Impact of earliest activation site location in the septal right ventricular outflow tract for identification of left vs right outflow tract origin of idiopathic ventricular arrhythmias

Acosta, Juan; Penela, Diego; Herczku, Csaba; Macías, Yolanda; Andreu, David; Fernández-Armenta, Juan; Cipolletta, Laura; Díaz, Andrés; Коршунов, В. В.; Brugada, Josép; Mont, Lluı́s; Cabrera, José Ángel; Sánchez‐Quintana, Damián; Berruezo, Antonio

doi:10.1016/j.hrthm.2014.12.029

Cited by 24 publications

(36 citation statements)

References 18 publications

(22 reference statements)

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“…two sets of unconnected vertices), whose centers correspond to lead locations, which are automatically detected with a simple k-means classification algorithm [38] (k=2). The center of each cloud can be considered as the lead location, because the electrical activation induced by a single lead will start at the point where the lead is located and uniformly propagated following the myocardial fiber direction [6], [7]. The localization of the RV lead is estimated on the epicardial EAM data since we do not have measurements from the endocardial RV.…”

Section: Methodsmentioning

confidence: 99%

“…At the time being, clinicians usually perform a visual assessment of the electrical activation patterns [2], [5], which is complemented by basic global indices such as the total activation time (TAT), or the QRS length provided by ECG and EAM data. Slightly more sophisticated analysis of electrical patterns have also been proposed [6], [7], based on simple indices (e.g. area and anisotropy) estimated on local activation time (LAT) isochrones extracted from EAMs.…”

Section: Introductionmentioning

confidence: 99%

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Quantitative Analysis of Electro-Anatomical Maps: Application to an Experimental Model of Left Bundle Branch Block/Cardiac Resynchronization Therapy

Iglesias

Duchateau

Butakoff

et al. 2017

IEEE J. Transl. Eng. Health Med.

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Electro-anatomical maps (EAMs) are commonly acquired in clinical routine for guiding ablation therapies. They provide voltage and activation time information on a 3-D anatomical mesh representation, making them useful for analyzing the electrical activation patterns in specific pathologies. However, the variability between the different acquisitions and anatomies hampers the comparison between different maps. This paper presents two contributions for the analysis of electrical patterns in EAM data from biventricular surfaces of cardiac chambers. The first contribution is an integrated automatic 2-D disk representation (2-D bull’s eye plot) of the left ventricle (LV) and right ventricle (RV) obtained with a quasi-conformal mapping from the 3-D EAM meshes, that allows an analysis of cardiac resynchronization therapy (CRT) lead positioning, interpretation of global (total activation time), and local indices (local activation time (LAT), surrogates of conduction velocity, inter-ventricular, and transmural delays) that characterize changes in the electrical activation pattern. The second contribution is a set of indices derived from the electrical activation: speed maps, computed from LAT values, to study the electrical wave propagation, and histograms of isochrones to analyze regional electrical heterogeneities in the ventricles. We have applied the proposed methods to look for the underlying physiological mechanisms of left bundle branch block (LBBB) and CRT, with the goal of optimizing the therapy by improving CRT response. To better illustrate the benefits of the proposed tools, we created a set of synthetically generated and fully controlled activation patterns, where the proposed representation and indices were validated. Then, the proposed analysis tools are used to analyze EAM data from an experimental swine model of induced LBBB with an implanted CRT device. We have analyzed and compared the electrical activation patterns at baseline, LBBB, and CRT stages in four animals: two without any structural disease and two with an induced infarction. By relating the CRT lead location with electrical dyssynchrony, we evaluated current hypotheses about lead placement in CRT and showed that optimal pacing sites should target the RV lead close to the apex and the LV one distant from it.

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Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Quantitative Analysis of Electro-Anatomical Maps: Application to an Experimental Model of Left Bundle Branch Block/Cardiac Resynchronization Therapy

Iglesias

Duchateau

Butakoff

et al. 2017

IEEE J. Transl. Eng. Health Med.

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“…We estimated the 5-ms and 10-ms isochronal areas of earliest activation in this study. Several studies have looked at the 10-ms isochronal area, 6,7,16,17) but we found the 10-ms isochronal area was overly large, because it included sites with lower precocity relative to the earliest onset of PVC. Instead, we found that the 5-ms isochronal area was more accurate for detecting suitable ablation sites for VAs, and in fact, a smaller 5-ms isochronal map area was able to predict successful ablation sites of VAs in this study with statistical significance.…”

Section: Discussionmentioning

confidence: 93%

“…Isochronal mapping: Herczku, et al 16) reported that the 10-ms isochronal map area of RVOT could predict whether the site of origin was in the RVOT or LVOT in patients with outflow tract VAs with V3 transition and septal earliest activation. Acosta, et al 17) reported that both the distance between the earliest activation site of RVOT and the pulmonary vein and the 10-ms isochronal longitudinal/perpendicular diameter ratio could predict whether the site of origin was in the LVOT or RVOT in outflow tract VAs with earliest activation site in the septal RVOT. These studies reported that RVOT origin and LVOT origin could be discriminated by mapping only the RVOT.…”

Section: Discussionmentioning

confidence: 99%

The Efficacy of Isochronal 3D Mapping-Based Ablation of Ventricular Arrhythmia

et al. 2017

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SummaryTreatment of ventricular arrhythmias (VAs) commonly involves ablating sites showing electrograms with the earliest activity relative to the VA, but there is no threshold value for prematurity guaranteeing success. Ablation of sites with great prematurity can still result in failure.We hypothesized that isochronal map area (ISCA), derived from isochrones indicating electrogram prematurity, could help identify ablation targets in VA patients, as well as predict outcome. Specifically, we hypothesized that smaller ICSA for a given prematurity value would indicate a shallower arrhythmogenic focus leading to a higher likelihood of successful ablation.We studied ICSA in 29 patients (12 males, 57 [17-65] 1,2) Thus, frequent idiopathic ventricular arrhythmias (VAs) are a target for catheter ablation. Ablation of sites with electrograms preceding the PVC on the 12-lead surface ECG by the longest period of time is expected to maximize the chances of successful elimination of PVCs, since they are likely to be closest to the ectopic focus. For purposes of this article, we will define the duration between a PVC and electrograms preceding it as prematurity. It would be useful if there were a threshold value of prematurity over which successful ablation was assured. Unfortunately, the range of prematurity values resulting in successful ablation overlaps with values for unsuccessful ablation sites, [3][4][5] and therefore, better or additional criteria are needed.We hypothesized that part of the reason that ablation of a site with great prematurity does not necessarily result in successful elimination of a focus is that intramural depth of the focus plays a role. A deeper focus may be more difficult to ablate, not only because of the ablative energy failing to reach the focus effectively, but because excitation reaching the endocardium will arrive at a larger area at the same precocity, so that the site ablated might not be directly above the focus. In contrast, a more superficial focus would produce a smaller excited area at the same precocity. We therefore tested whether what is called isochronal map area (ISCA) measurement could provide a new predictor for eliminating VAs, and whether more superficial sites of origin would have smaller ISCA (Figure 1). ISCA has been analyzed previously in patients with RVOT VAs, [6][7][8] but no one has ever evaluated its ability to discriminate between multiple sites of VA origin as we have attempted to do here.From the

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“…Moreover, the degree of electrogram prematurity at successful sites was fairly modest (mean: 29 ms) when compared with studies reporting successful activation times from the LV ostium and LV summit(7,8). Given the direct continuity of the myocardium adjacent to the aortic and pulmonic cusps at the level of the septum, it would be interesting to know the relative activation times within the closest LV structure at each successful pulmonic cusp site(9,10).Despite the high prevalence of supravalvular myocardial extensions, direct extensions within the pulmonic leaflets are rare(2). Thus, one must presume that ablation in these cases was directed rather at the myocardium at the ventriculo-arterial junction or within the crest of the RVOT.…”

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confidence: 98%

Pulmonic Cusp Ablation

Hutchinson

2015

Journal of the American College of Cardiology

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nbridled enthusiasm for catheter ablation of idiopathic outflow tract ventricular arrhythmias (VA) is tempered by suboptimal longterm procedural success. A recent multicenter report of outcomes after ablation of idiopathic premature ventricular contractions found 71% success (defined as a >80% reduction in premature ventricular contractions burden off antiarrhythmic agents) at a mean 20-month follow-up (1). Patients with right ventricular outflow tract (RVOT) ectopy fared best; however, the recurrence rate in these patients was a surprising 18%. In light of this experience, it is appropriate that we revisit RVOT ablation conceptually in an effort to improve both ablation efficiency and efficacy.The classical electrophysiological description of the RVOT with opposing planar septal and free wall surfaces provides an excellent construct for predicting geographical regions subtending VA origin; however, the 3-dimensional relationships of the great vessels are more complex, with ablation targets often not directly accessible from the endocardium. It is also useful to differentiate the "site of origin" from "site of successful ablation" for the VA; these sites are often spatially distinct with the former inaccessible to direct catheter mapping. Well known to cardiac anatomists, the presence of ventricular myocardial extensions beyond the pulmonic ventriculo-arterial junction were documented by Gami et al. in 74% of 602 autopsy specimens (2). They found both the prevalence and the length of these extensions above each of the pulmonic cusps were similar (anterior: 45%, 3.7 AE 2.2 mm; left: 52%, 3.6 AE 2.1 mm; and right: 60%, 4.0 AE 2.5 mm). Intercuspal myocardial extensions beyond the echocardiographic PV annulus were also present in 73% of hearts. Several reports have described mapping and ablation of VA within the pulmonary artery (PA) (3-5). Each of these used anterograde mapping of the PA, often at or above the level of the sinotubular junction. No consistent electrocardiographic signature for the VA in the PA is discernable from these studies; however, all reported a distinct electrophysiological hallmark: a sharp, delayed potential on the bipolar electrogram within the PA during sinus rhythm that reversed, becoming presystolic during the VA. The current approach to left ventricular (LV) outflow tract mapping of VA has occurred contemporaneously; numerous reports have described ablation within the aortic cusps to approach regions less readily accessible from the LV outflow tract. In light of the similar anatomical configurations of the great vessels, the potential value of ablation within the pulmonic cusps is self-evident. The report by Liao et al. (6) in this issue of the Journal provides detailed information regarding the anatomic, electrocardiographic, and electrophysiological characteristics of VA successfully eliminated with ablation from the pulmonary cusps. Their cohort of 24 patients was taken from a larger series of 244 patients presenting with idiopathic left bundle inferior axis VA referred for catheter ...

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Impact of earliest activation site location in the septal right ventricular outflow tract for identification of left vs right outflow tract origin of idiopathic ventricular arrhythmias

Cited by 24 publications

References 18 publications

Quantitative Analysis of Electro-Anatomical Maps: Application to an Experimental Model of Left Bundle Branch Block/Cardiac Resynchronization Therapy

Quantitative Analysis of Electro-Anatomical Maps: Application to an Experimental Model of Left Bundle Branch Block/Cardiac Resynchronization Therapy

The Efficacy of Isochronal 3D Mapping-Based Ablation of Ventricular Arrhythmia

Pulmonic Cusp Ablation

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