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Parreira L, Carmo P, Nunes S, Marinheiro R, Mesquita D, Zubarev S, Chmelevsky M, Hitchen R, Ferreira A, Pinho J, Marques L, Chambel D, Amador P, Caria R, Adragão P. Electrocardiographic imaging to guide ablation of ventricular arrhythmias and agreement between two different systems. J Electrocardiol 2023; 80:143-150. [PMID: 37390586 DOI: 10.1016/j.jelectrocard.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 04/22/2023] [Accepted: 06/08/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND AND AIM A recent study using an epicardial-only electrocardiographic imaging (ECGI), suggests that the agreement of ECGI activation mapping and that of the contact mapping for ventricular arrhythmias (VA) is poor. The aim of this study was to assess the diagnostic value of two endo-epicardial ECGI systems using different cardiac sources and the agreement between them. METHODS We performed 69 ECGI procedures in 52 patients referred for ablation of VA at our center. One system based on the extracellular potentials was used in 26 patients, the other based on the equivalent double layer model in 9, and both in 17 patients. The first uses up to 224 leads and the second just the 12‑lead ECG. The localization of the VA was done using a segmental model of the ventricles. A perfect match (PM) was defined as a predicted location within the same anatomic segment, whereas a near match (NM) as a predicted location within the same segment or a contiguous one. RESULTS 44 patients underwent ablation, corresponding to 58 ECGI procedures (37 with the first and 21 with the second system). The percentage of PMs and NMs was not significantly different between the two systems, respectively 76% and 95%, p = 0.077, and 97% and 100%, p = 1.000. In 14 patients that underwent ablation and had the ECGI performed with both systems, raw agreement for PMs was 79%, p = 0.250 for disagreement. CONCLUSIONS ECGI systems were useful to identify the origin of the VAs, and the results were reproducible regardless the cardiac source.
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Affiliation(s)
- Leonor Parreira
- Hospital Luz Lisbon, Portugal; Setubal Hospital Center, Portugal.
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Parreira L, Marinheiro R, Carmo P, Chambel D, Mesquita D, Amador P, Marques L, Mancelos S, Reis RP, Adragao P. Validation of an electrocardiographic marker of low voltage areas in the right ventricular outflow tract in patients with idiopathic ventricular arrhythmias. J Cardiovasc Electrophysiol 2022; 33:2322-2334. [PMID: 35971685 DOI: 10.1111/jce.15654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/11/2022] [Accepted: 08/07/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Previous studies have reported the presence of subtle abnormalities in the right ventricular outflow tract (RVOT) in patients with apparently normal hearts and ventricular arrhythmias (VAs) from the RVOT, including the presence of low voltage areas (LVAs). This LVAs seem to be associated with the presence of ST-segment elevation in V1 or V2 leads at the level of the 2nd intercostal space (ICS). OBJECTIVE Our aim was to validate an electrocardiographic marker of LVAs in the RVOT in patients with idiopathic outflow tract VAs. METHODS A total of 120 patients were studied, 84 patients referred for ablation of idiopathic VAs with an inferior axis by the same operator, and a control group of 36 patients without VAs. Structural heart disease including arrhythmogenic right ventricular cardiomyopathy was ruled out in all patients. An electrocardiogram was performed with V1-V2 at the 2nd ICS, and ST-segment elevation ≥1 mm and T-wave inversion beyond V1 were assessed. Bipolar voltage map of the RVOT was performed in sinus rhythm (0.5-1.5 mV color display). Areas with electrograms <1.5 mV were considered LVAs, and their presence was assessed. We compared three groups, VAs from the RVOT (n = 66), VAs from the LVOT (n = 18) and Control group (n = 36). ST-elevation, T-wave inversion and left versus right side of the VAs were tested as predictors of LVAs, respective odds ratio (ORs) (95% confidence interval [CI]) and p values, were calculated with univariate logist regression. Variables with a p < .005 were included in the multivariate analysis. RESULTS ST-segment elevation, T-wave inversion and LVAs were present in the RVOT group, LVOT group and Control group as follows: (62%, 17%, and 6%, p < .0001), (33%, 29%, and 0%, p = .001) and (62%, 25%, and 14%, p < .0001). The ST-segment elevation, T-wave inversion and right-sided VAs were all predictors of LVAs, respective unadjusted ORs (95% CI), p values were, 32.31 (11.33-92.13), p < .0001, 4.137 (1.615-10.60), p = .003 and 8.200 (3.309-20.32), p < .0001. After adjustment, the only independent predictor of LVAs was the ST-segment elevation, with an adjusted OR (95% CI) of 20.94 (6.787-64.61), p < .0001. CONCLUSION LVAs were frequently present in patients with idiopathic VAs. ST-segment elevation was the only independent predictor of their presence.
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Affiliation(s)
- Leonor Parreira
- Cardiology Department, Luz Hospital Lisbon, Lisboa, Portugal.,Cardiology Department, Setubal Hospital Centre, Setubal, Portugal
| | - Rita Marinheiro
- Cardiology Department, Setubal Hospital Centre, Setubal, Portugal
| | - Pedro Carmo
- Cardiology Department, Luz Hospital Lisbon, Lisboa, Portugal
| | - Duarte Chambel
- Cardiology Department, Setubal Hospital Centre, Setubal, Portugal
| | - Dinis Mesquita
- Cardiology Department, Setubal Hospital Centre, Setubal, Portugal
| | - Pedro Amador
- Cardiology Department, Setubal Hospital Centre, Setubal, Portugal
| | - Lia Marques
- Cardiology Department, Setubal Hospital Centre, Setubal, Portugal
| | - Sofia Mancelos
- Cardiology Department, Luz Hospital Lisbon, Lisboa, Portugal
| | | | - Pedro Adragao
- Cardiology Department, Luz Hospital Lisbon, Lisboa, Portugal
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Parreira L, Carmo P, Marinheiro R, Chambel D, Mesquita D, Amador P, Pinho J, Marques L, Reis RP, Adragao P. A simplified approach to radiofrequency catheter ablation of idiopathic ventricular outflow tract premature ventricular contractions. J Cardiovasc Electrophysiol 2022; 33:2308-2321. [PMID: 35938385 DOI: 10.1111/jce.15652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 07/14/2022] [Accepted: 08/01/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Frequently, low voltage areas (LVAs) and diastolic potentials (DPs) are present at ablation site in sinus rhythm in patients with idiopathic premature ventricular contractions (PVCs). OBJECTIVE Validate these findings as substrate for PVCs and evaluate the feasibility of a simplified substrate approach based on LVAs and DPs for ablation of idiopathic outflow tract PVCs, in patients with a low PVC burden during the procedure. METHODS Prospective single-arm clinical trial at two centers with comparison with a historical group, matched to age and gender. The study group consisted of consecutive patients referred for ablation of frequent idiopathic PVCs with inferior axis, that presented with less than 2 PVCs/min in first 5 minutes of the procedure. The ablation was based on fast mapping of the RVOT in sinus rhythm looking for LVAs and DPs, defined as isolated small amplitude potentials occurring after the T wave of the surface ECG. The area with LVAs and DPs was tagged, and a simplified activation mapping of the PVCs was done in that area. The procedure time, success rate and recurrence rate were compared with the historical group in whom ablation was performed based on activation and pace mapping only. A validation group without PVCs was also studied to assess the prevalence of LVAs and DPs in the general population. RESULTS The study (n=38), historical (n=38) and validation (n=38) groups did not differ in relation to age or gender. Prevalence of LVAs and DPs was significantly higher in the study group in comparison with the validation group, respectively, 71% vs 11%, p<0.0001 and 87% vs 8%, p<0.0001. Procedure time was significantly lower in the study group when comparing to the historical group, 130 (100-164) vs 183 (160-203) min, p<0.0001 and the success rate was significantly higher, 90% vs 64%, p=0.013. The recurrence rate in patients with a successful ablation was not significantly different between both groups, Log-Rank=0.125. CONCLUSION Prevalence of LVAs and DPs was significantly higher in the study group than in the validation group. The proposed approach proved to be feasible, faster and more efficient than the historical approach. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Leonor Parreira
- Setubal Hospital Centre, R. Camilo Castelo Branco 175, 2910-549, Setubal.,Luz Hospital Lisbon, Av. Lusiada 100, 1500-650, Lisboa
| | - Pedro Carmo
- Luz Hospital Lisbon, Av. Lusiada 100, 1500-650, Lisboa
| | - Rita Marinheiro
- Setubal Hospital Centre, R. Camilo Castelo Branco 175, 2910-549, Setubal
| | - Duarte Chambel
- Setubal Hospital Centre, R. Camilo Castelo Branco 175, 2910-549, Setubal
| | - Dinis Mesquita
- Setubal Hospital Centre, R. Camilo Castelo Branco 175, 2910-549, Setubal
| | - Pedro Amador
- Setubal Hospital Centre, R. Camilo Castelo Branco 175, 2910-549, Setubal
| | - Joana Pinho
- Luz Hospital Lisbon, Av. Lusiada 100, 1500-650, Lisboa
| | - Lia Marques
- Setubal Hospital Centre, R. Camilo Castelo Branco 175, 2910-549, Setubal
| | | | - Pedro Adragao
- Luz Hospital Lisbon, Av. Lusiada 100, 1500-650, Lisboa
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Parreira L, Carmo P, Marinheiro R, Mesquita D, Farinha J, Esteves A, Amador P, Ferreira A, Fonseca M, Caria R, Adragao P. Prolonged Right Ventricular Outflow Tract Endocardial Activation Duration and Presence of Deceleration Zones in Patients With Idiopathic Premature Ventricular Contractions. Association With Low Voltage Areas. Front Physiol 2021; 12:699559. [PMID: 34276420 PMCID: PMC8283314 DOI: 10.3389/fphys.2021.699559] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/04/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND AND AIMS The wavefront propagation velocity in the myocardium with fibrosis is characterized by the presence of deceleration zones and late activated zones, that are absent in the normal myocardium. Our aim was to study the right ventricular outflow tract (RVOT) endocardial activation duration in sinus rhythm, and assess the presence of deceleration zones, in patients with premature ventricular contractions (PVCs) and in controls. METHODS We studied 29 patients with idiopathic PVCs from the outflow tract, subjected to catheter ablation that had an activation and voltage map of the RVOT in sinus rhythm. A control group of 15 patients without PVCs that underwent ablation of supraventricular arrhythmias was also studied. RVOT endocardial activation duration and number of 10 ms isochrones across the RVOT were assessed. Propagation speed was calculated at the zone with the higher number of isochrones per cm radius. Deceleration zones were defined as zones with >3 isochrones within 1 cm radius. Low voltage areas were defined as areas with local electrogram with amplitude <1.5 mV. RESULTS The two groups did not differ in relation to age, gender or number of points in the map. RVOT endocardial activation duration and number of 10 ms isochrones were higher in the PVC group; 56 (41-66) ms vs. 39 (35-41) ms, p = 0.001 and 5 (4-8) vs. 4 (4-5), p = 0.001. Presence of deceleration zones and low voltage areas were more frequent in the PVC group; 20 (69%) vs. 0 (0%), p < 0.0001 and 21 (72%) vs. 0 (0%), p < 0.0001. The wavefront propagation speed was significantly lower in patients with PVCs than in the control group, 0.35 (0.27-0.40) vs. 0.63 (0.56-0.66) m/s, p < 0.0001. Patients with low voltage areas had longer activation duration 60 (52-67) vs. 36 (32-40) ms, p < 0.0001, more deceleration zones, 20 (95%) vs. 0 (0%), p < 0.0001, and lower wavefront propagation speed, 0.30 (0.26-0.36) vs. 0.54 (0.36-0.66) m/s, p = 0.002, than patients without low voltage areas. CONCLUSION Right ventricular outflow tract endocardial activation duration was longer, propagation speed was lower and deceleration zones were more frequent in patients with PVCs than in controls and were associated with the presence of low voltage areas.
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Affiliation(s)
- Leonor Parreira
- Department of Cardiology, Hospital Centre of Setubal, Setubal, Portugal
- Department of Cardiology, Luz Hospital Lisboa, Lisbon, Portugal
| | - Pedro Carmo
- Department of Cardiology, Luz Hospital Lisboa, Lisbon, Portugal
| | - Rita Marinheiro
- Department of Cardiology, Hospital Centre of Setubal, Setubal, Portugal
| | - Dinis Mesquita
- Department of Cardiology, Hospital Centre of Setubal, Setubal, Portugal
| | - José Farinha
- Department of Cardiology, Hospital Centre of Setubal, Setubal, Portugal
| | - Ana Esteves
- Department of Cardiology, Hospital Centre of Setubal, Setubal, Portugal
| | - Pedro Amador
- Department of Cardiology, Hospital Centre of Setubal, Setubal, Portugal
| | | | - Marta Fonseca
- Department of Cardiology, Hospital Centre of Setubal, Setubal, Portugal
| | - Rui Caria
- Department of Cardiology, Hospital Centre of Setubal, Setubal, Portugal
| | - Pedro Adragao
- Department of Cardiology, Luz Hospital Lisboa, Lisbon, Portugal
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Electrocardiographic and electrophysiological characteristics of idiopathic ventricular arrhythmias originating from the vicinity of tricuspid annulus. Sci Rep 2021; 11:8633. [PMID: 33883631 PMCID: PMC8060328 DOI: 10.1038/s41598-021-88036-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 04/07/2021] [Indexed: 11/24/2022] Open
Abstract
Electrocardiographic and electrophysiological characteristics of VAs originating from the vicinity of the TA are not fully understood. Hence, 104 patients (mean age 52.6 ± 17.9 years; 62 male) with VAs originating from the vicinity of the TA were enrolled. After electrophysiological evaluation and ablation, data were compared among those patients. The ECGs and the correction of the ECGs based on the long axis of the heart calculated from the chest X-Ray were also analyzed. VAs originating from the vicinity of TA had distinctive ECG characteristics that were useful for identifying the precise origin. Our localization algorithm adjusted by the angle between the cardiac long axis and the horizon was found to be accurate in predicting the exact ablation site in 92.3% (n = 96) cases. Logistic regression analysis showed fractionated electrograms, the magnitudes of the local atrial electrograms and a/V ratio were critical factors for successful ablation. Among the 104 patients with VAs, complete elimination could be achieved by RFCA in 96 patients (success rate 92.3%) during a follow-up period of 35.2 ± 19.6 months. This study suggests that the ablation site could be localized by ECG analysis adjusted by the angle between the cardiac long axis and the horizon. Fractionated electrograms, the magnitudes of the local atrial electrograms and a/V ratio were demonstrated to be critical factors for successful ablation.
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Fonseca M, Parreira L, Farinha JM, Marinheiro R, Esteves A, Gonçalves S, Caria R. Premature ventricular contractions of the right ventricular outflow tract: is there an incipient underlying disease? New insights from a speckle tracking echocardiography study. Indian Pacing Electrophysiol J 2021; 21:147-152. [PMID: 33607220 PMCID: PMC8116808 DOI: 10.1016/j.ipej.2021.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/19/2021] [Accepted: 02/11/2021] [Indexed: 12/20/2022] Open
Abstract
Context Premature ventricular contractions (PVCs) originating in the right ventricular outflow tract (RVOT) are traditionally considered idiopathic and benign. Echocardiographic conventional measurements are typically normal. Aims To assess whether right ventricle longitudinal strain, determined by two-dimensional speckle tracking echocardiography, differ between RVOT PVCs patients (treated with catheter ablation) and healthy controls. Methods We retrospectively selected patients with PVCs from the RVOT who underwent electrophysiological study and catheter ablation between 2016 and 2019. Patients with documented structural heart disease were excluded. Transthoracic echocardiography was performed and right ventricle global longitudinal strain (RV-GLS), free wall longitudinal strain (RVFW-LS) and left ventricle global longitudinal strain (LV-GLS) were determined as well as conventional ultrasound measurements of RV and LV function. Results We studied 21 patients with RVOT PVCs and 13 controls. Patients with PVCs from the RVOT had lower values of RV-GLS and RVFW-LS compared with the control group (−19.4% versus −22.5%, P = 0.015 and −22.1% versus −25.5, P = 0.041, respectively). They also had lower values of LV-GLS, although still within the normal range (−19.1% versus −20.9%, P = 0.047). Regarding RVOT PVCs patients only, RV-GLS and RVFW-LS had no correlation with the PVCs burden prior to catheter ablation and they did not differ between the patients in whom the catheter ablation was successful and those in whom it was not. RV-GLS also had a positive correlation with RVOT proximal diameter (r = 0.487, P = 0.025). Conclusions In this group of RVOT PVCs patients, we found worse RV longitudinal strain values (and therefore sub-clinical myocardial dysfunction) when compared to healthy controls.
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Affiliation(s)
- Marta Fonseca
- Centro Hospitalar de Setúbal, Cardiology Department, Setúbal, Portugal.
| | - Leonor Parreira
- Centro Hospitalar de Setúbal, Cardiology Department, Setúbal, Portugal.
| | | | - Rita Marinheiro
- Centro Hospitalar de Setúbal, Cardiology Department, Setúbal, Portugal.
| | - Ana Esteves
- Centro Hospitalar de Setúbal, Cardiology Department, Setúbal, Portugal.
| | - Sara Gonçalves
- Centro Hospitalar de Setúbal, Cardiology Department, Setúbal, Portugal.
| | - Rui Caria
- Centro Hospitalar de Setúbal, Cardiology Department, Setúbal, Portugal.
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Electrocardiographic imaging (ECGI): What is the minimal number of leads needed to obtain a good spatial resolution? J Electrocardiol 2020; 62:86-93. [PMID: 32835985 DOI: 10.1016/j.jelectrocard.2020.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 06/11/2020] [Accepted: 07/17/2020] [Indexed: 11/22/2022]
Abstract
AIMS Assess the minimal number of ECGI leads needed to obtain a good spatial resolution. METHODS We enrolled 20 patients that underwent ablation of premature ventricular or atrial contractions using Carto and ECGI with AMYCARD. We evaluated the agreement regarding the site of origin of the arrhythmia between the ECGI and Carto, the area and diameter of the earliest activation site obtained with the ECGI (EASa and EASd). Based on previous studies with pacemapping, we considered a good spatial resolution of the ECGI when the EASd measured on the isopotential map was less than 18 mm. In presence of agreement the ECGI was reprocessed: a) with half the number of electrode bands (8 leads per electrode band) and b) with 6 electrode bands. RESULTS The initial map was obtained with 23 (22-23) electrode bands per patient, corresponding to 143 (130-170) leads. Agreement rate was 85%, the median EASa and EASd were: 0.7 (0.5-1.3) cm2 and 9 (8-13) mm. With half the number of electrode bands including 73 (60-79) leads, agreement rate was 80%, the EASa and EASd were: 2.1 (1.5-6.2) cm2 and 16 (14 -28) mm. With only six electrode bands using 38 (30-42) leads, agreement rate was 55%, EASa and EASd were: 4.0 (3.3-5.0) cm2 and 23 (21-25) mm. The number of leads was a predictor of agreement with a good spatial resolution, OR (95% CI) of 1.138 (1.050-1.234), p = .002. According to the ROC curve, the minimal number of leads was 74 (AUC 0.981; 95% CI: 0.949-1.00, p < .0001). CONCLUSION Reducing the number of leads was associated with a lower agreement rate and a significant reduction of spatial resolution. However, the number of leads needed to achieve a good spatial resolution was less than the maximal available.
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