Substrate mapping for scar-related ventricular tachycardia in patients with resynchronization therapy—the importance of the pacing mode

Samuel H. Baldinger, Saurabh Kumar, Akira Fujii, Andreas Haeberlin, Jorge E. Romero, Laurence M. Epstein, Gregory F. Michaud, Usha B. Tedrow, Roy John, William G. Stevenson

Research output: Contribution to journalArticle

Abstract

Purpose: Targets for substrate-based catheter ablation of scar-related ventricular tachycardia (VT) include sites with fractionated and late potentials (LPs). We hypothesized that in patients with cardiac resynchronization therapy (CRT), the pacing mode may influence the timing of abnormal electrograms (EGMs) relative to the surface QRS complex. Methods: We assessed bipolar EGM characteristics in left ventricular low bipolar voltage areas (< 1.5 mV) from 10 patients with coronary disease and a CRT device undergoing catheter ablation for VT. EGMs at 81 sites were analyzed during three different pacing modes (biventricular (BiV), right ventricular (RV)-only, and left ventricular (LV)-only) pacing. Results: Stimulus to end of local electrogram duration (Stim-to-eEGM) depended significantly on the stimulation site (BiV, LV, or RV, p = 0.032). Single-chamber pacing unmasked LPs, not present during BiV pacing, in three patients. In another three patients, a concomitant increase in stimulus to end of surface QRS duration caused by single-site pacing compensated for the increase in Stim-to-eEGM duration, thereby prohibiting LP unmasking. Conclusion: The sequence of ventricular activation, as determined by the pacing site in patients with CRT devices, has a major influence on the detection of late potentials during substrate-guided ablation. Further study is warranted to define the optimal approaches, including the rhythm, for substrate mapping, but our findings suggest that BiV pacing may be most likely to obscure detection of late potentials as compared to single-site pacing.

Original languageEnglish (US)
JournalJournal of Interventional Cardiac Electrophysiology
DOIs
StatePublished - Jan 1 2019
Externally publishedYes

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Ventricular Tachycardia
Cardiac Resynchronization Therapy
Cicatrix
Cardiac Resynchronization Therapy Devices
Catheter Ablation
Coronary Disease

Keywords

  • Cardiac resynchronization therapy
  • Catheter ablation
  • Ischemic heart disease
  • Substrate modification
  • Ventricular tachycardia

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

Substrate mapping for scar-related ventricular tachycardia in patients with resynchronization therapy—the importance of the pacing mode. / Baldinger, Samuel H.; Kumar, Saurabh; Fujii, Akira; Haeberlin, Andreas; Romero, Jorge E.; Epstein, Laurence M.; Michaud, Gregory F.; Tedrow, Usha B.; John, Roy; Stevenson, William G.

In: Journal of Interventional Cardiac Electrophysiology, 01.01.2019.

Research output: Contribution to journalArticle

Baldinger, Samuel H. ; Kumar, Saurabh ; Fujii, Akira ; Haeberlin, Andreas ; Romero, Jorge E. ; Epstein, Laurence M. ; Michaud, Gregory F. ; Tedrow, Usha B. ; John, Roy ; Stevenson, William G. / Substrate mapping for scar-related ventricular tachycardia in patients with resynchronization therapy—the importance of the pacing mode. In: Journal of Interventional Cardiac Electrophysiology. 2019.
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abstract = "Purpose: Targets for substrate-based catheter ablation of scar-related ventricular tachycardia (VT) include sites with fractionated and late potentials (LPs). We hypothesized that in patients with cardiac resynchronization therapy (CRT), the pacing mode may influence the timing of abnormal electrograms (EGMs) relative to the surface QRS complex. Methods: We assessed bipolar EGM characteristics in left ventricular low bipolar voltage areas (< 1.5 mV) from 10 patients with coronary disease and a CRT device undergoing catheter ablation for VT. EGMs at 81 sites were analyzed during three different pacing modes (biventricular (BiV), right ventricular (RV)-only, and left ventricular (LV)-only) pacing. Results: Stimulus to end of local electrogram duration (Stim-to-eEGM) depended significantly on the stimulation site (BiV, LV, or RV, p = 0.032). Single-chamber pacing unmasked LPs, not present during BiV pacing, in three patients. In another three patients, a concomitant increase in stimulus to end of surface QRS duration caused by single-site pacing compensated for the increase in Stim-to-eEGM duration, thereby prohibiting LP unmasking. Conclusion: The sequence of ventricular activation, as determined by the pacing site in patients with CRT devices, has a major influence on the detection of late potentials during substrate-guided ablation. Further study is warranted to define the optimal approaches, including the rhythm, for substrate mapping, but our findings suggest that BiV pacing may be most likely to obscure detection of late potentials as compared to single-site pacing.",
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AU - Baldinger, Samuel H.

AU - Kumar, Saurabh

AU - Fujii, Akira

AU - Haeberlin, Andreas

AU - Romero, Jorge E.

AU - Epstein, Laurence M.

AU - Michaud, Gregory F.

AU - Tedrow, Usha B.

AU - John, Roy

AU - Stevenson, William G.

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N2 - Purpose: Targets for substrate-based catheter ablation of scar-related ventricular tachycardia (VT) include sites with fractionated and late potentials (LPs). We hypothesized that in patients with cardiac resynchronization therapy (CRT), the pacing mode may influence the timing of abnormal electrograms (EGMs) relative to the surface QRS complex. Methods: We assessed bipolar EGM characteristics in left ventricular low bipolar voltage areas (< 1.5 mV) from 10 patients with coronary disease and a CRT device undergoing catheter ablation for VT. EGMs at 81 sites were analyzed during three different pacing modes (biventricular (BiV), right ventricular (RV)-only, and left ventricular (LV)-only) pacing. Results: Stimulus to end of local electrogram duration (Stim-to-eEGM) depended significantly on the stimulation site (BiV, LV, or RV, p = 0.032). Single-chamber pacing unmasked LPs, not present during BiV pacing, in three patients. In another three patients, a concomitant increase in stimulus to end of surface QRS duration caused by single-site pacing compensated for the increase in Stim-to-eEGM duration, thereby prohibiting LP unmasking. Conclusion: The sequence of ventricular activation, as determined by the pacing site in patients with CRT devices, has a major influence on the detection of late potentials during substrate-guided ablation. Further study is warranted to define the optimal approaches, including the rhythm, for substrate mapping, but our findings suggest that BiV pacing may be most likely to obscure detection of late potentials as compared to single-site pacing.

AB - Purpose: Targets for substrate-based catheter ablation of scar-related ventricular tachycardia (VT) include sites with fractionated and late potentials (LPs). We hypothesized that in patients with cardiac resynchronization therapy (CRT), the pacing mode may influence the timing of abnormal electrograms (EGMs) relative to the surface QRS complex. Methods: We assessed bipolar EGM characteristics in left ventricular low bipolar voltage areas (< 1.5 mV) from 10 patients with coronary disease and a CRT device undergoing catheter ablation for VT. EGMs at 81 sites were analyzed during three different pacing modes (biventricular (BiV), right ventricular (RV)-only, and left ventricular (LV)-only) pacing. Results: Stimulus to end of local electrogram duration (Stim-to-eEGM) depended significantly on the stimulation site (BiV, LV, or RV, p = 0.032). Single-chamber pacing unmasked LPs, not present during BiV pacing, in three patients. In another three patients, a concomitant increase in stimulus to end of surface QRS duration caused by single-site pacing compensated for the increase in Stim-to-eEGM duration, thereby prohibiting LP unmasking. Conclusion: The sequence of ventricular activation, as determined by the pacing site in patients with CRT devices, has a major influence on the detection of late potentials during substrate-guided ablation. Further study is warranted to define the optimal approaches, including the rhythm, for substrate mapping, but our findings suggest that BiV pacing may be most likely to obscure detection of late potentials as compared to single-site pacing.

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KW - Substrate modification

KW - Ventricular tachycardia

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