P882Correlation between late gadolinium enhancement assessment of atrial scar and low voltage areas detected by endocardial voltage mapping

Background: Electroanatomic voltage mapping (EVM) is a promising modality for guiding endomyocardial biopsies (EMBs). However, few data support its feasibility and safety. We now report the largest cohort of patients undergoing EVM-guided EMBs to show its diagnostic yield and to compare it with a cardiac magnetic resonance (CMR)–guided approach. Methods: We included 162 consecutive patients undergoing EMB at our institution from 2010 to 2019. EMB was performed in pathological areas identified at EVM and CMR. CMR and EVM sensitivity and specificity regarding the identification of pathological substrates of myocardium were evaluated according to EMB results. Results: Preoperative CMR showed late gadolinium enhancement in 70% of the patients, whereas EVM identified areas of low voltage in 61%. Right (73%), left (19%), or both ventricles (8%) underwent sampling. EVM proved to have sensitivity similar to CMR (74% versus 77%), with specificity being 70% and 47%, respectively. In 12 patients with EMB-proven cardiomyopathy, EVM identified pathological areas that had been undetected at CMR evaluation. Sensitivity of pooled EVM and CMR was as high as 95%. EMB analysis allowed us to reach a new diagnosis, different from the suspected clinical diagnosis, in 39% of patients. The complications rate was low, mostly related to vascular access, with no patients requiring urgent management. Conclusions: EVM proved to be a promising tool for targeted EMB because of its sensitivity and specificity for identification of myocardial pathological substrates. EVM was demonstrated to have accuracy similar to CMR. EVM and CMR together conferred a positive predictive value of 89% on EMB.

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Characteristics of Patients With Arrhythmogenic Left Ventricular Cardiomyopathy

Circulation Arrhythmia and Electrophysiology ◽

10.1161/circep.120.009005 ◽

2020 ◽

Vol 13 (12) ◽

Author(s):

Michela Casella ◽

Alessio Gasperetti ◽

Rita Sicuso ◽

Edoardo Conte ◽

Valentina Catto ◽

...

Keyword(s):

Late Gadolinium Enhancement ◽

Right Ventricular ◽

Genetic Variants ◽

Task Force ◽

Arrhythmogenic Right Ventricular Cardiomyopathy ◽

Left Ventricular ◽

Ventricular Cardiomyopathy ◽

Gadolinium Enhancement ◽

Voltage Mapping ◽

Fatty Replacement

Background: Arrhythmogenic left ventricular cardiomyopathy (ALVC) is an under-characterized phenotype of arrhythmogenic cardiomyopathy involving the LV ab initio. ALVC was not included in the 2010 International Task Force Criteria for arrhythmogenic right ventricular cardiomyopathy diagnosis and data regarding this phenotype are scarce. Methods: Clinical characteristics were reported from all consecutive patients diagnosed with ALVC, defined as a LV isolated late gadolinium enhancement and fibro-fatty replacement at cardiac magnetic resonance plus genetic variants associated with arrhythmogenic right ventricular cardiomyopathy and of an endomyocardial biopsy showing fibro-fatty replacement complying with the 2010 International Task Force Criteria in the LV. Results: Twenty-five patients ALVC (53 [48–59] years, 60% male) were enrolled. T wave inversion in infero-lateral and left precordial leads were the most common ECG abnormalities. Overall arrhythmic burden at study inclusion was 56%. Cardiac magnetic resonance showed LV late gadolinium enhancement in the LV lateral and posterior basal segments in all patients. In 72% of the patients an invasive evaluation was performed, in which electroanatomical voltage mapping and electroanatomical voltage mapping-guided endomyocardial biopsy showed low endocardial voltages and fibro-fatty replacement in areas of late gadolinium enhancement presence. Genetic variants in desmosomal genes (desmoplakin and desmoglein-2) were identified in 12/25 of the cohort presenting pathogenic/likely pathogenic variants. A definite/borderline 2010 International Task Force Criteria arrhythmogenic right ventricular cardiomyopathy diagnosis was reached only in 11/25 patients. Conclusions: ALVC presents with a preferential involvement of the lateral and postero-lateral basal LV and is associated mostly with variants in desmoplakin and desmoglein-2 genes. An amendment to the current International Task Force Criteria is reasonable to better diagnose patients with ALVC.

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Agreement between gadolinium-enhanced cardiac magnetic resonance and electro-anatomical maps in patients with non-ischaemic dilated cardiomyopathy and ventricular arrhythmias

EP Europace ◽

10.1093/europace/euz127 ◽

2019 ◽

Vol 21 (9) ◽

pp. 1392-1399

Author(s):

Federica Torri ◽

Csilla Czimbalmos ◽

Livio Bertagnolli ◽

Sabrina Oebel ◽

Andreas Bollmann ◽

...

Keyword(s):

Ventricular Tachycardia ◽

Cardiac Magnetic Resonance ◽

Late Gadolinium Enhancement ◽

Magnetic Resonance ◽

Dilated Cardiomyopathy ◽

Ventricular Arrhythmias ◽

Low Voltage ◽

Gadolinium Enhancement ◽

Lge Cmr ◽

Good Agreement

Abstract Aims We sought to investigate the overlap between late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR) and electro-anatomical maps (EAM) of patients with non-ischaemic dilated cardiomyopathy (NIDCM) and how it relates with the outcomes after catheter ablation of ventricular arrhythmias (VA). Methods and results We identified 50 patients with NIDCM who received CMR and ablation for VA. Late gadolinium enhancement was detected in 16 (32%) patients, mostly in those presenting with sustained ventricular tachycardia (VT): 15 patients. Low-voltage areas (<1.5 mV) were observed in 23 (46%) cases; in 7 (14%) cases without evidence of LGE. Using a threshold of 1.5 mV, a good and partially good agreement between the bipolar EAM and LGE-CMR was observed in only 4 (8%) and 9 (18%) patients, respectively. With further adjustments of EAM to match the LGE, we defined new cut-off limits of median 1.5 and 5 mV for bipolar and unipolar maps, respectively. Most VT exits (12 out of 16 patients) were found in areas with LGE. VT exits were found in segments without LGE in two patients with VT recurrence as well as in two patients without recurrence, P = 0.77. In patients with VT recurrence, the LGE volume was significantly larger than in those without recurrence: 12% ± 5.8% vs. 6.9% ± 3.4%; P = 0.049. Conclusions In NIDCM, the agreement between LGE and bipolar EAM was fairly poor but can be improved with adjustment of the thresholds for EAM according to the amount of LGE. The outcomes were related to the volume of LGE.

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Abstract 5929: Evaluation of Myocardial Substrate with MRI Late Gadolinium Enhancement Allows for Earlier Detection of Cardiac Involvement Compared with Morphological Assessment in Primary AL Amyloidosis

Circulation ◽

10.1161/circ.118.suppl_18.s_1032 ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Imran Syed ◽

James Glockner ◽

DaLi Feng ◽

Philip A Araoz ◽

Matthew Martinez ◽

...

Keyword(s):

Late Gadolinium Enhancement ◽

Cardiac Involvement ◽

Low Voltage ◽

Left Ventricular ◽

Common Finding ◽

Morphological Evidence ◽

Al Amyloidosis ◽

Gadolinium Enhancement ◽

Myocardial Substrate ◽

Morphological Assessment

Objective: In AL amyloidosis, early detection of cardiac involvement is desirable because of prognostic and therapeutic implications. Recent pilot MRI studies have demonstrated that late gadolinium enhancement (LGE) is a common finding in cardiac amyloidosis (CA) and reflects interstitial expansion due to amyloid infiltration. However it is not known whether evaluation of the myocardial substrate via LGE MRI may allow for earlier detection of CA compared with morphological assessment on the basis of increased left ventricular thickness (LVT). Methods: Between January 2006 and December 2007, 100 patients with confirmed AL amyloidosis underwent LGE MRI at our institution to evaluate for CA. Morphological evidence of CA was considered to be present when LVT was increased (mean of septum and inferolateral wall > 12 mm). LGE images were analyzed for presence and pattern of LGE. Clinical data was also reviewed. Results: Increased LVT was present in 69 patients. Abnormal LGE images were present in 76 patients (global diffuse transmural or subendocardial LGE in 43, suboptimally nulled myocardium in 18, and focal patchy LGE in 15 patients). LGE was present in 21 of 22 patients with a diagnosis of CA on cardiac biopsy. Seven patients (10%) with increased LVT did not have LGE. Conversely of 31 pts with normal LVT, 14 (45%) had abnormal LGE on MRI (usually suboptimally nulled myocardium or focal patchy LGE) and also had significantly higher incidence of low voltage ECG (50% vs. 0%), lower absolute limb lead voltage (6.5±3 vs. 9.7±2.6 mm), increased RV thickness (4.9±1.1 vs. 4.1±1) and higher BNP (316±376 vs. 107±103) compared to 17 patients without LGE (Table 1 ). Conclusions: MRI LGE is common in patients with CA and evaluation of the myocardial substrate using this technique may allow for earlier detection of cardiac involvement in AL amyloidosis compared with morphological assessment on the basis of increased LVT.

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Comparison of electroanatomic voltage mapping with late gadolinium enhancement CMR

Journal of Cardiovascular Magnetic Resonance ◽

10.1186/1532-429x-16-s1-p153 ◽

2014 ◽

Vol 16 (S1) ◽

Author(s):

Dana C Peters ◽

Warren J Manning ◽

Mark E Josephson ◽

James S Duncan ◽

Sudhakar Chelikani

Keyword(s):

Late Gadolinium Enhancement ◽

Gadolinium Enhancement ◽

Voltage Mapping

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Association of left ventricular late gadolinium enhancement with left atrial low voltage areas in patients with atrial fibrillation

EP Europace ◽

10.1093/europace/euy013 ◽

2018 ◽

Vol 20 (10) ◽

pp. 1606-1611

Author(s):

Clara Stegmann ◽

Cosima Jahnke ◽

Ingo Paetsch ◽

Sebastian Hilbert ◽

Arash Arya ◽

...

Keyword(s):

Atrial Fibrillation ◽

Late Gadolinium Enhancement ◽

Left Atrial ◽

Low Voltage ◽

Left Ventricular ◽

Gadolinium Enhancement

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Three-dimensional late gadolinium enhancement increases the diagnostic yield of cardiovascular magnetic resonance to detect low voltage in the right ventricular outflow tract

EP Europace ◽

10.1093/europace/euab116.048 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

A Parreira ◽

A Ferreira ◽

P Carmo ◽

D Mesquita ◽

R Marinheiro ◽

...

Keyword(s):

Late Gadolinium Enhancement ◽

Low Voltage ◽

Three Dimensional ◽

Right Ventricular Outflow Tract ◽

Ventricular Outflow Tract ◽

Outflow Tract ◽

Gadolinium Enhancement ◽

Structural Abnormalities ◽

The Right ◽

Lge Cmr

Abstract Funding Acknowledgements Type of funding sources: None. Background Cardiac magnetic resonance (CMR) using late gadolinium enhancement (LGE) fails to detect scar tissue in patients with electroanatomical abnormalities and biopsy-proven structural heart disease. It has shown conflicting data regarding existence of structural abnormalities in patients with idiopathic premature ventricular contractions (PVCs) from the right ventricular outflow tract (RVOT). Three- dimensional (3D) LGE enables high-spatial resolution more appropriate to the thin-walled right ventricle than two-dimensional (2D) LGE. Objective Our aim was to evaluate if the use of 3D-LGE would improve the performance of CMR to detect low voltage areas in the RVOT of patients with PVCs. Methods Since May 2020 we performed 3D-LGE CMR in 11 consecutive patients that underwent ablation of frequent PVCs. A control group of 11 consecutive patients that underwent catheter ablation by the same operator and had a 2D-LGE CMR performed before ablation was also studied. All patients had normal 2D-LGE CMR. A 3D electroanatomical bipolar voltage map of the RVOT was performed in sinus rhythm (0.5 mV-1.5 mV colour display). Areas with electrograms <1.5 mV represented the LVA. The area adjacent to the pulmonary valve usually displays voltage between 0.5 and 1.5 mV and is classified as transitional-voltage zone. Presence of LVAs outside this transitional-voltage zone were estimated. We compared the accuracy of CMR for detecting LVA in the two groups: 3D LGE and 2D LGE. Results The median number of points used for the voltage map was 344 (242-450). 18 patients (82%) displayed LVAs. The site of origin of the PVCs was the RVOT in 17 patients and the left ventricular outflow tract (LVOT) in 5. Comparison between groups is displayed in the table. 2D LGE CMR failed to demonstrate abnormalities of the RVOT in any of the patients that presented with LVAs. 3D CMR showed presence of fibrosis (Figure) in 3 out of 9 patients with LVAs (33%). Conclusion CMR using 3-D LGE techniques showed an increased power to diagnose structural abnormalities. This technique may be a better choice in initial stages of RVOT disease. All sampleN = 223D-LGE CMRN = 112D-LGE CMRN = 11p-valueAge in years, median (Q1-Q3)47 (35-68)62 (34-55)42 (34-55)0.243Male gender, n (%)8 (36)3 (27)5 (46)0.330PVCs RVOT/LVOT17/59/28/30.500Nº points in the map, median (Q1-Q3)344 (242-450)350 (259-450)300 (158-345)0.076Low voltage areas, n (%)18 (82)9 (82)9 (82)0.707Abstract Figure.

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