In silico pace-mapping: prediction of left vs. right outflow tract origin in idiopathic ventricular arrhythmias with patient-specific electrophysiological simulations

Abstract Aims A pre-operative non-invasive identification of the site of origin (SOO) of outflow tract ventricular arrhythmias (OTVAs) is important to properly plan radiofrequency ablation procedures. Although some algorithms based on electrocardiograms (ECGs) have been developed to predict left vs. right ventricular origins, their accuracy is still limited, especially in complex anatomies. The aim of this work is to use patient-specific electrophysiological simulations of the heart to predict the SOO in OTVA patients. Methods and results An in silico pace-mapping procedure was designed and used on 11 heart geometries, generating for each case simulated ECGs from 12 clinically plausible SOO. Subsequently, the simulated ECGs were compared with patient ECG data obtained during the clinical tachycardia using the 12-lead correlation coefficient (12-lead ρ). Left ventricle (LV) vs. right ventricle (RV) SOO was estimated by computing the LV/RV ratio for each patient, obtained by dividing the average 12-lead ρ value of the LV- and RV-SOO simulated ECGs, respectively. Simulated ECGs that had virtual sites close to the ablation points that stopped the arrhythmia presented higher correlation coefficients. The LV/RV ratio correctly predicted LV vs. RV SOO in 10/11 cases; 1.07 vs. 0.93 P < 0.05 for 12-lead ρ. Conclusion The obtained results demonstrate the potential of the developed in silico pace-mapping technique to complement standard ECG for the pre-operative planning of complex ventricular arrhythmias.

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87Non-invasive virtual prediction of site of origin in outflow tract ventricular arrhythmias with a patient-specific computational model

European Heart Journal ◽

10.1093/eurheartj/ehx501.87 ◽

2017 ◽

Vol 38 (suppl_1) ◽

Author(s):

R. Doste ◽

D. Soto-Iglesias ◽

G. Bernardino ◽

R. Sebastian ◽

M. Sermesant ◽

...

Keyword(s):

Computational Model ◽

Ventricular Arrhythmias ◽

Outflow Tract ◽

Patient Specific

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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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A Combined In Vivo, In Vitro, In Silico Approach for Patient-Specific Haemodynamic Studies of Aortic Dissection

Annals of Biomedical Engineering ◽

10.1007/s10439-020-02603-z ◽

2020 ◽

Vol 48 (12) ◽

pp. 2950-2964

Author(s):

Mirko Bonfanti ◽

Gaia Franzetti ◽

Shervanthi Homer-Vanniasinkam ◽

Vanessa Díaz-Zuccarini ◽

Stavroula Balabani

Keyword(s):

Aortic Dissection ◽

In Silico ◽

Clinical Decision ◽

Patient Specific ◽

Type B ◽

Non Invasive ◽

Cfd Models ◽

Numerical Predictions

AbstractThe optimal treatment of Type-B aortic dissection (AD) is still a subject of debate, with up to 50% of the cases developing late-term complications requiring invasive intervention. A better understanding of the patient-specific haemodynamic features of AD can provide useful insights on disease progression and support clinical management. In this work, a novel in vitro and in silico framework to perform personalised studies of AD, informed by non-invasive clinical data, is presented. A Type-B AD was investigated in silico using computational fluid dynamics (CFD) and in vitro by means of a state-of-the-art mock circulatory loop and particle image velocimetry (PIV). Both models not only reproduced the anatomical features of the patient, but also imposed physiologically-accurate and personalised boundary conditions. Experimental flow rate and pressure waveforms, as well as detailed velocity fields acquired via PIV, are extensively compared against numerical predictions at different locations in the aorta, showing excellent agreement. This work demonstrates how experimental and numerical tools can be developed in synergy to accurately reproduce patient-specific AD blood flow. The combined platform presented herein constitutes a powerful tool for advanced haemodynamic studies for a range of vascular conditions, allowing not only the validation of CFD models, but also clinical decision support, surgical planning as well as medical device innovation.

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Idiopathic Outflow Tract Ventricular Arrhythmia Ablation: Pearls and Pitfalls

Arrhythmia & Electrophysiology Review ◽

10.15420/aer.2019.6.2 ◽

2019 ◽

Vol 8 (2) ◽

pp. 116-121 ◽

Cited By ~ 1

Author(s):

Jackson J Liang ◽

Yasuhiro Shirai ◽

Aung Lin ◽

Sanjay Dixit

Keyword(s):

Ventricular Arrhythmias ◽

Left Ventricular Systolic Dysfunction ◽

Systolic Dysfunction ◽

Structural Heart Disease ◽

Careful Analysis ◽

Intracardiac Echocardiography ◽

Left Ventricular ◽

Outflow Tract ◽

Successful Ablation ◽

Pace Mapping

Idiopathic outflow tract ventricular arrhythmias (VAs) occur typically in patients without structural heart disease. They are often symptomatic and can sometimes lead to left ventricular systolic dysfunction. Both activation and pace mapping are utilised for successful ablation of these arrhythmias. Pace mapping is particularly helpful when the VA is infrequent and/or cannot be elucidated during the ablation procedure. VAs originating from different sites in the outflow tract region have distinct QRS patterns on the 12-lead ECG and careful analysis of the latter can help predict the site of origin of these arrhythmias. Successful ablation of these VAs requires understanding of the detailed anatomy of the OT region, which can be accomplished through electroanatomic mapping tools and intracardiac echocardiography.

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Utility of automated template matching for the interpretation of pace mapping in patients ablated due to outflow tract ventricular arrhythmias

EP Europace ◽

10.1093/europace/euu392 ◽

2015 ◽

Vol 17 (9) ◽

pp. 1428-1434 ◽

Cited By ~ 4

Author(s):

Rafal Kuteszko ◽

Mariusz Pytkowski ◽

Michal M. Farkowski ◽

Aleksander Maciag ◽

Maciej Sterlinski ◽

...

Keyword(s):

Template Matching ◽

Ventricular Arrhythmias ◽

Outflow Tract ◽

Pace Mapping

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In-Silico Evaluation of an Iterative Pace-Mapping Technique to Guide Catheter Ablation of Ventricular Ectopy

2019 Computing in Cardiology Conference (CinC) ◽

10.22489/cinc.2019.351 ◽

2019 ◽

Author(s):

Andony Arrieula ◽

Hubert Cochet ◽

Pierre Jaïs ◽

Michel Haïssaguerre ◽

Mark Potse

Keyword(s):

Catheter Ablation ◽

In Silico ◽

Mapping Technique ◽

Ventricular Ectopy ◽

Guide Catheter ◽

Pace Mapping

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Characteristics and outcomes of pace mapping for ablation of premature ventricular complexes

European Heart Journal ◽

10.1093/ehjci/ehaa946.0419 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M.J.B Kemme ◽

R Ozer ◽

M.J Mulder ◽

H.A Hauer ◽

G.J.M Tahapary ◽

...

Keyword(s):

Ventricular Outflow Tract ◽

Left Ventricular ◽

Outflow Tract ◽

Mapping Technique ◽

Premature Ventricular Complexes ◽

Successful Ablation ◽

Mapping System ◽

Ablation Success ◽

Pace Mapping ◽

Activation Mapping

Abstract Background/Introduction Activation mapping is the “gold standard” for localisation of the site of origin during mapping and ablation of symptomatic premature ventricular complexes (PVC). In case of suppression of PVCs during the procedure, the origin of the PVC can be located using a pace mapping technique. The PASO module is an addition in the CARTO3 mapping system that calculates the correlation between the induced and observed 12-lead ECG PVC morphology, and visualises this correlation on an isochronal 3D colour map. Purpose The aim of this study was to compare the follow-up success rate of pace mapping using the PASO module and activation mapping and to determine cut-off values for clinical success. Methods Seventy-six consecutive ablation procedures of symptomatic PVCs were included in this single-center retrospective study. Mapping and ablation parameters were derived from the CARTO3 mapping system. Ablation success was defined as a ≥95% reduction in PVC burden on 24-hour Holter recordings or absence of the clinical PVC on multiple ECGs in case of multiple PVC morphologies. Logistic regression analysis was performed to evaluate the relationship between applied mapping methods and ablation parameters. Optimal cut-off values of ablation characteristics for successful ablation were determined using ROC curves. Results Thirty-five (46%) patients were male and 39 (51%) patients had a reduced left ventricular ejection fraction. Pace mapping was used in 36 (47%) patients. Baseline PVC burden was lower in patients when pace mapping was applied (18% vs. 28%, p<0.001). The use of either mapping technique was influenced by PVC localisation (p=0.004). Pace mapping was used predominantly in the right ventricular outflow tract (n=21/31) whereas activation mapping was used predominantly in the left ventricle (n=14/22) and left ventricular outflow tract (n=7/7). Ablation success did not differ between activation mapping (77.5%) and pace mapping (77.8%). Median [IQR] maximum PASO correlation was 98.2% [97.1–98.6] for successful ablations and 96.5% [92.9–97.5] for unsuccessful ablations (p=0.030). The optimal cut-off value for successful ablation of the PASO correlation was 97.6% (AUC 0.754, sensitivity 68%, specificity 88%). There were no significant differences in other ablation parameters between both groups. Conclusion This study indicates that pace mapping using PASO is a good alternative for activation mapping for localisation of the PVC. A minimum PASO correlation coefficient of 97.6% is the optimal cut-off value for successful PVC ablation. ROC of maximum PASO coefficient Funding Acknowledgement Type of funding source: None

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