A Novel Algorithm for Determining Endocardial VT Exit Site from 12-Lead Surface ECG Characteristics in Human, Infarct-Related Ventricular Tachycardia

Verapamil-sensitive fascicular ventricular tachycardia (VT) is the most common form of idiopathic left VT. According to the QRS morphology and the successful ablation site, left fascicular VT can be classified into three subgroups: left posterior fascicular VT, whose QRS morphology shows right bundle branch block (RBBB) configuration and superior axis (common form); left anterior fascicular VT, whose QRS morphology shows RBBB configuration and right-axis deviation (uncommon form), and upper septal fascicular VT, whose QRS morphology shows narrow QRS configuration and normal or right-axis deviation (rare form). Posterior and anterior fascicular VT can be successfully ablated at the posterior or anterior mid-septum with a diastolic Purkinje potential during VT or at the VT exit site with a fused pre-systolic Purkinje potential. Upper septal fascicular VT can also be ablated at the site with diastolic Purkinje potential at the upper septum. Recognition of the heterogeneity of this VT and its unique characteristics should facilitate appropriate diagnosis and therapy.

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Abstract 16187: Validation of Novel Algorithm to Automate Detection of Fractionated Electrograms During Ventricular Tachycardia (VT) Ablation

Circulation ◽

10.1161/circ.132.suppl_3.16187 ◽

2015 ◽

Vol 132 (suppl_3) ◽

Author(s):

Pouria Alipour ◽

Yaariv Khaykin ◽

Meysam Pirbaglou ◽

Paul Ritvo ◽

Gal Hayam ◽

...

Keyword(s):

Ventricular Tachycardia ◽

Area Under The Curve ◽

High Sensitivity ◽

Left Ventricular ◽

Target Area ◽

Automate Detection ◽

Noise Threshold ◽

Vt Ablation ◽

Patient At Risk ◽

Novel Algorithm

Introduction: Ablation of ventricular tachycardia (VT) substrate in patient at risk for VT in the setting of ischemic heart disease is a technically challenging procedure. We thought to evaluate a novel algorithm used to automatically identify target electrograms. Methods: 16 consecutive patients (70±10 years of age, 90% male, 34±18% LV EF) had 20 ablations for ischemic VT using CARTO 3 mapping system over 2 years. Left ventricular (LV) substrate was mapped during right ventricular (RV) apical stimulation. Navistar Thermocool 3.5 mm irrigated tip catheters were used in all patients. A novel algorithm counting the number of electrogram deflections (NOD) crossing the 0.05mV noise threshold and duration of time from first to last such deflection during the window of interest (total fractionation time, TFT) was applied to all acquired maps after ablation was complete. Snapshots of 200 electrograms representing the high and low end of TFT and NOD values were presented to a group of 8 electrophysiologists experienced in VT ablation who were asked to select electrograms they would target for substrate ablation. The diagnostic accuracy of TFT and NOD values was then analysed. Results: Across the range of TFT values (0.0-281.0 ms), a cut-off value of 49.0 ms (81.6% sensitivity, 57% specificity) was established as an optimal indicator of an ablation target. Area under the curve for TFT was 0.675 (95% CI: 0.59-0.75, p=0.001). For NOD values (0.0-70.0 deflections), a cut off of 4.5 deflections (88.0% Sensitivity, 57 % specificity) was established as an optimal indicator of an ablation target. The area under the curve for NOD yielded an area of 0.75 (95% CI: 0.68-0.82, P=0.001). For TFT-NOD product as a variable, a cut-off value of 64 (91.0% Sensitivity, 52.4 % specificity) an optimal indicator of an ablation target. The Area under the curve for NOD and TFT multiple was 0.72 (95% CI: 0.65-0.80, P=0.001). Conclusion: A novel algorithm may be able to automatically classify LV substrate during mapping and ablation of ischemic VT with high sensitivity and acceptable specificity.

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Non-invasive Cardiac Radiation for Ablation of Ventricular Tachycardia: a New Therapeutic Paradigm in Electrophysiology

Arrhythmia & Electrophysiology Review ◽

10.15420/aer.7.1.eo1 ◽

2018 ◽

Vol 7 (1) ◽

pp. 8 ◽

Cited By ~ 10

Author(s):

Eun-Jeong Kim ◽

Giovanni Davogustto ◽

William G Stevenson ◽

Roy M John ◽

◽

...

Keyword(s):

Ventricular Tachycardia ◽

Cardiac Tissue ◽

Imaging Techniques ◽

Case Series ◽

Structural Heart Disease ◽

Multicenter Studies ◽

Invasive Approach ◽

Non Invasive ◽

Surface Ecg ◽

Early Case

Non-invasive ablation of cardiac tissue to control ventricular tachycardia (VT) is a novel therapeutic consideration in the management of ventricular arrhythmias associated with structural heart disease. The technique involves the use of stereotactic radiotherapy delivered to VT substrates. Although invasive mapping can be used to identify the target, the use of non-invasive ECG and imaging techniques combined with multi-electrode body-surface ECG recordings offers the potential of a completely non-invasive approach. Early case series have demonstrated a consistent decrease in VT burden and sufficient early safety to allow more detailed multicenter studies. Such studies are currently in progress to further evaluate this promising technology.

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Abstract 5690: Idiopathic Catecholamine-sensitive Epicardial Ventricular Tachycardia At The Crux Of The Heart

Circulation ◽

10.1161/circ.118.suppl_18.s_985-a ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Harish Doppalapudi ◽

Karthik Ramaswamy ◽

Joon Ahn ◽

Takumi Yamada ◽

G Neal Kay

Keyword(s):

Ventricular Tachycardia ◽

Catheter Ablation ◽

Coronary Sinus ◽

Clinical Syndrome ◽

Epicardial Surface ◽

Surface Ecg ◽

Coronary Venous System ◽

The Right ◽

Mean Cycle ◽

Middle Cardiac Vein

Idiopathic ventricular tachycardia (VT) has been described from the epicardial surface of the left ventricle (LV), usually near the summit of the LV in the outflow tract. Ablation of these VTs may be possible by delivery of energy within the coronary venous system or directly on the epicardial surface. We describe a distinct syndrome of focal epicardial VT induced by catecholamine infusion that arises from the crux of the heart. Among 340 cases of idiopathic VT referred for catheter ablation, 4 patients were identified with a clinical syndrome of catecholamine sensitive VT that was mapped to the epicardial surface at the crux of the heart. There were 3 males and 1 female (age 31–79 yrs, mean 58). VT was sustained in all patients and associated with syncope or near syncope in 3 of 4 pts. The LVEF was >0.55 in 3 pts and mildly depressed (0.45) in 1 pt. In all pts VT could be induced with programmed stimulation or burst pacing from the right ventricular apex but required the infusion of isoproterenol for induction in 3. The VT was very rapid with a mean cycle length of 264 msec. The surface ECG during VT demonstrated a left superior axis QRS morphology in all pts, with an abrupt precordial tansition from V1 to V2 in 3 pts and R waves across the precordium in one. The precordial maximal deflection index was > 0.55 in all pts (mean 0.67). The site of earliest activation during intracardiac mapping occurred at the crux of the heart with activation in the middle cardiac vein or proximal coronary sinus recorded 20 –50 msec (mean −38 msec) prior to the onset of the surface QRS. Catheter ablation with irrigated RF was attempted within the middle cardiac vein or proximal coronary sinus in all pts and was successful in 1. In 2 of 3 remaining pts, percutaneous epicardial RF ablation was attempted and was successful. Simultaneous coronary angiography demonstrated the site of earliest activation within 5–10 mm of the proximal posterior descending coronary artery (PDA). There was no acute narrowing of the PDA in any pt following ablation. Idiopathic VT may arise from the epicardial surface at the crux of the heart in close proximity to the PDA. This syndrome can result in very rapid, catecholamine sensitive VT, and may require careful attention to the PDA during ablation.

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