Initial Experience with High-density Mapping of Ischemic Ventricular Tachycardia Using a Narrow 0.1-mV to 0.25-mV Border-zone Window

Abstract Recurrent ventricular tachydisrhythmias (VT) episodes have a negative impact in the outcome of patients (P) already with an implantable cardioverter-defibrillator (ICD). Elimination of arrhythmic reentry circuits represents a difficult challenge, mainly due to the induction of intolerable VTs, with multiple ECG morphologies, requiring rapid interruption. Substrate guided ablation has been used as a promising approach strategy to treat recurrent VTs. Aim: to assess long-term results of a VT substrate-based ablation using high-density mapping in P with an ICD, severe left ventricular (LV) dysfunction and recurrent appropriate ICD therapy. Methods: 16P (12 men, non-ischemic cardiomyopathy 67%, 55 ± 13 years, LV ejection fraction 32 ± 6%) and recurrent appropriate shocks despite antiarrhythmic drug therapy and optimal heart failure medication. All P underwent a protocol of ventricular programmed stimulation (600 ms/S3) to obtain baseline VT documentation. A sinus rhythm (SR) voltage map was created using a 3D electroanatomic mapping system (CARTO) with a high-density mapping catheter (PentaRay) to delineate areas of scarred myocardium (ventricular bipolar voltage ≤0,5 mV – dense scar; 0,5-1,5 mV – border zone; ≥1,5 mV – healthy tissue) and provide high-resolution electrophysiological mapping. The substrate modification included catheter elimination of local abnormal ventricular activities (LAVA) - fractionated, splited, low-amplitude/long-lasting, late potentials, pre-systolic potentials - and linear ablation to obtain scars homogenization and scar dechanneling. Pace-mapping techniques were used when capture was possible. LV approach was retrograde in 6 cases, transeptal in 4 and endo-epicardial in 2 cases. In 2P the ablation was performed in the right ventricle. Results: VTs were induced and interrupted with bursts or external DC shocks. LAVA were identified and ablated in all P. Eleven P underwent modification of scar areas. The mean duration of the procedure was 153 mn (103-218 mn), with radiofrequency ranging from 18 to 60 mn (mean 33 min), and a mean fluoroscopy time of 16 mn. Non-inducibility was achieved in 75% of the cases. There was 1 pericardial tamponade drained successfully. During a follow-up of 48 ± 18 months, 75% had no VT recurrences, 2P underwent redo ablation, 1P died from stroke. Conclusion: Catheter ablation of VT based on substrate modification guided by high-density mapping is feasible and safe in P with LV dysfunction. This approach may be of clinical relevance, with potential benefits in reducing VT burden.

Download Full-text

High-Density Mapping in Ventricular Tachycardia Ablation: A PentaRay® Study

Cardiology Research ◽

10.14740/cr636w ◽

2017 ◽

Vol 8 (6) ◽

pp. 293-303 ◽

Cited By ~ 8

Author(s):

Petra Maagh ◽

Arnd Christoph ◽

Henning Dopp ◽

Markus Sebastian Mueller ◽

Gunnar Plehn ◽

...

Keyword(s):

Ventricular Tachycardia ◽

High Density ◽

Ventricular Tachycardia Ablation ◽

Density Mapping

Download Full-text

P1457Does high density mapping increase the efficacy of ischemic ventricular tachycardia ablation?

EP Europace ◽

10.1093/europace/euaa162.087 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

A Nunes Ferreira ◽

G Silva ◽

N Cortez-Dias ◽

P Silverio-Antonio ◽

T Rodrigues ◽

...

Keyword(s):

Ventricular Tachycardia ◽

High Density ◽

Electrical Storm ◽

High Morbidity ◽

Amiodarone Therapy ◽

Ventricular Tachycardia Ablation ◽

Density Mapping ◽

Vt Ablation

Abstract Introduction The treatment of ventricular tachycardia (VT) in patients (pts) with ischemic heart disease (IHD) represents a challenge because of its high morbidity and mortality rates and low long-term success rates. In the VANISH clinical trial, 51% of pts undergoing the conventional ablation technique developed within 2 years the combined outcome of mortality or electrical storm (ES) or appropriate CDI shock. The use of high-density substrate maps can lead to greater precision in substrate evaluation and ideally to improved ablation success. Objectives To assess the efficacy of substrate-guided ischemic VT ablation using high-density mapping. Methods Single-center prospective study of consecutive IHD pts submitted to endocardial ablation of substrate-guided VT using multipolar catheters (PentaRayTM or HDGridTM) and three-dimensional mapping systems with automatic annotation software. The maps were evaluated in order to identify the intra-cicatricial channels (areas of bipolar voltage <1.5mV) in which sequential propagation of local abnormal ventricular activities (LAVAs) were observed, during or after QRS. The ablation strategy aimed at the abolition of all intra-cicatricial LAVAs, directing the radiofrequency applications primarily to the entrances of the channels. The success of ablation was assessed by the primary outcome (death by any cause or ES or appropriate CDI shock) at 2 years and compared to the population of the VANISH study undergoing conventional ablation, using Cox regression and Kaplan- Meier survival analysis. Results We included 40 patients, 95% males, 70 ± 8 years, mean ejection fraction 34 ± 10%. 82% on previous amiodarone therapy and 72% were ICD carriers. 32% underwent ablation during hospitalization for ES and 20% had previously undergone VT ablation. The median duration of substrate mapping was 74 minutes, with a mean of 2290 collected points. Major complications were seen in 1 patient (aortic dissection). During a mean follow-up time of 17.3 ± 12.9 months, the long-term success rate of VT ablation was 75%. Additionally, there was a reduction in the proportion of patients receiving amiodarone before vs after ablation (82% vs. 45% respectively). The rate of events observed during follow-up was lower than expected, namely by comparison with the population of the VANISH study undergoing conventional ablation (25% vs 51% at 24 months, HR 0.42 CI 95% 0.2-0.88, p = 0.022), reflecting a relative risk reduction of 58%. Conclusions High density mapping allows a detailed characterization of the dysrhythmic substrate in patients with VT in an IHD context. Our results suggest that these technological innovations may be improving the clinical success of VT ablation. Abstract Figure.

Download Full-text

Polymorphic Reentrant Ventricular Tachycardia in the Isolated Rabbit Heart Studied by High-Density Mapping

Circulation ◽

10.1161/01.cir.0000019407.35848.af ◽

2002 ◽

Vol 105 (25) ◽

pp. 3053-3061 ◽

Cited By ~ 27

Author(s):

Lucas Boersma ◽

Zoltan Zetelaki ◽

Josep Brugada ◽

Maurits Allessie

Keyword(s):

Ventricular Tachycardia ◽

Rabbit Heart ◽

High Density ◽

Density Mapping ◽

Isolated Rabbit Heart

Download Full-text

Impact of substrate-based ablation for ventricular tachycardia in patients with frequent appropriate implantable cardioverter-defibrillator therapy and dilated cardiomyopathy: Long-term experience with high-density mapping

Revista Portuguesa de Cardiologia (English Edition) ◽

10.1016/j.repce.2021.11.006 ◽

2021 ◽

Vol 40 (11) ◽

pp. 865-873

Author(s):

Mário Oliveira ◽

Pedro Cunha ◽

Bruno Valente ◽

Guilherme Portugal ◽

Ana Lousinha ◽

...

Keyword(s):

Ventricular Tachycardia ◽

Dilated Cardiomyopathy ◽

Implantable Cardioverter Defibrillator ◽

High Density ◽

Implantable Cardioverter Defibrillator Therapy ◽

Cardioverter Defibrillator ◽

Density Mapping ◽

Long Term Experience

Download Full-text

P5691Independent assessment if an image-processing service for the treatment of patients with ventricular tachycardias

European Heart Journal ◽

10.1093/eurheartj/ehz746.0633 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

F Spies ◽

M Kuhne ◽

P Brantner ◽

P Haaf ◽

I Zeljkovic ◽

...

Keyword(s):

Image Processing ◽

Ischemic Cardiomyopathy ◽

High Density ◽

Border Zone ◽

The Internet ◽

Dual Energy Ct ◽

Density Mapping ◽

Wall Thinning ◽

Internet Platform ◽

Ventricular Tachycardias

Abstract Background/Introduction Substrate-based radiofrequency ablation (RFA) in combination with pre-procedural computed tomography (CT) or cardiac Magnetic Resonance Imaging (cMRI) emerged as a promising approach to treat ventricular tachycardias (VT). However, image-processing and 3D reconstruction of the relevant structures to embed them into a 3D electroanatomical mapping (EAM) system is time consuming and requires highly experienced personal and a dedicated software. Purpose The aim of the study was to present the first independent experience with a commercially available service of a internet platform in patients referred for RFA of VTs. Methods Seven consecutive patients (pts) with ischemic cardiomyopathy (ICM), non- ischemic cardiomyopathy (NICM) and dilated cardiomyopathy (DCM) referred for VT RFA underwent contrast-enhanced dual-energy CT. The anonymized DICOM dataset was uploaded to the internet platform. After processing by the specialists, the dataset was downloaded and exported in a format compatible with the 3D EAM System. The EAM was performed in sinus rhythm using a 3.5mm open-irrigated tip catheter or a magnetic remote 3.5mm open-irrigated tip catheter in combination with the remote magnetic navigation-system. A multipolar high-density mapping catheter was used in 6 pts. Scar was defined as bipolar voltage <0.5 mV, and scar border zone ≥0.5mV and <1.5 mV. Results of the internet platform-derived wall thinning (WT), scars and the defined substrate based on 3d EAM voltage maps were transferred into a 17-segment model, and the filling of every single segment was rated as 0%, 25%, 50%, 75% and 100%. For analysis, agreement of the filling (percentage) of the individual segments was quantified. Results Mean age was 67±8 year, BMI was 28±5 kg/m2 and 86% were males. File transfers and image processing was feasible in all patients. Agreement between the defined substrate (<0,5mV) and WT of 4mm was very good (≥90%) in 3 pts, good (≥75% & <90%) in one patient, moderate (≥50% & <75%) in one patient and poor (<50%) in one patient. Patient #1 #2 #3 #4 #5 #6 #7 Sex male male male female male male male Age 63y 56y 71y 65y 60y 69y 81y BMI 31kg/m2 32kg/m2 19kg/m2 25kg/m2 28kg/m2 34kg/m2 29kg/m2 LVEF 25% 60% 25% 25% 25% 31% 34% EDVI 123ml/m2 184ml/m2 69ml/m2 114ml/m2 142ml/m2 105ml/m2 75ml/m2 Catheter multipolar high-density + 3.5mm open-irrigated tip 3.5mm open-irrigated tip multipolar high-density + 3.5mm open-irrigated tip multipolar high-density + 3.5mm open-irrigated tip multipolar high-density + magnetic remote 3.5mm open-irrigated tip multipolar high-density + magnetic remote 3.5mm open-irrigated tip multipolar high-density + magnetic remote 3.5mm open-irrigated tip Quality 98% 96% 91% 66% 89% no match 53% Quality = Percentage match between defined substrate and WT. Superimpose – wall thinning and FAM Conclusion(s) Integration of substrate-based segmentation using the service of the internet platform is feasible in daily practice. Agreement between voltage-map based substrate definition and internet platform-based WT was satisfactory in the majority of patients.

Download Full-text