Noninvasive Electrocardiographic Imaging of Arrhythmogenic Substrates and Ventricular Arrhythmias in Patients

Abstract Background Correct preoperative topical diagnostics of atrial and ventricular arrhythmias allows for operation time reduction by facilitating the ablation target localization, especially in case of several ectopic sources. Purpose To implement a non-invasive electrocardiographic imaging (ECGI) technique in CARTO system for aiming at topical diagnostics of focal arrhythmias improving. Methods Twelve patients (m/f – 10/2, age (min–max) – 50,5 (32–71)) with focal arrhythmias underwent ECGI in combination with CT or MR imaging. Two subjects had atrial premature contractions (PAC), while ten patients suffered from ventricular premature contractions (PVC) with indications for ablation. Before the ablation procedure Carto LAT mapping was performed in all patients. Using ECGI epi-/endocardial polygonal models of the heart were created, isopotential and activation maps were calculated, uploaded into the Carto system and merged with the CARTO FAM models (Figure 1). Results For six patients with PVC and two patients with PAC, earliest activation zones (EAZs) anatomical locations obtained by invasive and non-invasive methods were the same (RVOT septum, RVOT lateral-anterior and RV lateral-basal walls, right aortic cusp, LVOT, coronary sinus (CS), CS ostium, RA posterior wall), and arrhythmias ablation was successful. Two patients featured coherent EAZs (RV lateral-basal wall and RVOT septum) but a negative ablation outcome. In one patient, EAZs were situated in different anatomical regions: CARTO showed the PVC EAZ in RV septum, whereas Amycard system identified endocardial surface of lateral-basal RV wall. In this patient, PVC was ablated partially. For another patient with MRI late enhancement area in LV lateral wall the EAZs were in the same LV segment but with mismatch in epi/endocardial surface. Conclusion Non-invasive and invasive activation maps merge can improve localization of ablation targets in focal arrhythmias, potentially increasing effectiveness of the EP procedure and reducing operation time.

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Topical diagnosis of polymorphic ventricular arrhythmias by noninvasive electrocardiographic imaging

Journal of Electrocardiology ◽

10.1016/j.jelectrocard.2013.05.108 ◽

2013 ◽

Vol 46 (4) ◽

pp. e29

Author(s):

M.P. Chmelevsky ◽

S.V. Zubarev ◽

T.V. Treshkur ◽

D.S. Lebedev

Keyword(s):

Ventricular Arrhythmias ◽

Electrocardiographic Imaging ◽

Topical Diagnosis

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Electrocardiographic Imaging for Atrial Fibrillation: A Perspective From Computer Models and Animal Experiments to Clinical Value

Frontiers in Physiology ◽

10.3389/fphys.2021.653013 ◽

2021 ◽

Vol 12 ◽

Author(s):

João Salinet ◽

Rubén Molero ◽

Fernando S. Schlindwein ◽

Joël Karel ◽

Miguel Rodrigo ◽

...

Keyword(s):

Atrial Fibrillation ◽

Electrical Activity ◽

Ventricular Arrhythmias ◽

Animal Experiments ◽

Computer Models ◽

Clinical Results ◽

Clinical Value ◽

Electrocardiographic Imaging ◽

Human Experiments

Electrocardiographic imaging (ECGI) is a technique to reconstruct non-invasively the electrical activity on the heart surface from body-surface potential recordings and geometric information of the torso and the heart. ECGI has shown scientific and clinical value when used to characterize and treat both atrial and ventricular arrhythmias. Regarding atrial fibrillation (AF), the characterization of the electrical propagation and the underlying substrate favoring AF is inherently more challenging than for ventricular arrhythmias, due to the progressive and heterogeneous nature of the disease and its manifestation, the small volume and wall thickness of the atria, and the relatively large role of microstructural abnormalities in AF. At the same time, ECGI has the advantage over other mapping technologies of allowing a global characterization of atrial electrical activity at every atrial beat and non-invasively. However, since ECGI is time-consuming and costly and the use of electrical mapping to guide AF ablation is still not fully established, the clinical value of ECGI for AF is still under assessment. Nonetheless, AF is known to be the manifestation of a complex interaction between electrical and structural abnormalities and therefore, true electro-anatomical-structural imaging may elucidate important key factors of AF development, progression, and treatment. Therefore, it is paramount to identify which clinical questions could be successfully addressed by ECGI when it comes to AF characterization and treatment, and which questions may be beyond its technical limitations. In this manuscript we review the questions that researchers have tried to address on the use of ECGI for AF characterization and treatment guidance (for example, localization of AF triggers and sustaining mechanisms), and we discuss the technological requirements and validation. We address experimental and clinical results, limitations, and future challenges for fruitful application of ECGI for AF understanding and management. We pay attention to existing techniques and clinical application, to computer models and (animal or human) experiments, to challenges of methodological and clinical validation. The overall objective of the study is to provide a consensus on valuable directions that ECGI research may take to provide future improvements in AF characterization and treatment guidance.

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A novel non-invasive electrocardiographic imaging technique facilitates the preprocedural diagnostic workup of patients with infrequent ventricular arrhythmias

EP Europace ◽

10.1093/europace/euab116.037 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

K Lesina ◽

MG Hoogendijk ◽

A De Wit ◽

E Peters ◽

T Szili- Torok

Keyword(s):

Ventricular Arrhythmias ◽

Cardiac Computed Tomography ◽

Treatment Success ◽

Outpatient Setting ◽

Anatomical Reconstruction ◽

Patient Specific ◽

Success Rates ◽

Electrocardiographic Imaging ◽

Non Invasive ◽

Group A

Abstract Funding Acknowledgements Type of funding sources: None. Background Catheter ablation (CA) fails in considerable numbers of patients with ventricular arrhythmias (VAs). Possible reasons include absence and non-inducibility, multifocal origin and anatomically difficult locations of premature ventricular complexes (PVCs) and ventricular tachycardias (VTs). A novel non-invasive electrocardiographic imaging (ECGI) diagnostic tool may help to determine the best treatment strategy of these patients. Purpose To evaluate outpatient ECGI (VIVO, View Into Ventricular Onset, Catheter Precision, NJ) to tailor treatment of patients with infrequent ventricular arrhythmias referred for CA. Methods Thirteen patients in an outpatient setting with VAs were included in this pilot-study. All patients underwent ECGI mapping using VIVO. It is a novel technique that localize the origin of VAs using a combination of 12-lead ECG and a patient specific 3D anatomical reconstruction of the heart and thorax using cardiac magnetic resonance imaging (MRI) or cardiac computed tomography imaging (CT). The technique is based on virtual simulation of pace-mapping and has a unique feature that the imaging can be performed independently from recording of the arrhythmias. Suitability for ablation was based on the VIVO mapping in this cohort. Results Among the 13 patients enrolled (10 female, 3 male, age 39 ±15 years), a total of 16 PVC/VT morphologies were analyzed using VIVO. Ten of them had a low PVC burden (<8%). Ten patients underwent pre-procedural cardiac MRI and 4 had CT imaging. Seven of the patients had structurally normal hearts, while the remaining 6 had non-ischemic cardiomyopathy. Based on the VIVO mapping findings the patients were divided in two groups. Group A: 7 patients in whom ablation was considered suitable. In this group a VIVO based anatomy CA was attempted in 3 patients for PVCs. Two out of these were successful. Three patients were offered CA but was declined by patient decision (suboptimal balance between burden, complaints and the offered success rates without procedural hard endpoint). Another patient is offered and is waiting for CA. The other group B: 6 patients in whom VIVO mapping was consistent with an unacceptable chance for treatment success were not offered CA. This included: 4 patients with a multifocal origin and a low burden of PVCs. One patient had different diagnosis (atrial fibrillation) and another had no PVC’s during 12-lead ECG monitoring. Conclusions Non-invasive ECGI pace-map is a unique tool that can identify the origin of infrequent VAs in an outpatient clinical setting in order to screen out patients not feasible for CA. Low burden PVCs maybe attempted to be ablated when the source is clearly associated of certain anatomical structures.

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Evaluation of noninvasive electrophysiological imaging accuracy for focal atrial arrhythmias

European Heart Journal ◽

10.1093/ehjci/ehaa946.3702 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M Budanova ◽

M Chmelevsky ◽

S Zubarev ◽

T Treshkur ◽

D Lebedev

Keyword(s):

Ventricular Arrhythmias ◽

High Accuracy ◽

Atrial Pacing ◽

Atrial Arrhythmias ◽

Electrocardiographic Imaging ◽

Epicardial Surface ◽

Atrial Contraction ◽

Premature Atrial Contraction ◽

Endocardial Surface ◽

The Right

Abstract Background High accuracy of noninvasive electrocardiographic imaging (ECGI) has recently been shown for topical diagnostics of ventricular arrhythmias. However, the precision of diagnostics of atrial focal arrhythmias requires clarification. To estimate the accuracy of ECGI for premature atrial contraction (PAC) we performed atrial pacing in patients with CRT system and compared early activation zone (EAZ) with pacemaker's tip location. Purpose To determine the accuracy of ECGI for focal atrial arrhythmias using atrial pacing. Methods Twenty-six patients (m/f – 18/9), age (min–max) 52 (26–78) with CRT system and pacemaker's tip location in the right atrium (RA) appendage underwent ECGI (“Amycard 01C”) in combination with CT or MR imaging. Thirty-four atrial pacing (mono- and bipolar) was performed in all patients using standard amplitude 1.5–3.8 mV. Epi-/endocardial polygonal heart models were created and isopotential maps were calculated. The distance between EAZ and the pacemaker's tip were measured for ECG recordings without using the isoline filter on endocardial surface (Fig. 1) as well as for epicardial surface. The time between epicardial and endocardial EAZ breakthrough was calculated also. Results On endocardial surface the EAZ was located in RA appendage, the base of superior cava vena or superior lateral RA wall. The distance (mm) (Me (min; max)) between EAZ and the pacemacer's tip was 28 (6; 68). For epicardial surface in most cases the EAZ was also located in RA appendage, the base of superior cava vena or superior lateral RA wall. In two cases the EAZ was located in inferior septal RA wall, in one case - in superior septal RA wall and in five cases the EAZ was undetectable. The distance between EAZ and the pacemacer's tip was 22 (6; 48). The time (ms) (Mean; Me (min; max)) between EAZ of the endocardial and epicardial surfaces was 16; 7 (0; 68). Conclusion ECGI allows to assess the location of focal atrial arrhythmias on endocardial surface and sometimes on epicardial surface also within the three segments. The results of this study revealed that accuracy of ECGI for atrial arrhythmias is worse than for ventricular arrhythmias. However, it is better on epicardial surface of atrium when EAZ can be determined. Funding Acknowledgement Type of funding source: None

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