications

References 16 publications

Correlation of Scar in Cardiac MRI and High‐Resolution Contact Mapping of Left Ventricle in a Chronic Infarct Model

Correlation of Scar in Cardiac MRI and High‐Resolution Contact Mapping of Left Ventricle in a Chronic Infarct Model

Ventricular arrhythmias in nonischemic cardiomyopathy

CD34+ Cell Transplantation Improves Right Ventricular Function in Patients with Nonischemic Dilated Cardiomyopathy

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