Isolated Potentials During Sinus Rhythm and Pace-Mapping Within Scars as Guides for Ablation of Post-Infarction Ventricular Tachycardia

Bogun, Frank; Good, Eric; Reich, Stephen; Elmouchi, Darryl; Igic, Petar; Lemola, Kristina; Tschopp, David; Jongnarangsin, Krit; Oral, Hakan; Chugh, Aman; Pelosi, Frank; Morady, Fred

doi:10.1016/j.jacc.2005.12.062

Cited by 217 publications

(152 citation statements)

References 15 publications

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“…ILPs, which represent delayed activation of surviving muscle bundles within scarred myocardium, are now considered the most suitable targets for ablation of critical isthmuses of the circuits for reentrant tachycardias 4, 6, 7, 9. In clinical practice, these low‐amplitude late potentials are sought in and around low‐voltage areas.…”

Section: Discussionmentioning

confidence: 99%

“…Substrate mapping to identify the abnormal low‐voltage areas and the critical components of possible VT circuits (surviving myocardial bundles) is an effective strategy and often the only method available. Although several approaches have been utilized for substrate mapping,3, 4, 5, 6 one of the simplest and most direct is to record the isolated late potentials (ILPs) generated by the late activation of the isolated myocardial bundles during sinus rhythm5, 7, 8, 9 or ventricular pacing. This approach has two limitations.…”

Section: Introductionmentioning

confidence: 99%

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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: 99%

Section: Introductionmentioning

confidence: 99%

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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“…31,32 Of note, mapping of abnormal EGMs during RV pacing may be more sensitive than during normal sinus rhythm (NSR) or biventricular pacing due to a change in the direction of the activation wave front (see Figure 1). 33 Following substrate characterisation, VT induction is attempted ( Figure 2).…”

Section: Substrate Characterisationmentioning

confidence: 99%

Ventricular Tachycardia Ablation – The Right Approach for the Right Patient

Sadek¹,

Schaller²,

Supple³

et al. 2014

Arrhythm Electrophysiol Rev

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Scar-related reentrant ventricular tachycardia (VT) may be present in a variety of structural heart disease (SHD) phenotypes. In this setting, VT circuits are comprised of viable myocytes separated by fibrosis, allowing for the slow conduction needed to facilitate reentry.1,2 Aetiologies of fibrosis include ischaemic heart disease (IHD), inflammatory conditions, infiltrative cardiomyopathy, dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy and arrhythmogenic right ventricular (RV) dysplasia.Implantable cardioverter defibrillators (ICDs) are the mainstay of therapy for the prevention of sudden cardiac death in patients with SHD.3 However, ICD shocks are associated with diminished quality of life and increased mortality.4-6 Anti-arrhythmic drugs (AADs) have an important role in shock reduction; however these agents often have limited efficacy and significant side-effects. 7,8 Catheter ablation has assumed an increasingly important role in the management of VT. In patients with IHD and drug-refractory VT, ablation has been shown to reduce arrhythmia recurrence and ICD therapies. 9-11Patients who have VT rendered non-inducible by an ablation procedure have a lower VT recurrence rate and mortality compared with those who still have inducible arrhythmias after the ablation.12 Catheter ablation has also been shown to be effective in the treatment of VT storm in patients with SHD receiving chronic AAD therapy. 13In the setting of non-ischaemic SHD, catheter ablation outcome varies according to the nature of the underlying heart disease, with a greater need for epicardial mapping and ablation, higher recurrence rate and more AAD use in long-term follow-up.14-16 For the most part, VT ablation remains underutilised and some patients may benefit from earlier intervention. 17Although ablation also has an important role in the management of patients with idiopathic VT, this review will focus on ablation of scarrelated reentrant VT, the most common mechanism of monomorphic VT in patients with SHD. Pre-procedural PlanningHeart failure optimisation is important for decreasing the risk of Electrocardiographic CharacterisationTwelve-lead electrocardiograms (ECGs) of all clinical VTs are important in localising VT exit sites, identifying potential ablation targets and directing the best ablation strategy including possible epicardial access.In the setting of non-ischaemic IHD, morphological criteria suggesting Abstract Scar-related reentry is the most common mechanism of monomorphic ventricular tachycardia (VT) in patients with structural heart disease. Catheter ablation has assumed an increasingly important role in the management of VT in this setting, and has been shown to reduce VT recurrence and implantable cardioverter defibrillator (ICD) shocks. The approach to mapping and ablation will depend on the underlying heart disease etiology, VT inducibility and haemodynamic stability. This review explores pre-procedural planning, approach to ablation of both mappable and unmappable VT, and post-procedural testing. Future de...

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“…33,[56][57][58] The aim of LAVA ablation is the dissociation or isolation of surviving myocardial fibres within scar regions. 33 Importantly, the endpoint of LAVA-based ablation is complete LAVA elimination.…”

Section: A C B Dmentioning

confidence: 99%

New Ablation Technologies and Techniques

Mahida

Berte

Yamashita

et al. 2014

Arrhythmia &Amp; Electrophysiology Review

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Since the first catheter ablation for cardiac arrhythmia more than three decades ago, ablation technology has continually evolved at a rapid pace. Much of the early progress in the field was made in ablation of supraventricular tachycardias. Following a seminal study from Haïssaguerre et al. 1 in 1998, which demonstrated that pulmonary vein triggers are important sources of atrial fibrillation (AF), the approach to management of AF underwent a revolution. Electrical isolation of pulmonary veins (PVs) using catheter ablation became an established therapeutic strategy in patients with paroxysmal AF. During subsequent years, the role of ablation in AF expanded, and more extensive strategies involving ablation of non-pulmonary vein triggers and modification of the left atrial substrate were demonstrated to be effective, even in persistent forms of AF. New Technologies and Techniques for AF AblationCurrently, the most widely used technique for PV isolation involves delivery of point-by-point ablation lesions around the circumference of the vein. A number of different variations to the approach have been developed. During the early stages of PV isolation, a 'segmental approach' which involved targeting the earliest PV potentials at the ostium of the PV was commonly used. Due to high reconnection rates and the risk of PV stenosis, the technique has progressively been modified and the prevailing technique involves circumferential antral ablation to achieve PV isolation. AbstractCatheter ablation is an established treatment strategy for a range of different cardiac arrhythmias. Over the past decade two major areas of expansion have been ablation of atrial fibrillation (AF) and ventricular tachycardia (VT) in the context of structurally abnormal hearts. In parallel with the expanding role of catheter ablation for AF and VT, multiple novel technologies have been developed which aim to increase safety and procedural success. Areas of development include novel catheter designs, novel navigation technologies and higher resolution imaging techniques. The aim of the present review is to provide an overview of novel developments in AF ablation and VT ablation in patients with of structural cardiac diseases.

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Isolated Potentials During Sinus Rhythm and Pace-Mapping Within Scars as Guides for Ablation of Post-Infarction Ventricular Tachycardia

Cited by 217 publications

References 15 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 Tachycardia Ablation – The Right Approach for the Right Patient

New Ablation Technologies and Techniques

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