Impact of Multidirectional Pacing on Activation and Repolarization Parameters to Localize Ischemic Ventricular Tachycardia Circuits

Adam S.C. Dennis; Michele Orini; Eva Melis Hesselkilde; Arnela Saljic; Benedikt M. Linz; Stefan M. Sattler; James Williams; Jacob Tfelt-Hansen; Thomas Jespersen; Anthony W.C. Chow; Pier D. Lambiase

doi:10.1016/j.jacep.2024.07.028

Impact of Multidirectional Pacing on Activation and Repolarization Parameters to Localize Ischemic Ventricular Tachycardia Circuits

Adam S.C. Dennis, Michele Orini, Eva Melis Hesselkilde, Arnela Saljic, Benedikt M. Linz, Stefan M. Sattler, James Williams, Jacob Tfelt-Hansen, Thomas Jespersen, Anthony W.C. Chow, Pier D. Lambiase^*

^*Corresponding author for this work

Research output: Contribution to journal › Article › peer-review

Abstract

Background: In ventricular tachycardia (VT), optimal substrate mapping strategies identifying arrhythmogenic sites are not established. Objectives: This study sought to evaluate multidirectional pacing on the distribution of specific conduction and repolarization metrics to localize re-entrant VT sites in a porcine infarct model. Methods: Substrate maps were created in 13 pigs with chronic myocardial infarction using the Advisor HD Grid (Abbott) during right ventricular (RV), left ventricular, biventricular pacing (BIV), and sinus rhythm (SR). Critical VT sites of early-, mid-, and late-diastolic signals were delineated. Vulnerable sites to re-entry were defined as sites of latest activation timing within and post-QRS complex, largest activation and activation-recovery interval gradients. Distances between the 20 most vulnerable sites and diastolic VT points were measured, and identification of VT points was assessed using the area under the receiver-operating characteristic curve. Results: A total of 34 VTs were mapped, and 48 sinus and pacing maps were obtained (10 BIV, 13 left ventricular, 13 RV, 12 SR). Late potential mapping in SR was taken as the established clinical standard for comparison. Latest activation time with BIV pacing provided the closest localization for VT isthmus (median 5.5 mm; IQR: 7.15 mm; P < 0.005). The gradient of activation-recovery interval using RV pacing had closest localization for VT exit and entrance (median 10.6 mm; IQR: 5.0 mm; P < 0.005 and 9.4 mm; IQR: 8.0 mm; P < 0.05). Global sensitivity and specificity analysis showed that gradient of activation-recovery interval in SR achieved the highest area under the receiver-operating characteristic curve, with similar results from the gradient of activation timing. Conclusions: Multidirectional pacing in combination with conduction and repolarization parameters enables better localization of VT diastolic critical sites vs SR late potentials.

Original language	English
Pages (from-to)	2314-2324
Number of pages	11
Journal	JACC: Clinical Electrophysiology
Volume	10
Issue number	11
DOIs	https://doi.org/10.1016/j.jacep.2024.07.028
Publication status	Published - Nov 2024

Keywords

electroanatomic mapping
substrate mapping
ventricular tachycardia

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10.1016/j.jacep.2024.07.028

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Dennis, A. S. C., Orini, M., Melis Hesselkilde, E., Saljic, A., Linz, B. M., Sattler, S. M., Williams, J., Tfelt-Hansen, J., Jespersen, T., Chow, A. W. C., & Lambiase, P. D. (2024). Impact of Multidirectional Pacing on Activation and Repolarization Parameters to Localize Ischemic Ventricular Tachycardia Circuits. JACC: Clinical Electrophysiology, 10(11), 2314-2324. https://doi.org/10.1016/j.jacep.2024.07.028

@article{36a783e1ae2a423097ea7345664b04a6,

title = "Impact of Multidirectional Pacing on Activation and Repolarization Parameters to Localize Ischemic Ventricular Tachycardia Circuits",

abstract = "Background: In ventricular tachycardia (VT), optimal substrate mapping strategies identifying arrhythmogenic sites are not established. Objectives: This study sought to evaluate multidirectional pacing on the distribution of specific conduction and repolarization metrics to localize re-entrant VT sites in a porcine infarct model. Methods: Substrate maps were created in 13 pigs with chronic myocardial infarction using the Advisor HD Grid (Abbott) during right ventricular (RV), left ventricular, biventricular pacing (BIV), and sinus rhythm (SR). Critical VT sites of early-, mid-, and late-diastolic signals were delineated. Vulnerable sites to re-entry were defined as sites of latest activation timing within and post-QRS complex, largest activation and activation-recovery interval gradients. Distances between the 20 most vulnerable sites and diastolic VT points were measured, and identification of VT points was assessed using the area under the receiver-operating characteristic curve. Results: A total of 34 VTs were mapped, and 48 sinus and pacing maps were obtained (10 BIV, 13 left ventricular, 13 RV, 12 SR). Late potential mapping in SR was taken as the established clinical standard for comparison. Latest activation time with BIV pacing provided the closest localization for VT isthmus (median 5.5 mm; IQR: 7.15 mm; P < 0.005). The gradient of activation-recovery interval using RV pacing had closest localization for VT exit and entrance (median 10.6 mm; IQR: 5.0 mm; P < 0.005 and 9.4 mm; IQR: 8.0 mm; P < 0.05). Global sensitivity and specificity analysis showed that gradient of activation-recovery interval in SR achieved the highest area under the receiver-operating characteristic curve, with similar results from the gradient of activation timing. Conclusions: Multidirectional pacing in combination with conduction and repolarization parameters enables better localization of VT diastolic critical sites vs SR late potentials.",

keywords = "electroanatomic mapping, substrate mapping, ventricular tachycardia",

author = "Dennis, {Adam S.C.} and Michele Orini and {Melis Hesselkilde}, Eva and Arnela Saljic and Linz, {Benedikt M.} and Sattler, {Stefan M.} and James Williams and Jacob Tfelt-Hansen and Thomas Jespersen and Chow, {Anthony W.C.} and Lambiase, {Pier D.}",

note = "Publisher Copyright: {\textcopyright} 2024 American College of Cardiology Foundation",

year = "2024",

month = nov,

doi = "10.1016/j.jacep.2024.07.028",

language = "English",

volume = "10",

pages = "2314--2324",

journal = "JACC: Clinical Electrophysiology",

issn = "2405-500X",

publisher = "Elsevier USA",

number = "11",

}

Dennis, ASC, Orini, M, Melis Hesselkilde, E, Saljic, A, Linz, BM, Sattler, SM, Williams, J, Tfelt-Hansen, J, Jespersen, T, Chow, AWC & Lambiase, PD 2024, 'Impact of Multidirectional Pacing on Activation and Repolarization Parameters to Localize Ischemic Ventricular Tachycardia Circuits', JACC: Clinical Electrophysiology, vol. 10, no. 11, pp. 2314-2324. https://doi.org/10.1016/j.jacep.2024.07.028

TY - JOUR

T1 - Impact of Multidirectional Pacing on Activation and Repolarization Parameters to Localize Ischemic Ventricular Tachycardia Circuits

AU - Dennis, Adam S.C.

AU - Orini, Michele

AU - Melis Hesselkilde, Eva

AU - Saljic, Arnela

AU - Linz, Benedikt M.

AU - Sattler, Stefan M.

AU - Williams, James

AU - Tfelt-Hansen, Jacob

AU - Jespersen, Thomas

AU - Chow, Anthony W.C.

AU - Lambiase, Pier D.

PY - 2024/11

Y1 - 2024/11

N2 - Background: In ventricular tachycardia (VT), optimal substrate mapping strategies identifying arrhythmogenic sites are not established. Objectives: This study sought to evaluate multidirectional pacing on the distribution of specific conduction and repolarization metrics to localize re-entrant VT sites in a porcine infarct model. Methods: Substrate maps were created in 13 pigs with chronic myocardial infarction using the Advisor HD Grid (Abbott) during right ventricular (RV), left ventricular, biventricular pacing (BIV), and sinus rhythm (SR). Critical VT sites of early-, mid-, and late-diastolic signals were delineated. Vulnerable sites to re-entry were defined as sites of latest activation timing within and post-QRS complex, largest activation and activation-recovery interval gradients. Distances between the 20 most vulnerable sites and diastolic VT points were measured, and identification of VT points was assessed using the area under the receiver-operating characteristic curve. Results: A total of 34 VTs were mapped, and 48 sinus and pacing maps were obtained (10 BIV, 13 left ventricular, 13 RV, 12 SR). Late potential mapping in SR was taken as the established clinical standard for comparison. Latest activation time with BIV pacing provided the closest localization for VT isthmus (median 5.5 mm; IQR: 7.15 mm; P < 0.005). The gradient of activation-recovery interval using RV pacing had closest localization for VT exit and entrance (median 10.6 mm; IQR: 5.0 mm; P < 0.005 and 9.4 mm; IQR: 8.0 mm; P < 0.05). Global sensitivity and specificity analysis showed that gradient of activation-recovery interval in SR achieved the highest area under the receiver-operating characteristic curve, with similar results from the gradient of activation timing. Conclusions: Multidirectional pacing in combination with conduction and repolarization parameters enables better localization of VT diastolic critical sites vs SR late potentials.

AB - Background: In ventricular tachycardia (VT), optimal substrate mapping strategies identifying arrhythmogenic sites are not established. Objectives: This study sought to evaluate multidirectional pacing on the distribution of specific conduction and repolarization metrics to localize re-entrant VT sites in a porcine infarct model. Methods: Substrate maps were created in 13 pigs with chronic myocardial infarction using the Advisor HD Grid (Abbott) during right ventricular (RV), left ventricular, biventricular pacing (BIV), and sinus rhythm (SR). Critical VT sites of early-, mid-, and late-diastolic signals were delineated. Vulnerable sites to re-entry were defined as sites of latest activation timing within and post-QRS complex, largest activation and activation-recovery interval gradients. Distances between the 20 most vulnerable sites and diastolic VT points were measured, and identification of VT points was assessed using the area under the receiver-operating characteristic curve. Results: A total of 34 VTs were mapped, and 48 sinus and pacing maps were obtained (10 BIV, 13 left ventricular, 13 RV, 12 SR). Late potential mapping in SR was taken as the established clinical standard for comparison. Latest activation time with BIV pacing provided the closest localization for VT isthmus (median 5.5 mm; IQR: 7.15 mm; P < 0.005). The gradient of activation-recovery interval using RV pacing had closest localization for VT exit and entrance (median 10.6 mm; IQR: 5.0 mm; P < 0.005 and 9.4 mm; IQR: 8.0 mm; P < 0.05). Global sensitivity and specificity analysis showed that gradient of activation-recovery interval in SR achieved the highest area under the receiver-operating characteristic curve, with similar results from the gradient of activation timing. Conclusions: Multidirectional pacing in combination with conduction and repolarization parameters enables better localization of VT diastolic critical sites vs SR late potentials.

KW - electroanatomic mapping

KW - substrate mapping

KW - ventricular tachycardia

UR - http://www.scopus.com/inward/record.url?scp=85208685954&partnerID=8YFLogxK

U2 - 10.1016/j.jacep.2024.07.028

DO - 10.1016/j.jacep.2024.07.028

M3 - Article

C2 - 39453293

AN - SCOPUS:85208685954

SN - 2405-500X

VL - 10

SP - 2314

EP - 2324

JO - JACC: Clinical Electrophysiology

JF - JACC: Clinical Electrophysiology

IS - 11

ER -

Impact of Multidirectional Pacing on Activation and Repolarization Parameters to Localize Ischemic Ventricular Tachycardia Circuits

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