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Haberl C, Crean AM, Zelt JGE, Redpath CJ, deKemp RA. Role of Nuclear Imaging in Cardiac Stereotactic Body Radiotherapy for Ablation of Ventricular Tachycardia. Semin Nucl Med 2024; 54:427-437. [PMID: 38658301 DOI: 10.1053/j.semnuclmed.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 04/26/2024]
Abstract
Ventricular tachycardia (VT) is a life-threatening arrhythmia common in patients with structural heart disease or nonischemic cardiomyopathy. Many VTs originate from regions of fibrotic scar tissue, where delayed electrical signals exit scar and re-enter viable myocardium. Cardiac stereotactic body radiotherapy (SBRT) has emerged as a completely noninvasive alternative to catheter ablation for the treatment of recurrent or refractory ventricular tachycardia. While there is no common consensus on the ideal imaging workflow, therapy planning for cardiac SBRT often combines information from a plurality of imaging modalities including MRI, CT, electroanatomic mapping and nuclear imaging. MRI and CT provide detailed anatomic information, and late enhancement contrast imaging can indicate regions of fibrosis. Electroanatomic maps indicate regions of heterogenous conduction voltage or early activation which are indicative of arrhythmogenic tissue. Some early clinical adopters performing cardiac SBRT report the use of myocardial perfusion and viability nuclear imaging to identify regions of scar. Nuclear imaging of hibernating myocardium, inflammation and sympathetic innervation have been studied for ventricular arrhythmia prognosis and in research relating to catheter ablation of VT but have yet to be studied in their potential applications for cardiac SBRT. The integration of information from these many imaging modalities to identify a target for ablation can be challenging. Multimodality image registration and dedicated therapy planning tools may enable higher target accuracy, accelerate therapy planning workflows and improve patient outcomes. Understanding the pathophysiology of ventricular arrhythmias, and localizing the arrhythmogenic tissues, is vital for successful ablation with cardiac SBRT. Nuclear imaging provides an arsenal of imaging strategies to identify regional scar, hibernation, inflammation, and sympathetic denervation with some advantages over alternative imaging strategies.
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Affiliation(s)
- Connor Haberl
- University of Ottawa Heart Institute, Ottawa, ON; Carleton University, Ottawa, ON
| | - Andrew M Crean
- University of Ottawa Heart Institute, Ottawa, ON; North West Heart Center, University of Manchester Foundation NHS Trust, Manchester, UK
| | - Jason G E Zelt
- The Ottawa Hospital, Ottawa, ON; Department of Medicine, University of Ottawa, Ottawa, ON
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Joy G, Lopes LR, Webber M, Ardissino AM, Wilson J, Chan F, Pierce I, Hughes RK, Moschonas K, Shiwani H, Jamieson R, Velazquez PP, Vijayakumar R, Dall'Armellina E, Macfarlane PW, Manisty C, Kellman P, Davies RH, Tome M, Koncar V, Tao X, Guger C, Rudy Y, Hughes AD, Lambiase PD, Moon JC, Orini M, Captur G. Electrophysiological Characterization of Subclinical and Overt Hypertrophic Cardiomyopathy by Magnetic Resonance Imaging-Guided Electrocardiography. J Am Coll Cardiol 2024; 83:1042-1055. [PMID: 38385929 PMCID: PMC10945386 DOI: 10.1016/j.jacc.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/08/2024] [Accepted: 01/09/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Ventricular arrhythmia in hypertrophic cardiomyopathy (HCM) relates to adverse structural change and genetic status. Cardiovascular magnetic resonance (CMR)-guided electrocardiographic imaging (ECGI) noninvasively maps cardiac structural and electrophysiological (EP) properties. OBJECTIVES The purpose of this study was to establish whether in subclinical HCM (genotype [G]+ left ventricular hypertrophy [LVH]-), ECGI detects early EP abnormality, and in overt HCM, whether the EP substrate relates to genetic status (G+/G-LVH+) and structural phenotype. METHODS This was a prospective 211-participant CMR-ECGI multicenter study of 70 G+LVH-, 104 LVH+ (51 G+/53 G-), and 37 healthy volunteers (HVs). Local activation time (AT), corrected repolarization time, corrected activation-recovery interval, spatial gradients (GAT/GRTc), and signal fractionation were derived from 1,000 epicardial sites per participant. Maximal wall thickness and scar burden were derived from CMR. A support vector machine was built to discriminate G+LVH- from HV and low-risk HCM from those with intermediate/high-risk score or nonsustained ventricular tachycardia. RESULTS Compared with HV, subclinical HCM showed mean AT prolongation (P = 0.008) even with normal 12-lead electrocardiograms (ECGs) (P = 0.009), and repolarization was more spatially heterogenous (GRTc: P = 0.005) (23% had normal ECGs). Corrected activation-recovery interval was prolonged in overt vs subclinical HCM (P < 0.001). Mean AT was associated with maximal wall thickness; spatial conduction heterogeneity (GAT) and fractionation were associated with scar (all P < 0.05), and G+LVH+ had more fractionation than G-LVH+ (P = 0.002). The support vector machine discriminated subclinical HCM from HV (10-fold cross-validation accuracy 80% [95% CI: 73%-85%]) and identified patients at higher risk of sudden cardiac death (accuracy 82% [95% CI: 78%-86%]). CONCLUSIONS In the absence of LVH or 12-lead ECG abnormalities, HCM sarcomere gene mutation carriers express an aberrant EP phenotype detected by ECGI. In overt HCM, abnormalities occur more severely with adverse structural change and positive genetic status.
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Affiliation(s)
- George Joy
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom.
| | - Luis R Lopes
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Matthew Webber
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Medical Research Council Unit for Lifelong Health and Ageing, University College London, London, United Kingdom; Centre for Inherited Heart Muscle Conditions, Department of Cardiology, Royal Free London NHS Foundation Trust, London, United Kingdom
| | | | - James Wilson
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Fiona Chan
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Medical Research Council Unit for Lifelong Health and Ageing, University College London, London, United Kingdom; Centre for Inherited Heart Muscle Conditions, Department of Cardiology, Royal Free London NHS Foundation Trust, London, United Kingdom
| | - Iain Pierce
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom; Medical Research Council Unit for Lifelong Health and Ageing, University College London, London, United Kingdom
| | - Rebecca K Hughes
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Konstantinos Moschonas
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Hunain Shiwani
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Robert Jamieson
- Electrocardiology Section, School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Paula P Velazquez
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Cardiology Clinical and Academic Group, St George's University of London and St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Ramya Vijayakumar
- Cardiac Bioelectricity and Arrhythmia Center, Washington University, St Louis, Missouri, USA
| | - Erica Dall'Armellina
- Biomedical Imaging Sciences Department, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Peter W Macfarlane
- Electrocardiology Section, School of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Charlotte Manisty
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Peter Kellman
- National Heart, Lung, and Blood Institute, National Institutes of Health, DHHS, Bethesda, Maryland, USA
| | - Rhodri H Davies
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom; Medical Research Council Unit for Lifelong Health and Ageing, University College London, London, United Kingdom
| | - Maite Tome
- Cardiology Clinical and Academic Group, St George's University of London and St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Vladan Koncar
- École Nationale Supérieure des Arts et Industries Textiles, University of Lille, Lille, France
| | - Xuyuan Tao
- École Nationale Supérieure des Arts et Industries Textiles, University of Lille, Lille, France
| | | | - Yoram Rudy
- Cardiac Bioelectricity and Arrhythmia Center, Washington University, St Louis, Missouri, USA
| | - Alun D Hughes
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Medical Research Council Unit for Lifelong Health and Ageing, University College London, London, United Kingdom
| | - Pier D Lambiase
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - James C Moon
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Michele Orini
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Medical Research Council Unit for Lifelong Health and Ageing, University College London, London, United Kingdom
| | - Gabriella Captur
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Medical Research Council Unit for Lifelong Health and Ageing, University College London, London, United Kingdom; Centre for Inherited Heart Muscle Conditions, Department of Cardiology, Royal Free London NHS Foundation Trust, London, United Kingdom
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Toloubidokhti M, Gharbia OA, Parkosa A, Trayanova N, Nazarian S, Sapp JL, Wang L. Understanding the Utility of Endocardial Electrocardiographic Imaging in Epi-Endocardial Mapping of 3D Reentrant Circuits. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.13.24304259. [PMID: 38559058 PMCID: PMC10980114 DOI: 10.1101/2024.03.13.24304259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background Studies of VT mechanisms are largely based on a 2D portrait of reentrant circuits on one surface of the heart. This oversimplifies the 3D circuit that involves the depth of the myocardium. Simultaneous epicardial and endocardial (epi-endo) mapping was shown to facilitate a 3D delineation of VT circuits, which is however difficult via invasive mapping. Objective This study investigates the capability of noninvasive epicardial-endocardial electrocardiographic imaging (ECGI) to elucidate the 3D construct of VT circuits, emphasizing the differentiation of epicardial, endocardial, and intramural circuits and to determine the proximity of mid-wall exits to the epicardial or endocardial surfaces. Methods 120-lead ECGs of VT in combination with subject-specific heart-torso geometry are used to compute unipolar electrograms (CEGM) on ventricular epicardium and endocardia. Activation isochrones are constructed, and the percentage of activation within VT cycle length is calculated on each surface. This classifies VT circuits into 2D (surface only), uniform transmural, nonuniform transmural, and mid-myocardial (focal on surfaces). Furthermore, the endocardial breakthrough time was accurately measured using Laplacian eigenmaps, and by correlating the delay time of the epi-endo breakthroughs, the relative distance of a mid-wall exit to the epicardium or the endocardium surfaces was identified. Results We analyzed 23 simulated and in-vivo VT circuits on post-infarction porcine hearts. In simulated circuits, ECGI classified 21% as 2D and 78% as 3D: 82.6% of these were correctly classified. The relative timing between epicardial and endocardial breakthroughs was correctly captured across all cases. In in-vivo circuits, ECGI classified 25% as 2D and 75% as 3D: in all cases, circuit exits and entrances were consistent with potential critical isthmus delineated from combined LGE-MRI and catheter mapping data. Conclusions ECGI epi-endo mapping has the potential for fast delineation of 3D VT circuits, which may augment detailed catheter mapping for VT ablation.
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Affiliation(s)
- Maryam Toloubidokhti
- College of Computing and Information Sciences, Rochester Institute of Technology, Rochester, NY, USA
| | - Omar A Gharbia
- Department of Otolaryngology, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Adityo Parkosa
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Natalia Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Saman Nazarian
- School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - John L Sapp
- Department of Medicine, QEII Health Sciences Centre, Halifax, NS, Canada
| | - Linwei Wang
- College of Computing and Information Sciences, Rochester Institute of Technology, Rochester, NY, USA
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Roukoz H, Tholakanahalli V. Epicardial ablation of ventricular tachycardia in ischemic cardiomyopathy: A review and local experience. Indian Pacing Electrophysiol J 2024; 24:84-93. [PMID: 38340957 PMCID: PMC11010455 DOI: 10.1016/j.ipej.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 10/29/2023] [Accepted: 02/07/2024] [Indexed: 02/12/2024] Open
Abstract
Myocardial scar in ischemic cardiomyopathy is predominantly endocardial, however, between 5% and 15% of these patients have an arrhythmogenic epicardial substrate. Percutaneous epicardial ablation should be considered in patients with ICM and VT especially if they failed an endocardial ablation. Simultaneous epicardial and endocardial ablation of VT in ICM may reduce short- and medium-term VT recurrence compared with an endocardial only approach. Cardiac imaging could be used to help guide patient selection for a combined epi-endo approach. Complications related to epicardial access can happen in up to 7% of patients. Epicardial ablation in these patients should be referred to experienced tertiary centers. We review the literature and share interesting cases.
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Webber M, Joy G, Bennett J, Chan F, Falconer D, Shiwani H, Davies RH, Krausz G, Tanackovic S, Guger C, Gonzalez P, Martin E, Wong A, Rapala A, Direk K, Kellman P, Pierce I, Rudy Y, Vijayakumar R, Chaturvedi N, Hughes AD, Moon JC, Lambiase PD, Tao X, Koncar V, Orini M, Captur G. Technical development and feasibility of a reusable vest to integrate cardiovascular magnetic resonance with electrocardiographic imaging. J Cardiovasc Magn Reson 2023; 25:73. [PMID: 38044439 PMCID: PMC10694972 DOI: 10.1186/s12968-023-00980-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/12/2023] [Indexed: 12/05/2023] Open
Abstract
BACKGROUND Electrocardiographic imaging (ECGI) generates electrophysiological (EP) biomarkers while cardiovascular magnetic resonance (CMR) imaging provides data about myocardial structure, function and tissue substrate. Combining this information in one examination is desirable but requires an affordable, reusable, and high-throughput solution. We therefore developed the CMR-ECGI vest and carried out this technical development study to assess its feasibility and repeatability in vivo. METHODS CMR was prospectively performed at 3T on participants after collecting surface potentials using the locally designed and fabricated 256-lead ECGI vest. Epicardial maps were reconstructed to generate local EP parameters such as activation time (AT), repolarization time (RT) and activation recovery intervals (ARI). 20 intra- and inter-observer and 8 scan re-scan repeatability tests. RESULTS 77 participants were recruited: 27 young healthy volunteers (HV, 38.9 ± 8.5 years, 35% male) and 50 older persons (77.0 ± 0.1 years, 52% male). CMR-ECGI was achieved in all participants using the same reusable, washable vest without complications. Intra- and inter-observer variability was low (correlation coefficients [rs] across unipolar electrograms = 0.99 and 0.98 respectively) and scan re-scan repeatability was high (rs between 0.81 and 0.93). Compared to young HV, older persons had significantly longer RT (296.8 vs 289.3 ms, p = 0.002), ARI (249.8 vs 235.1 ms, p = 0.002) and local gradients of AT, RT and ARI (0.40 vs 0.34 ms/mm, p = 0,01; 0.92 vs 0.77 ms/mm, p = 0.03; and 1.12 vs 0.92 ms/mm, p = 0.01 respectively). CONCLUSION Our high-throughput CMR-ECGI solution is feasible and shows good reproducibility in younger and older participants. This new technology is now scalable for high throughput research to provide novel insights into arrhythmogenesis and potentially pave the way for more personalised risk stratification. CLINICAL TRIAL REGISTRATION Title: Multimorbidity Life-Course Approach to Myocardial Health-A Cardiac Sub-Study of the MRC National Survey of Health and Development (NSHD) (MyoFit46). National Clinical Trials (NCT) number: NCT05455125. URL: https://clinicaltrials.gov/ct2/show/NCT05455125?term=MyoFit&draw=2&rank=1.
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Affiliation(s)
- Matthew Webber
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, ECIA 7BE, UK
- Institute of Cardiovascular Science, University College London, Huntley Street, London, WC1E 6DD, UK
- Centre for Inherited Heart Muscle Conditions, Department of Cardiology, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
- Medical Research Council Unit for Lifelong Health and Ageing at UCL, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - George Joy
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, ECIA 7BE, UK
- Institute of Cardiovascular Science, University College London, Huntley Street, London, WC1E 6DD, UK
| | - Jonathan Bennett
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, ECIA 7BE, UK
- Institute of Cardiovascular Science, University College London, Huntley Street, London, WC1E 6DD, UK
| | - Fiona Chan
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, ECIA 7BE, UK
- Institute of Cardiovascular Science, University College London, Huntley Street, London, WC1E 6DD, UK
| | - Debbie Falconer
- Centre for Inherited Heart Muscle Conditions, Department of Cardiology, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
| | - Hunain Shiwani
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, ECIA 7BE, UK
- Institute of Cardiovascular Science, University College London, Huntley Street, London, WC1E 6DD, UK
| | - Rhodri H Davies
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, ECIA 7BE, UK
- Institute of Cardiovascular Science, University College London, Huntley Street, London, WC1E 6DD, UK
| | - Gunther Krausz
- g.Tec Medical Engineering GmbH, Siernigtrabe 14, 4521, Schiedlberg, Austria
| | | | - Christoph Guger
- g.Tec Medical Engineering GmbH, Siernigtrabe 14, 4521, Schiedlberg, Austria
| | - Pablo Gonzalez
- ELEM Biotech, S.L, Barcelona, Spain
- Department of Computer Applications in Science and Engineering, Barcelona Supercomputing Center (BSC), 08034, Barcelona, Spain
- Department of Information and Communication Technologies, Physense, Universitat Pempeu Fabra, Barcrlona, Spain
| | - Emma Martin
- Medical Research Council Unit for Lifelong Health and Ageing at UCL, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Andrew Wong
- Medical Research Council Unit for Lifelong Health and Ageing at UCL, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Alicja Rapala
- Medical Research Council Unit for Lifelong Health and Ageing at UCL, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Kenan Direk
- Medical Research Council Unit for Lifelong Health and Ageing at UCL, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Peter Kellman
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Iain Pierce
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, ECIA 7BE, UK
- Institute of Cardiovascular Science, University College London, Huntley Street, London, WC1E 6DD, UK
- Medical Research Council Unit for Lifelong Health and Ageing at UCL, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Yoram Rudy
- Cardiac Bioelectricity and Arrhythmia Center, Washington University, St. Louis, MO, 63130, USA
- Department of Biomedical Engineering, Washington University, St. Louis, MO, 63130, USA
| | - Ramya Vijayakumar
- Cardiac Bioelectricity and Arrhythmia Center, Washington University, St. Louis, MO, 63130, USA
- Department of Biomedical Engineering, Washington University, St. Louis, MO, 63130, USA
| | - Nishi Chaturvedi
- Institute of Cardiovascular Science, University College London, Huntley Street, London, WC1E 6DD, UK
- Medical Research Council Unit for Lifelong Health and Ageing at UCL, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Alun D Hughes
- Institute of Cardiovascular Science, University College London, Huntley Street, London, WC1E 6DD, UK
- Medical Research Council Unit for Lifelong Health and Ageing at UCL, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - James C Moon
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, ECIA 7BE, UK
- Institute of Cardiovascular Science, University College London, Huntley Street, London, WC1E 6DD, UK
| | - Pier D Lambiase
- Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, ECIA 7BE, UK
- Institute of Cardiovascular Science, University College London, Huntley Street, London, WC1E 6DD, UK
| | - Xuyuan Tao
- École Nationale Supérieure des Arts et Industries Textiles, 2 allée Louise et Victor Champier, 59056, Roubaix CEDEX 1, France
| | - Vladan Koncar
- École Nationale Supérieure des Arts et Industries Textiles, 2 allée Louise et Victor Champier, 59056, Roubaix CEDEX 1, France
| | - Michele Orini
- Institute of Cardiovascular Science, University College London, Huntley Street, London, WC1E 6DD, UK
- Medical Research Council Unit for Lifelong Health and Ageing at UCL, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Gabriella Captur
- Institute of Cardiovascular Science, University College London, Huntley Street, London, WC1E 6DD, UK.
- Centre for Inherited Heart Muscle Conditions, Department of Cardiology, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK.
- Medical Research Council Unit for Lifelong Health and Ageing at UCL, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
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Keyt LK, Atwood T, Bruggeman A, Mundt AJ, Feld GK, Krummen DE, Ho G. Successful Noninvasive 12-Lead ECG Mapping-Guided Radiotherapy of Inaccessible Ventricular Tachycardia Substrate Due to Mechanical Valves. JACC Case Rep 2023; 15:101870. [PMID: 37283824 PMCID: PMC10240275 DOI: 10.1016/j.jaccas.2023.101870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/21/2023] [Accepted: 04/13/2023] [Indexed: 06/08/2023]
Abstract
In patients presenting with refractory ventricular tachycardia (VT) and aortic and mitral mechanical prosthetic valves, traditional catheter ablation is challenging. We describe a case in which a novel noninvasive computational electrocardiogram mapping algorithm localized VT sources originating from substrate near the mechanical valves, in which stereotactic ablative radiotherapy eliminated VT in 1.5-year follow-up. (Level of Difficulty: Advanced.).
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Affiliation(s)
- Lucas K. Keyt
- Department of Medicine, Division of Cardiology, University of California-San Diego, La Jolla, California, USA
| | - Todd Atwood
- Department of Radiation Medicine and Applied Sciences, University of California-San Diego, La Jolla, California, USA
| | - Andrew Bruggeman
- Department of Radiation Medicine and Applied Sciences, University of California-San Diego, La Jolla, California, USA
| | - Arno J. Mundt
- Department of Radiation Medicine and Applied Sciences, University of California-San Diego, La Jolla, California, USA
| | - Gregory K. Feld
- Department of Medicine, Division of Cardiology, University of California-San Diego, La Jolla, California, USA
| | - David E. Krummen
- Department of Medicine, Division of Cardiology, University of California-San Diego, La Jolla, California, USA
| | - Gordon Ho
- Department of Medicine, Division of Cardiology, University of California-San Diego, La Jolla, California, USA
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Bear LR, Bergquist JA, Abell E, Cochet H, MacLeod RS, Dubois R, Serinagaoglu Y. Investigation into the importance of using natural PVCs and pathological models for potential-based ECGI validation. Front Physiol 2023; 14:1198002. [PMID: 37275229 PMCID: PMC10232953 DOI: 10.3389/fphys.2023.1198002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 04/28/2023] [Indexed: 06/07/2023] Open
Abstract
Introduction: Premature ventricular contractions (PVCs) are one of the most commonly targeted pathologies for ECGI validation, often through ventricular stimulation to mimic the ectopic beat. However, it remains unclear if such stimulated beats faithfully reproduce spontaneously occurring PVCs, particularly in the case of the R-on-T phenomenon. The objective of this study was to determine the differences in ECGI accuracy when reconstructing spontaneous PVCs as compared to ventricular-stimulated beats and to explore the impact of pathophysiological perturbation on this reconstruction accuracy. Methods: Langendorff-perfused pig hearts (n = 3) were suspended in a human torso-shaped tank, and local hyperkalemia was induced through perfusion of a high-K+ solution (8 mM) into the LAD. Recordings were taken simultaneously from the heart and tank surfaces during ventricular pacing and during spontaneous PVCs (including R-on-T), both at baseline and high K+. Epicardial potentials were reconstructed from torso potentials using ECGI. Results: Spontaneously occurring PVCs were better reconstructed than stimulated beats at baseline in terms of electrogram morphology [correlation coefficient (CC) = 0.74 ± 0.05 vs. CC = 0.60 ± 0.10], potential maps (CC = 0.61 ± 0.06 vs. CC = 0.51 ± 0.12), and activation time maps (CC = 0.86 ± 0.07 vs. 0.76 ± 0.10), though there was no difference in the localization error (LE) of epicardial origin (LE = 14 ± 6 vs. 15 ± 11 mm). High K+ perfusion reduced the accuracy of ECGI reconstructions in terms of electrogram morphology (CC = 0.68 ± 0.10) and AT maps (CC = 0.70 ± 0.12 and 0.59 ± 0.23) for isolated PVCs and paced beats, respectively. LE trended worse, but the change was not significant (LE = 17 ± 9 and 20 ± 12 mm). Spontaneous PVCs were less well when the R-on-T phenomenon occurred and the activation wavefronts encountered a line of block. Conclusion: This study demonstrates the differences in ECGI accuracy between spontaneous PVCs and ventricular-paced beats. We also observed a reduction in this accuracy near regions of electrically inactive tissue. These results highlight the need for more physiologically realistic experimental models when evaluating the accuracy of ECGI methods. In particular, reconstruction accuracy needs to be further evaluated in the presence of R-on-T or isolated PVCs, particularly when encountering obstacles (functional or anatomical) which cause line of block and re-entry.
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Affiliation(s)
- Laura R. Bear
- IHU-Liryc, Heart Rhythm Disease Institute, Foundation Bordeaux Université, Bordeaux, France
- University Bordeaux, CRCTB, Bordeaux, France
- INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Jake A. Bergquist
- Scientific Computing and Imaging Institute, University of Utah, Salt LakeCity, UT, United States
- Norra Eccles Harrison Cardiovascular Research and Training Institute (CVRTI), University of Utah, Salt LakeCity, UT, United States
- Department of Biomedical Engineering, University of Utah, Salt LakeCity, UT, United States
| | - Emma Abell
- IHU-Liryc, Heart Rhythm Disease Institute, Foundation Bordeaux Université, Bordeaux, France
- University Bordeaux, CRCTB, Bordeaux, France
- INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Hubert Cochet
- IHU-Liryc, Heart Rhythm Disease Institute, Foundation Bordeaux Université, Bordeaux, France
- University Bordeaux, CRCTB, Bordeaux, France
- INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
- Bordeaux University Hospital (CHU), Pessac, France
| | - Rob S. MacLeod
- Scientific Computing and Imaging Institute, University of Utah, Salt LakeCity, UT, United States
- Norra Eccles Harrison Cardiovascular Research and Training Institute (CVRTI), University of Utah, Salt LakeCity, UT, United States
- Department of Biomedical Engineering, University of Utah, Salt LakeCity, UT, United States
| | - Remi Dubois
- IHU-Liryc, Heart Rhythm Disease Institute, Foundation Bordeaux Université, Bordeaux, France
- University Bordeaux, CRCTB, Bordeaux, France
- INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Yesim Serinagaoglu
- Electrical-Electronics Engineering Department, Middle East Technical University, Ankara, Türkiye
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8
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Correlation of MRI premature ventricular contraction activation pattern in bigeminy with electrophysiology study-confirmed site of origin. Int J Cardiovasc Imaging 2023; 39:145-152. [PMID: 36598692 DOI: 10.1007/s10554-022-02707-8] [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: 12/19/2021] [Accepted: 08/01/2022] [Indexed: 01/07/2023]
Abstract
Although PVCs commonly lead to degraded cine cardiac MRI (CMR), patients with PVCs may have relatively sharp cine images of both normal and ectopic beats ("double beats") when the rhythm during CMR is ventricular bigeminy, and only one beat of the pair is detected for gating. MRI methods for directly imaging premature ventricular contractions (PVCs) are not yet widely available. Localization of PVC site of origin with images may be helpful in planning ablations. The contraction pattern of the PVCs in bigeminy provides a "natural experiment" for investigating the potential utility of PVC imaging for localization. The purpose of this study was to evaluate the correlation of the visually assessed site of the initial contraction of the ectopic beats with the site of origin found by electroanatomic mapping. Images from 7 of 86 consecutive patients who underwent CMR prior to PVC ablation were found to include clear cine images of bigeminy. The visually apparent site of origin of the ectopic contraction was determined by three experienced, blinded CMR readers and correlated with each other, and with PVC site of origin determined by 3D electroanatomic mapping during catheter ablation. Blinded ascertainment of visually apparent initial contraction pattern for PVC localization was within 2 wall segments of PVC origin by 3D electroanatomic mapping 76% of the time. Our data from patients with PVCs with clear images of the ectopic beats when in bigeminy provide proof-of-concept that CMR ectopic beat contraction patterns analysis may provide a novel method for localizing PVC origin prior to ablation procedures. Direct imaging of PVCs with use of newer cardiac imaging methods, even without the presence of bigeminy, may thus provide valuable data for procedural planning.
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9
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Pandozi C, Mariani MV, Chimenti C, Maestrini V, Filomena D, Magnocavallo M, Straito M, Piro A, Russo M, Galeazzi M, Ficili S, Colivicchi F, Severino P, Mancone M, Fedele F, Lavalle C. The scar: the wind in the perfect storm-insights into the mysterious living tissue originating ventricular arrhythmias. J Interv Card Electrophysiol 2023; 66:27-38. [PMID: 35072829 PMCID: PMC9931863 DOI: 10.1007/s10840-021-01104-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 12/27/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Arrhythmic death is very common among patients with structural heart disease, and it is estimated that in European countries, 1 per 1000 inhabitants yearly dies for sudden cardiac death (SCD), mainly as a result of ventricular arrhythmias (VA). The scar is the result of cardiac remodelling process that occurs in several cardiomyopathies, both ischemic and non-ischemic, and is considered the perfect substrate for re-entrant and non-re-entrant arrhythmias. METHODS Our aim was to review published evidence on the histological and electrophysiological properties of myocardial scar and to review the central role of cardiac magnetic resonance (CMR) in assessing ventricular arrhythmias substrate and its potential implication in risk stratification of SCD. RESULTS Scarring process affects both structural and electrical myocardial properties and paves the background for enhanced arrhythmogenicity. Non-uniform anisotropic conduction, gap junctions remodelling, source to sink mismatch and refractoriness dispersion are some of the underlining mechanisms contributing to arrhythmic potential of the scar. All these mechanisms lead to the initiation and maintenance of VA. CMR has a crucial role in the evaluation of patients suffering from VA, as it is considered the gold standard imaging test for scar characterization. Mounting evidences support the use of CMR not only for the definition of gross scar features, as size, localization and transmurality, but also for the identification of possible conducting channels suitable of discrete ablation. Moreover, several studies call out the CMR-based scar characterization as a stratification tool useful in selecting patients at risk of SCD and amenable to implantable cardioverter-defibrillator (ICD) implantation. CONCLUSIONS Scar represents the substrate of ventricular arrhythmias. CMR, defining scar presence and its features, may be a useful tool for guiding ablation procedures and for identifying patients at risk of SCD amenable to ICD therapy.
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Affiliation(s)
- C. Pandozi
- grid.416357.2Department of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - Marco Valerio Mariani
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - C. Chimenti
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - V. Maestrini
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - D. Filomena
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - M. Magnocavallo
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - M. Straito
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - A. Piro
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - M. Russo
- grid.416357.2Department of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - M. Galeazzi
- grid.416357.2Department of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - S. Ficili
- ASP, Ragusa Maggiore Hospital, Modica, Italy
| | - F. Colivicchi
- grid.416357.2Department of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - P. Severino
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - M. Mancone
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - F. Fedele
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - C. Lavalle
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
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10
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Stoks J, Hermans BJM, Boukens BJD, Holtackers RJ, Gommers S, Kaya YS, Vernooy K, Cluitmans MJM, Volders PGA, Ter Bekke RMA. High-resolution structural-functional substrate-trigger characterization: Future roadmap for catheter ablation of ventricular tachycardia. Front Cardiovasc Med 2023; 10:1112980. [PMID: 36873402 PMCID: PMC9978225 DOI: 10.3389/fcvm.2023.1112980] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 02/03/2023] [Indexed: 02/18/2023] Open
Abstract
Introduction Patients with ventricular tachyarrhythmias (VT) are at high risk of sudden cardiac death. When appropriate, catheter ablation is modestly effective, with relatively high VT recurrence and complication rates. Personalized models that incorporate imaging and computational approaches have advanced VT management. However, 3D patient-specific functional electrical information is typically not considered. We hypothesize that incorporating non-invasive 3D electrical and structural characterization in a patient-specific model improves VT-substrate recognition and ablation targeting. Materials and methods In a 53-year-old male with ischemic cardiomyopathy and recurrent monomorphic VT, we built a structural-functional model based on high-resolution 3D late-gadolinium enhancement (LGE) cardiac magnetic resonance imaging (3D-LGE CMR), multi-detector computed tomography (CT), and electrocardiographic imaging (ECGI). Invasive data from high-density contact and pace mapping obtained during endocardial VT-substrate modification were also incorporated. The integrated 3D electro-anatomic model was analyzed off-line. Results Merging the invasive voltage maps and 3D-LGE CMR endocardial geometry led to a mean Euclidean node-to-node distance of 5 ± 2 mm. Inferolateral and apical areas of low bipolar voltage (<1.5 mV) were associated with high 3D-LGE CMR signal intensity (>0.4) and with higher transmurality of fibrosis. Areas of functional conduction delay or block (evoked delayed potentials, EDPs) were in close proximity to 3D-LGE CMR-derived heterogeneous tissue corridors. ECGI pinpointed the epicardial VT exit at ∼10 mm from the endocardial site of origin, both juxtaposed to the distal ends of two heterogeneous tissue corridors in the inferobasal left ventricle. Radiofrequency ablation at the entrances of these corridors, eliminating all EDPs, and at the VT site of origin rendered the patient non-inducible and arrhythmia-free until the present day (20 months follow-up). Off-line analysis in our model uncovered dynamic electrical instability of the LV inferolateral heterogeneous scar region which set the stage for an evolving VT circuit. Discussion and conclusion We developed a personalized 3D model that integrates high-resolution structural and electrical information and allows the investigation of their dynamic interaction during arrhythmia formation. This model enhances our mechanistic understanding of scar-related VT and provides an advanced, non-invasive roadmap for catheter ablation.
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Affiliation(s)
- Job Stoks
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, Netherlands.,Department of Advanced Computing Sciences, Maastricht University, Maastricht, Netherlands.,Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
| | - Ben J M Hermans
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands
| | - Bas J D Boukens
- Department of Physiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, Netherlands.,Department of Medical Biology, Amsterdam University Medical Center (UMC), Amsterdam Medical Center (AMC), Amsterdam, Netherlands
| | - Robert J Holtackers
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, Netherlands
| | - Suzanne Gommers
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, Netherlands
| | - Yesim S Kaya
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, Netherlands
| | - Matthijs J M Cluitmans
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, Netherlands.,Philips Research, Eindhoven, Netherlands
| | - Paul G A Volders
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, Netherlands
| | - Rachel M A Ter Bekke
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center+, Maastricht, Netherlands
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11
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Krummen DE, Villongco CT, Ho G, Schricker AA, Field ME, Sung K, Kacena KA, Martinson MS, Hoffmayer KS, Hsu JC, Raissi F, Feld GK, McCulloch AD, Han FT. Forward-Solution Noninvasive Computational Arrhythmia Mapping: The VMAP Study. Circ Arrhythm Electrophysiol 2022; 15:e010857. [PMID: 36069189 PMCID: PMC9509662 DOI: 10.1161/circep.122.010857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 08/16/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND The accuracy of noninvasive arrhythmia source localization using a forward-solution computational mapping system has not yet been evaluated in blinded, multicenter analysis. This study tested the hypothesis that a computational mapping system incorporating a comprehensive arrhythmia simulation library would provide accurate localization of the site-of-origin for atrial and ventricular arrhythmias and pacing using 12-lead ECG data when compared with the gold standard of invasive electrophysiology study and ablation. METHODS The VMAP study (Vectorcardiographic Mapping of Arrhythmogenic Probability) was a blinded, multicenter evaluation with final data analysis performed by an independent core laboratory. Eligible episodes included atrial and ventricular: tachycardia, fibrillation, pacing, premature atrial and ventricular complexes, and orthodromic atrioventricular reentrant tachycardia. Mapping system results were compared with the gold standard site of successful ablation or pacing during electrophysiology study and ablation. Mapping time was assessed from time-stamped logs. Prespecified performance goals were used for statistical comparisons. RESULTS A total of 255 episodes from 225 patients were enrolled from 4 centers. Regional accuracy for ventricular tachycardia and premature ventricular complexes in patients without significant structural heart disease (n=75, primary end point) was 98.7% (95% CI, 96.0%-100%; P<0.001 to reject predefined H0 <0.80). Regional accuracy for all episodes (secondary end point 1) was 96.9% (95% CI, 94.7%-99.0%; P<0.001 to reject predefined H0 <0.75). Accuracy for the exact or neighboring segment for all episodes (secondary end point 2) was 97.3% (95% CI, 95.2%-99.3%; P<0.001 to reject predefined H0 <0.70). Median spatial accuracy was 15 mm (n=255, interquartile range, 7-25 mm). The mapping process was completed in a median of 0.8 minutes (interquartile range, 0.4-1.4 minutes). CONCLUSIONS Computational ECG mapping using a forward-solution approach exceeded prespecified accuracy goals for arrhythmia and pacing localization. Spatial accuracy analysis demonstrated clinically actionable results. This rapid, noninvasive mapping technology may facilitate catheter-based and noninvasive targeted arrhythmia therapies. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04559061.
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Affiliation(s)
- David E. Krummen
- Department of Medicine, University of California San Diego, La Jolla
- Veterans Affairs San Diego Healthcare System, San Diego
| | | | - Gordon Ho
- Department of Medicine, University of California San Diego, La Jolla
- Veterans Affairs San Diego Healthcare System, San Diego
| | | | | | - Kevin Sung
- Department of Medicine, University of California San Diego, La Jolla
| | | | | | - Kurt S. Hoffmayer
- Department of Medicine, University of California San Diego, La Jolla
- Veterans Affairs San Diego Healthcare System, San Diego
| | - Jonathan C. Hsu
- Department of Medicine, University of California San Diego, La Jolla
| | - Farshad Raissi
- Department of Medicine, University of California San Diego, La Jolla
| | - Gregory K. Feld
- Department of Medicine, University of California San Diego, La Jolla
| | - Andrew D. McCulloch
- Department of Medicine, University of California San Diego, La Jolla
- Department of Bioengineering, University of California San Diego, La Jolla
| | - Frederick T. Han
- Department of Medicine, University of California San Diego, La Jolla
- Veterans Affairs San Diego Healthcare System, San Diego
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12
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Graham AJ, Orini M, Zacur E, Dhillon G, Jones D, Prabhu S, Pugliese F, Lowe M, Ahsan S, Earley MJ, Chow A, Sporton S, Dhinoja M, Hunter RJ, Schilling RJ, Lambiase PD. Assessing Noninvasive Delineation of Low-Voltage Zones Using ECG Imaging in Patients With Structural Heart Disease. JACC Clin Electrophysiol 2022; 8:426-436. [PMID: 35450597 DOI: 10.1016/j.jacep.2021.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study sought to assess the association between electrocardiographic imaging (ECGI) parameters and voltage from simultaneous electroanatomic mapping (EAM). BACKGROUND ECGI offers noninvasive assessment of electrophysiologic features relevant for mapping ventricular arrhythmia and its substrate, but the accuracy of ECGI in the delineation of scar is unclear. METHODS Sixteen patients with structural heart disease underwent simultaneous ECGI (CardioInsight, Medtronic) and contact EAM (CARTO, Biosense-Webster) during ventricular tachycardia catheter ablation, with 7 mapped epicardially. ECGI and EAM geometries were coregistered using anatomic landmarks. ECGI points were paired to the closest site on the EAM within 10 mm. The association between EAM voltage and ECGI features from reconstructed epicardial unipolar electrograms was assessed by mixed-effects regression models. The classification of low-voltage regions was performed using receiver-operating characteristic analysis. RESULTS A total of 9,541 ECGI points (median: 596; interquartile range: 377-737 across patients) were paired to an EAM site. Epicardial EAM voltage was associated with ECGI features of signal fractionation and local repolarization dispersion (N = 7; P < 0.05), but they poorly classified sites with bipolar voltage of <1.5 mV or <0.5 mV thresholds (median area under the curve across patients: 0.50-0.62). No association was found between bipolar EAM voltage and low-amplitude reconstructed epicardial unipolar electrograms or ECGI-derived bipolar electrograms. Similar results were found in the combined cohort (n = 16), including endocardial EAM voltage compared to epicardial ECGI features (n = 9). CONCLUSIONS Despite a statistically significant association between ECGI features and EAM voltage, the accuracy of the delineation of low-voltage zones was modest. This may limit ECGI use for pr-procedural substrate analysis in ventricular tachycardia ablation, but it could provide value in risk assessment for ventricular arrhythmias.
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Affiliation(s)
- Adam J Graham
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Michele Orini
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
| | - Ernesto Zacur
- Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
| | - Gurpreet Dhillon
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Daniel Jones
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Sandeep Prabhu
- Department of Cardiology, The Alfred Hospital, Melbourne, Australia
| | - Francesca Pugliese
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Martin Lowe
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Syed Ahsan
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Mark J Earley
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Anthony Chow
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Simon Sporton
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Mehul Dhinoja
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Ross J Hunter
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Richard J Schilling
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom
| | - Pier D Lambiase
- Barts Heart Centre, Barts Health National Health Service Trust, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom.
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13
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Orini M, Seraphim A, Graham A, Bhuva A, Zacur E, Kellman P, Schilling R, Hunter R, Dhinoja M, Finlay MC, Ahsan S, Chow AW, Moon JC, Lambiase PD, Manisty C. Detailed Assessment of Low-Voltage Zones Localization by Cardiac MRI in Patients With Implantable Devices. JACC Clin Electrophysiol 2022; 8:225-235. [PMID: 35210080 DOI: 10.1016/j.jacep.2021.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 10/05/2021] [Accepted: 10/08/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The purpose of this study was to assess the performance and limitations of low-voltage zones (LVZ) localization by optimized late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) scar imaging in patients with cardiac implantable electronic devices (CIEDs). BACKGROUND Scar evaluation by LGE-CMR can assist ventricular tachycardia (VT) ablation, but challenges with electroanatomical maps coregistration and presence of imaging artefacts from CIED limit accuracy. METHODS A total of 10 patients underwent VT ablation and preprocedural LGE-CMR using wideband imaging. Scar was segmented from CMR pixel signal intensity maps using commercial software (ADAS-VT, Galgo Medical) with bespoke tools and compared with detailed electroanatomical maps (CARTO). Coregistration of EP and imaging-derived scar was performed using the aorta as a fiducial marker, and the impact of coregistration was determined by assessing intraobserver/interobserver variability and using computer simulations. Spatial smoothing was applied to assess correlation at different spatial resolutions and to reduce noise. RESULTS Pixel signal intensity maps localized low-voltage zones (V <1.5 mV) with area under the receiver-operating characteristic curve: 0.82 (interquartile range [IQR]: 0.76-0.83), sensitivity 74% (IQR: 71%-77%), and specificity 78% (IQR: 73%-83%) and correlated with bipolar voltage (r = -0.57 [IQR: -0.68 to -0.42]) across patients. In simulations, small random shifts and rotations worsened LVZ localization in at least some cases. The use of the full aortic geometry ensured high reproducibility of LVZ localization (r >0.86 for area under the receiver-operating characteristic curve). Spatial smoothing improved localization of LVZ. Results for LVZ with V <0.5 mV were similar. CONCLUSIONS In patients with CIEDs, novel wideband CMR sequences and personalized coregistration strategies can localize LVZ with good accuracy and may assist VT ablation procedures.
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Affiliation(s)
- Michele Orini
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Department of Cardiac Electrophysiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Andreas Seraphim
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Department of Cardiac Electrophysiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Adam Graham
- Department of Cardiac Electrophysiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Anish Bhuva
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Ernesto Zacur
- Department of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
| | - Peter Kellman
- National Institutes of Health, Bethesda, Maryland, USA
| | - Richard Schilling
- Department of Cardiac Electrophysiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Ross Hunter
- Department of Cardiac Electrophysiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Mehul Dhinoja
- Department of Cardiac Electrophysiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Malcolm C Finlay
- Department of Cardiac Electrophysiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Syed Ahsan
- Department of Cardiac Electrophysiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Anthony W Chow
- Department of Cardiac Electrophysiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - James C Moon
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Pier D Lambiase
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Department of Cardiac Electrophysiology, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom.
| | - Charlotte Manisty
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom.
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14
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OUP accepted manuscript. Eur Heart J 2022; 43:1248-1250. [DOI: 10.1093/eurheartj/ehab912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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15
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Gagyi RB, Hoogendijk M, Yap SC, Szili-Torok T. Treatment of brief episodes of highly symptomatic supraventricular and ventricular arrhythmias: a methodological review. Expert Rev Med Devices 2021; 18:1155-1163. [PMID: 34854768 DOI: 10.1080/17434440.2021.2012449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Patients with brief arrhythmias are a challenging group to treat effectively with catheter ablation. Current standard approaches for the localization and treatment of brief arrhythmias suffer from several limitations, including the lack of spatiotemporal stability and adequate resolution. Recently, novel methods became available that open new perspectives and can be implemented both on the atrial and ventricular level to approach the diagnosis and treatment of these arrhythmias. AREAS COVERED In this paper, we demonstrate in each section a novel mapping modality that has a potential to approach arrhythmias considered unmappable in the past. After describing the method, we focused on the most important features of each system that makes mapping of short arrhythmias feasible. At the end of each section, we gave a short overview about necessary developments to improve the utility of these systems in the near future. EXPERT OPINION Treating brief episodes of tachycardias remains a challenge and can cause significant frustration for electrophysiologists. Although the broadening of the indication is clearly visible, currently available sequential mapping techniques often fail to map short-lived arrhythmias. New beneficial technological features permit the mapping of these previously considered unmappable arrhythmias, and offer a new perspective in their management.
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Affiliation(s)
- Rita B Gagyi
- Department of Cardiology, Electrophysiology, Erasmus Mc, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mark Hoogendijk
- Department of Cardiology, Electrophysiology, Erasmus Mc, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Sing-Chien Yap
- Department of Cardiology, Electrophysiology, Erasmus Mc, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Tamas Szili-Torok
- Department of Cardiology, Electrophysiology, Erasmus Mc, University Medical Center Rotterdam, Rotterdam, The Netherlands
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16
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Stevenson WG, Sapp JL. Newer Methods for VT Ablation and When to Use Them. Can J Cardiol 2021; 38:502-514. [PMID: 34942300 DOI: 10.1016/j.cjca.2021.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 12/03/2021] [Accepted: 12/11/2021] [Indexed: 02/07/2023] Open
Abstract
Radiofrequency (RF) catheter ablation has long been an important therapy for ventricular tachycardia and frequent symptomatic premature ventricular beats and nonsustained arrhythmias when antiarrhythmic drugs fail to suppress the arrhythmias. It is increasingly used in preference to antiarrhythmic drugs, sparing the patient drug adverse effects. Ablation success varies with the underlying heart disease and type of arrhythmia, being very effective for patients without structural heart disease, less in structural heart disease. Failure occurs when a target for ablation cannot be identified, or ablation lesions fail to reach and abolish the arrhythmia substrate that may be extensive, intramural or subepicardial in location. Approaches to improving ablation lesion creation are modifications to RF ablation and emerging investigational techniques. Easily implemented modifications to RF methods include manipulating the size and location of the cutaneous dispersive electrode, increasing RF delivery duration, and use of lower tonicity catheter irrigation (usually 0.45% saline). When catheters can be placed on either side of culprit substrate RF can be delivered in a bipolar or simultaneous unipolar configuration that can be successful. Catheters with extendable/retractable irrigated needles for RF delivery are under investigation in clinical trials. Cryoablation is potentially useful in specific situations when maintaining contact is difficult. Transvascular ethanol ablation and stereotactic radioablation have both shown promise for arrhythmias that fail other ablation strategies. Although substantial clinical progress has been achieved, further improvement is clearly needed. With ability to increase ablation lesion size, continued careful evaluation of safety, which has been excellent for standard RF ablation, remains important.
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Affiliation(s)
- William G Stevenson
- The Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; The Heart Rhythm Service, Department of Medicine, Division of Cardiology, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada.
| | - John L Sapp
- The Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; The Heart Rhythm Service, Department of Medicine, Division of Cardiology, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
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17
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Dedukh EV, Yashkov MV, Artyukhina EA, Revishvili AS. Diagnostic potential of non-invasive mapping in the treatment of ventricular tachycardia in a patient with postinfarction scar: a case report. КАРДИОВАСКУЛЯРНАЯ ТЕРАПИЯ И ПРОФИЛАКТИКА 2021. [DOI: 10.15829/1728-8800-2022-2947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
A case report of ventricular tachycardia (VT) treatment in a patient after myocardial infarction using non-invasive real-time electrophysiological mapping is presented. This clinical observation demonstrates the diagnostic possibilities of non-invasive mapping in the treatment of VT with hemodynamic instability. Non-invasive mapping can be used as a method for visualizing the early activation and slow conduction zones in hemodynamically instable VT, when effective endocardial mapping is not possible.
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Affiliation(s)
- E. V. Dedukh
- A.V. Vishnevsky National Medical Research Center of Surgery
| | - M. V. Yashkov
- A.V. Vishnevsky National Medical Research Center of Surgery
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18
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Graham AJ, Schilling RJ. The Use of Electrocardiographic Imaging in Localising the Origin of Arrhythmias During Catheter Ablation of Ventricular Tachycardia. Arrhythm Electrophysiol Rev 2021; 10:211-217. [PMID: 34777827 PMCID: PMC8576495 DOI: 10.15420/aer.2021.27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/09/2021] [Indexed: 11/10/2022] Open
Abstract
Non-invasive electrocardiographic imaging (ECGI) is a novel clinical tool for mapping ventricular arrhythmia. Using multiple body surface electrodes to collect unipolar electrograms and conventional medical imaging of the heart, an epicardial shell can be created to display calculated electrograms. This calculation is achieved by solving the inverse problem and allows activation times to be calculated from a single beat. The technology was initially pioneered in the US using an experimental torso-shaped tank. Accuracy from studies in humans has varied. Early data was promising, with more recent work suggesting only moderate accuracy when reproducing cardiac activation. Despite these limitations, the system has been successfully used in pioneering work with non-invasive cardiac radioablation to treat ventricular arrhythmia. This suggests that the resolution may be sufficient for treatment of large target areas. Although untested in a well conducted clinical study it is likely that it would not be accurate enough to guide more discreet radiofrequency ablation.
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Affiliation(s)
- Adam J Graham
- Barts Heart Centre, St Bartholomew's Hospital, London, UK
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19
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Siedow M, Brownstein J, Prasad RN, Loccoh E, Harfi TT, Okabe T, Tong MS, Afzal MR, Williams T. Cardiac radioablation in the treatment of ventricular tachycardia. Clin Transl Radiat Oncol 2021; 31:71-79. [PMID: 34646951 PMCID: PMC8498093 DOI: 10.1016/j.ctro.2021.02.005] [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: 02/02/2021] [Revised: 02/02/2021] [Accepted: 02/08/2021] [Indexed: 11/25/2022] Open
Abstract
Cardiac radioablation with SBRT is a very promising non-invasive modality for the treatment of refractory VT and potentially other cardiac arrhythmias. Initial reports indicate that it is relatively safe and associated with excellent responses, particularly in reduction of ICD-related events, need for anti-arrhythmic medications, and resulting in significantly improved quality of life for patients. Establishment of objective criteria for candidates for cardiac radioablation will accelerate the adoption of this important radiation therapy modality in the treatment of refractory VT and other cardiac arrhythmias in the coming years. In addition, in order to develop more prospective safety and efficacy data, treatment of patients should ideally be performed in the context of clinical trials or prospective registries at, or in collaboration with, experienced centers. Taken together, the future of cardiac radioablation is rich and worthy of further investigation to become a standard treatment in the armamentarium against refractory VT.
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Affiliation(s)
- Michael Siedow
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jeremy Brownstein
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Rahul N. Prasad
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Emefah Loccoh
- Department of Radiation Oncology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Thura T. Harfi
- Division of Cardiovascular Medicine, The Ohio State University Medical Center, Columbus, OH, USA
| | - Toshimasa Okabe
- Division of Cardiovascular Medicine, The Ohio State University Medical Center, Columbus, OH, USA
| | - Matthew S. Tong
- Division of Cardiovascular Medicine, The Ohio State University Medical Center, Columbus, OH, USA
| | - Muhammad R. Afzal
- Division of Cardiovascular Medicine, The Ohio State University Medical Center, Columbus, OH, USA
| | - Terence Williams
- Department of Radiation Oncology, City of Hope National Medical Center, Duarte, CA, USA
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20
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Advances in Mapping of Ventricular Tachycardia. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00951-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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21
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Ho G, Atwood TF, Bruggeman AR, Moore KL, McVeigh E, Villongco CT, Han FT, Hsu JC, Hoffmayer KS, Raissi F, Lin GY, Schricker A, Woods CE, Cheung JP, Taira AV, McCulloch A, Birgersdotter-Green U, Feld GK, Mundt AJ, Krummen DE. Computational ECG mapping and respiratory gating to optimize stereotactic ablative radiotherapy workflow for refractory ventricular tachycardia. Heart Rhythm O2 2021; 2:511-520. [PMID: 34667967 PMCID: PMC8505208 DOI: 10.1016/j.hroo.2021.09.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Stereotactic ablative radiotherapy (SAbR) is an emerging therapy for refractory ventricular tachycardia (VT). However, the current workflow is complicated, and the precision and safety in patients with significant cardiorespiratory motion and VT targets near the stomach may be suboptimal. OBJECTIVE We hypothesized that automated 12-lead electrocardiogram (ECG) mapping and respiratory-gated therapy may improve the ease and precision of SAbR planning and facilitate safe radiation delivery in patients with refractory VT. METHODS Consecutive patients with refractory VT were studied at 2 hospitals. VT exit sites were localized using a 3-D computational ECG algorithm noninvasively and compared to available prior invasive mapping. Radiotherapy (25 Gy) was delivered at end-expiration when cardiac respiratory motion was ≥0.6 cm or targets were ≤2 cm from the stomach. RESULTS In 6 patients (ejection fraction 29% ± 13%), 4.2 ± 2.3 VT morphologies per patient were mapped. Overall, 7 out of 7 computational ECG mappings (100%) colocalized to the identical cardiac segment when prior invasive electrophysiology study was available. Respiratory gating was associated with smaller planning target volumes compared to nongated volumes (71 ± 7 vs 153 ± 35 cc, P < .01). In 2 patients with inferior wall VT targets close to the stomach (6 mm proximity) or significant respiratory motion (22 mm excursion), no GI complications were observed at 9- and 12-month follow-up. Implantable cardioverter-defibrillator shocks decreased from 23 ± 12 shocks/patient to 0.67 ± 1.0 (P < .001) post-SAbR at 6.0 ± 4.9 months follow-up. CONCLUSIONS A workflow including computational ECG mapping and protocol-guided respiratory gating is feasible, is safe, and may improve the ease of SAbR planning. Studies to validate this workflow in larger populations are required.
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Affiliation(s)
- Gordon Ho
- Department of Medicine-Cardiology, University of California San Diego, La Jolla, California
| | - Todd F. Atwood
- Department of Radiation Medicine, University of California San Diego, La Jolla, California
| | - Andrew R. Bruggeman
- Department of Radiation Medicine, University of California San Diego, La Jolla, California
| | - Kevin L. Moore
- Department of Radiation Medicine, University of California San Diego, La Jolla, California
| | - Elliot McVeigh
- Department of Bioengineering, University of California San Diego, La Jolla, California
| | | | - Frederick T. Han
- Department of Medicine-Cardiology, University of California San Diego, La Jolla, California
| | - Jonathan C. Hsu
- Department of Medicine-Cardiology, University of California San Diego, La Jolla, California
| | - Kurt S. Hoffmayer
- Department of Medicine-Cardiology, University of California San Diego, La Jolla, California
| | - Farshad Raissi
- Department of Medicine-Cardiology, University of California San Diego, La Jolla, California
| | - Grace Y. Lin
- Department of Pathology, University of California San Diego, La Jolla, California
| | - Amir Schricker
- Department of Cardiac Electrophysiology, Mills-Peninsula Medical Center, Sutter Health, Burlingame, California
| | - Christopher E. Woods
- Department of Cardiac Electrophysiology, Mills-Peninsula Medical Center, Sutter Health, Burlingame, California
| | - Joey P. Cheung
- Department of Radiation Oncology, Mills-Peninsula Medical Center, Sutter Health, Burlingame, California
| | - Al V. Taira
- Department of Radiation Oncology, Mills-Peninsula Medical Center, Sutter Health, Burlingame, California
| | - Andrew McCulloch
- Department of Bioengineering, University of California San Diego, La Jolla, California
| | | | - Gregory K. Feld
- Department of Medicine-Cardiology, University of California San Diego, La Jolla, California
| | - Arno J. Mundt
- Department of Radiation Medicine, University of California San Diego, La Jolla, California
| | - David E. Krummen
- Department of Medicine-Cardiology, University of California San Diego, La Jolla, California
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22
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Schuler S, Pilia N, Potyagaylo D, Loewe A. Cobiveco: Consistent biventricular coordinates for precise and intuitive description of position in the heart - with MATLAB implementation. Med Image Anal 2021; 74:102247. [PMID: 34592711 DOI: 10.1016/j.media.2021.102247] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 11/18/2022]
Abstract
Ventricular coordinates are widely used as a versatile tool for various applications that benefit from a description of local position within the heart. However, the practical usefulness of ventricular coordinates is determined by their ability to meet application-specific requirements. For regression-based estimation of biventricular position, for example, a symmetric definition of coordinate directions in both ventricles is important. For the transfer of data between different hearts as another use case, the consistency of coordinate values across different geometries is particularly relevant. To meet these requirements, we compare different approaches to compute coordinates and present Cobiveco, a symmetric, consistent and intuitive biventricular coordinate system that builds upon existing coordinate systems, but overcomes some of their limitations. A novel one-way transfer error is introduced to assess the consistency of the coordinates. Normalized distances along bijective trajectories between two boundaries were found to be superior to solutions of Laplace's equation for defining coordinate values, as they show better linearity in space. Evaluation of transfer and linearity errors on 36 patient geometries revealed a more than 4-fold improvement compared to a state-of-the-art method. Finally, we show two application examples underlining the relevance for cardiac data processing. Cobiveco MATLAB code is available under a permissive open-source license.
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Affiliation(s)
- Steffen Schuler
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Fritz-Haber-Weg 1, Karlsruhe 76131, Germany.
| | - Nicolas Pilia
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Fritz-Haber-Weg 1, Karlsruhe 76131, Germany
| | | | - Axel Loewe
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Fritz-Haber-Weg 1, Karlsruhe 76131, Germany
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23
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Nguyen D, Jeudy J, Restrepo AJ, Dickfeld TM. A Novel Use of Noninvasive Registered Electrocardiographic Imaging Map for Localization of VT and PVC. JACC Case Rep 2021; 3:591-593. [PMID: 34317583 PMCID: PMC8302781 DOI: 10.1016/j.jaccas.2021.01.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 12/11/2020] [Accepted: 01/06/2021] [Indexed: 11/24/2022]
Abstract
A 33-year-old woman presented with sustained monomorphic ventricular tachycardia (VT). The 12-lead electrocardiogram, 3-dimensional (3D) picture of chest electrodes, and cardiac magnetic resonance were used to create a noninvasive 3D electrocardiographic imaging map to identify the most likely site of VT origin. This map was integrated with a 3D mapping system to aid in VT ablation. (Level of Difficulty: Advanced.).
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Affiliation(s)
- Daniel Nguyen
- Maryland Arrhythmia and Cardiac Imaging Group (MACIG) Cardiac Electrophysiology Section, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jean Jeudy
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Alejandro Jimenez Restrepo
- Maryland Arrhythmia and Cardiac Imaging Group (MACIG) Cardiac Electrophysiology Section, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Timm-Michael Dickfeld
- Maryland Arrhythmia and Cardiac Imaging Group (MACIG) Cardiac Electrophysiology Section, University of Maryland School of Medicine, Baltimore, Maryland, USA
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24
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Campbell T, Bennett RG, Kotake Y, Kumar S. Updates in Ventricular Tachycardia Ablation. Korean Circ J 2021; 51:15-42. [PMID: 33377327 PMCID: PMC7779814 DOI: 10.4070/kcj.2020.0436] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/27/2020] [Indexed: 02/06/2023] Open
Abstract
Sudden cardiac death (SCD) due to recurrent ventricular tachycardia is an important clinical sequela in patients with structural heart disease. As a result, ventricular tachycardia (VT) has emerged as a major clinical and public health problem. The mechanism of VT is predominantly mediated by re-entry in the presence of arrhythmogenic substrate (scar), though focal mechanisms are also important. Catheter ablation for VT, when compared to standard medical therapy, has been shown to improve VT-free survival and burden of device therapies. Approaches to VT ablation are dependent on the underlying disease process, broadly classified into idiopathic (no structural heart disease) or structural heart disease (ischemic or non-ischemic heart disease). This update aims to review recent advances made for the treatment of VT ablation, with respect to current clinical trials, peri-procedure risk assessments, pre-procedural cardiac imaging, electro-anatomic mapping and advances in catheter and non-catheter based ablation techniques.
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Affiliation(s)
- Timothy Campbell
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- Westmead Applied Research Centre, University of Sydney, New South Wales, Australia
| | - Richard G Bennett
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- Westmead Applied Research Centre, University of Sydney, New South Wales, Australia
| | - Yasuhito Kotake
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- Westmead Applied Research Centre, University of Sydney, New South Wales, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- Westmead Applied Research Centre, University of Sydney, New South Wales, Australia.
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25
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Prospective Multicenter Assessment of a New Intraprocedural Automated System for Localizing Idiopathic Ventricular Arrhythmia Origins. JACC Clin Electrophysiol 2020; 7:395-407. [PMID: 33736758 DOI: 10.1016/j.jacep.2020.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 08/31/2020] [Accepted: 09/06/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The objective of this study was to present a new system, the Automatic Arrhythmia Origin Localization (AAOL) system, which used incomplete electroanatomic mapping (EAM) for localization of idiopathic ventricular arrhythmia (IVA) origin on the patient-specific geometry of left ventricular, right ventricular, and neighboring vessels. The study assessed the accuracy of the system in localizing IVA source sites on cardiac structures where pace mapping is challenging. BACKGROUND An intraprocedural automated site of origin localization system was previously developed to identify the origin of early left ventricular activation by using 12-lead electrocardiograms (ECGs). However, it has limitations, as it could not identify the site of origin in the right ventricle and relied on acquiring a complete EAM. METHODS Twenty patients undergoing IVA catheter ablation had a 12-lead ECG recorded during clinical arrhythmia and during pacing at various locations identified on EAM geometries. The new system combined 3-lead (III, V2, and V6) 120-ms QRS integrals and patient-specific EAM geometry with pace mapping to predict the site of earliest ventricular activation. The predicted site was projected onto EAM geometry. RESULTS Twenty-three IVA origin sites were clinically identified by activation mapping and/or pace mapping (8, right ventricle; 15, left ventricle, including 8 from the posteromedial papillary muscle, 2 from the aortic root, and 1 from the distal coronary sinus). The new system achieved a mean localization accuracy of 3.6 mm for the 23 mapped IVAs. CONCLUSIONS The new intraprocedural AAOL system achieved accurate localization of IVA origin in ventricles and neighboring vessels, which could facilitate ablation procedures for patients with IVAs.
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26
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Sapp JL, Zhou S, Wang L. Mapping Ventricular Tachycardia With Electrocardiographic Imaging. Circ Arrhythm Electrophysiol 2020; 13:e008255. [PMID: 32069088 DOI: 10.1161/circep.120.008255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- John L Sapp
- Department of Medicine, Dalhousie University, and the QEII Health Sciences Centre, Halifax, NS, Canada (J.L.S.)
| | - Shijie Zhou
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Institute of Computational Medicine, Johns Hopkins University, Baltimore, MD (S.Z.)
| | - Linwei Wang
- College of Computing and Information Sciences, Rochester Institute of Technology, Rochester, NY (L.W.)
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