Aims Patients with ischaemic cardiomyopathy (ICM) referred for catheter ablation of ventricular tachycardia (VT) are at risk for end-stage heart failure (HF) due to adverse remodelling. Local... Show moreAims Patients with ischaemic cardiomyopathy (ICM) referred for catheter ablation of ventricular tachycardia (VT) are at risk for end-stage heart failure (HF) due to adverse remodelling. Local unipolar voltages (UV) decrease with loss of viable myocardium. A UV parameter reflecting global viable myocardium may predict prognosis. We evaluate if a newly proposed parameter, area-weighted unipolar voltage (awUV), can predict HF-related outcomes [HFO; HF death/left ventricular (LV) assist device/heart transplant] in ICM. Methods and results From endocardial voltage maps of consecutive patients with ICM referred for VT ablation, awUV was calculated by weighted interpolation of local UV. Associations between clinical and mapping parameters and HFO were evaluated and validated in a second cohort. The derivation cohort consisted of 90 patients [age 68 +/- 8 years; LV ejection fraction (LVEF) 35% interquartile range (IQR) (24-40)] and validation cohort of 60 patients [age 67 +/- 9, LVEF 39% IQR (29-45)]. In the derivation cohort, during a median follow-up of 45 months [IQR (34-83)], 36 (43%) patients died and 23 (26%) had HFO. Patients with HFO had lower awUV [4.51 IQR (3.69-5.31) vs. 7.03 IQR (6.08-9.2), P < 0.001]. A reduction in awUV [optimal awUV (5.58) cut-off determined by receiver operating characteristics analysis] was a strong predictor of HFO (3-year HFO survival 97% vs. 57%). The cut-off value was confirmed in the validation cohort (2-year HFO-free survival 96% vs. 60%). Conclusion The newly proposed parameter awUV, easily available from routine voltage mapping, may be useful at identifying ICM patients at high risk for HFO.[GRAPHICS] Show less
Background: Poor outcome after atrial tachycardia (AT) radiofrequency catheter ablation (RFCA) in repaired congenital heart disease (CHD) has been attributed to CHD complexity. This may not apply... Show moreBackground: Poor outcome after atrial tachycardia (AT) radiofrequency catheter ablation (RFCA) in repaired congenital heart disease (CHD) has been attributed to CHD complexity. This may not apply to contemporary patients. The objective of our study was to assess outcome after RFCA for AT in contemporary patients with CHD according to prior atrial surgery and predefined procedural endpoints. Methods: Patients with CHD referred for AT RFCA to 3 European centers were classified as no atrial surgery/cannulation only, limited or extensive prior atrial surgery. Procedural success was predefined as termination and nonreinducibility for focal AT and bidirectional block across ablation lines for intra-atrial reentrant tachycardia and after empirical substrate ablation for noninducible patients. Patients were followed for AT recurrence and mortality. Results: Ablation was performed in 290 patients (41 +/- 17 years, 59% male; 3-dimensional mapping 89%, irrigated tip catheters 90%, transbaffle access 15%). In 197, 233 AT were targeted (196 intra-atrial reentrant tachycardia [64% cavotricuspid (mitral) isthmus-dependent, 33% systemic-venous incision-dependent] and 37 focal AT). In 93 noninducible patients, empirical substrate ablation was performed. Procedural success was achieved in 209 (84%) patients. AT recurred in 148 (54%) 10 (interquartile range, 0-25) months after RFCA. AT-free survival was significantly better in patients with no atrial repair/cannulation only and in patients with complete procedural success independently of CHD complexity. From 94 patients undergoing reablation, the initially targeted substrate had recovered in 64%. Conclusions: In contemporary patients with CHD, outcome after AT ablation is associated with presence of prior atrial surgery and achievement of predefined procedural endpoints rather than CHD complexity. Techniques to improve lesion durability are likely to further improve long-term outcome. Show less
OBJECTIVES This study sought to evaluate whether right ventricular (RV) tissue heterogeneity on computed tomography (CT): 1) is associated with conduction delay in arrhythmogenic right ventricular... Show moreOBJECTIVES This study sought to evaluate whether right ventricular (RV) tissue heterogeneity on computed tomography (CT): 1) is associated with conduction delay in arrhythmogenic right ventricular cardiomyopathy (ARVC); and 2) distinguishes patients with ARVC from those with exercise-induced arrhythmogenic remodeling (EIAR) and control individuals.BACKGROUND ARVC is characterized by fibrofatty replacement, related to conduction delay and ventricular tachycardiac. Distinguishing ARVC from acquired, EIAR is challenging.METHODS Patients with ARVC or EIAR and combined endocardial-epicardiat electroanatomic voltage mapping for VT ablation with CT integration were enrolled. Patients without structural heart disease served as control individuals. Tissue heterogeneity on CT (CT heterogeneity) was automatically quantified within the 2-mm subepicardium of the entire RV free wall at normal sites and tow voltage sites harboring late potentials (LP+) in ARVC/EIAR.RESULTS Seventeen patients with ARVC (15 mates; age: 50 17 years), 9 patients with EIAR (7 males; age: 45 14 years) and 17 control individuals (14 males; age: 50 +/- 15 years) were enrolled. Of 5,215 ARVC mapping points, 560 (11%) showed LP+ . CT heterogeneity was higher at sites with LP-i compared to normal sites (median: 31 HU/mm; IQR: 23 to 46 HU/mm vs. median: 16 HU/mm; IQR: 13 to 21 HU/mm; p < 0.001). The optimal CT heterogeneity cutoff for detection of LP+ was 25 HU/mm (area under the curve [AUG 0.80; sensitivity: 72%; specificity: 78%). Overall CT heterogeneity allowed highly accurate differentiation between patients with ARVC and control individuals (AUC: 0.97; sensitivity: 100%; specificity: 82%) and between ARVC and EIAR (AUC: 0.78; sensitivity: 65%; spedficity: 89%).CONCLUSIONS In patients with ARVC, tissue heterogeneity on CT can be used to identify LP+ as a surrogate for ventricular tachycardia substrate. The overall tissue heterogeneity on CT allows the distinguishing of patients with ARVC from those with EIAR and control individuals. (C) 2020 by the American College of Cardiology Foundation. Show less
Hoogendoorn, J.C.; Sramko, M.; Venlet, J.; Siontis, K.C.; Kumar, S.; Singh, R.; ... ; Zeppenfeld, K. 2020
OBJECTIVES This study sought to investigate the value of electroanatomical voltage mapping (EAVM) to distinguish cardiac sarcoidosis (CS) from arrhythmogenic right ventricular cardiomyopathy (ARVC)... Show moreOBJECTIVES This study sought to investigate the value of electroanatomical voltage mapping (EAVM) to distinguish cardiac sarcoidosis (CS) from arrhythmogenic right ventricular cardiomyopathy (ARVC) in patients with ventriculartachycardia from the right ventricle (RV).BACKGROUND CS can mimic ARVC. Because scar in ARVC is predominantly subepicardial, this study hypothesized that the relative sizes of endocardial low bipolar voltage (BV) to low unipolar voltage (UV) areas may distinguish CS from ARVC.METHODS Patients with CS affecting the RV (n = 14), patients with gene-positive ARVC (n = 13), and a reference group of patients without structural heart disease (n = 9) who underwent RV endocardial EAVM were included. RV regionspecific BV and UV cutoffs were derived from control subjects. In CS and ARVC, segmental involvement was determined and low-voltage areas were measured, using <1.5 mV for BV and <3.9 mV, <4.4 mV, and <5.5 mV for UV. The ratio between low BV and low UV area was calculated generating 3 parameters: Ratio3.9, Ratio4.4 and Ratio5.5, respectively.RESULTS In control subjects, BV and UV varied significantly among RV regions. The basal septum was involved in 71% of CS patients and in none of ARVC patients. Ratio5.5 discriminated CS from ARVC the best. An algorithm including Ratio5.5≥0.45 and basal septal involvement identified CS with 93% sensitivity and 85% specificity. This was validated in a separate population (CS [n = 6], ARVC [n = 10]) with 100% sensitivity and 100% specificity.CONCLUSIONS EAVM provides detailed information about scar characteristics and scar distribution in the RV. An algorithm combining Ratio5.5 (area BV <1.5 mV/area UV <5.5 mV) and bipolar basal septal involvement allows accurate diagnosis of (isolated) CS in patients presenting with monomorphic ventricular tachycardia from the RV. Show less
Siontis, K.C.; Kim, H.M.; Stevenson, W.G.; Fujii, A.; Bella, P. della; Vergara, P.; ... ; Bogun, F.M. 2016
