Assuntos
Infecções por Coronavirus/prevenção & controle , Técnicas Eletrofisiológicas Cardíacas/métodos , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Gestão da Segurança/organização & administração , COVID-19 , Infecções por Coronavirus/epidemiologia , Técnicas Eletrofisiológicas Cardíacas/estatística & dados numéricos , Feminino , Serviços de Saúde , Humanos , Liderança , Masculino , América do Norte , Saúde Ocupacional , Avaliação de Resultados em Cuidados de Saúde , Pandemias/estatística & dados numéricos , Segurança do Paciente , Pneumonia Viral/epidemiologia , Sociedades Médicas/organização & administraçãoRESUMO
BACKGROUND: Innervation is a critical component of arrhythmogenesis and may present an important trigger/substrate modifier not used in current ventricular tachycardia (VT) ablation strategies. METHODS AND RESULTS: Fifteen patients referred for ischemic VT ablation underwent preprocedural cardiac (123)I- meta-iodobenzylguanidine ((123)I-mIBG) imaging, which was used to create 3-dimensional (3D) innervation models and registered to high-density voltage maps. 3D (123)I-mIBG innervation maps demonstrated areas of complete denervation and (123)I-mIBG transition zone in all patients, which corresponded to 0% to 31% and 32% to 52% uptake. (123)I-mIBG denervated areas were ≈2.5-fold larger than bipolar voltage-defined scar (median, 24.6% [Q1-Q3, 18.3%-34.4%] versus 10.6% [Q1-Q3, 3.9%-16.4%]; P<0.001) and included the inferior wall in all patients, with no difference in the transition/border zone (11.4% [Q1-Q3, 9.5%-13.2%] versus 16.6% [Q1-Q3, 12.0%-18.8%]; P=0.07). Bipolar/unipolar voltages varied widely within areas of denervation (0.8 mV [Q1-Q3, 0.3-1.7 mV] and 4.0 mV [Q1-Q3, 2.9-5.6 mV]) and (123)I-mIBG transition zones (0.8 mV [Q1-Q3, 0.4-1.8 mV] and 4.6 mV [Q1-Q3, 3.2-6.3 mV]). Bipolar voltages in denervated areas and (123)I-mIBG transition zones were <0.5 mV, 0.5 to 1.5 mV, and >1.5 mV in 35%, 36%, and 29%, as well as 35%, 35%, and 30%, respectively (P>0.05). Successful ablation sites were within bipolar voltage-defined scar (7%), border zone (57%), and areas of normal voltage (36%), but all ablation sites were abnormally innervated (denervation/(123)I-mIBG transition zone in 50% each). CONCLUSIONS: (123)I-mIBG innervation defects are larger than bipolar voltage-defined scar and cannot be detected with standard voltage criteria. Thirty-six percent of successful VT ablation sites demonstrated normal voltages (>1.5 mV), but all ablation sites were within the areas of abnormal innervation. (123)I-mIBG innervation maps may provide critical information about triggers/substrate modifiers and could improve understanding of VT substrate and facilitate VT ablation. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique Identifier: NCT01250912.
Assuntos
3-Iodobenzilguanidina , Ablação por Cateter , Ventrículos do Coração , Interpretação de Imagem Assistida por Computador , Imageamento Tridimensional , Compostos Radiofarmacêuticos , Sistema Nervoso Simpático/diagnóstico por imagem , Taquicardia Ventricular/diagnóstico por imagem , Taquicardia Ventricular/cirurgia , Potenciais de Ação , Idoso , Algoritmos , Baltimore , Ablação por Cateter/efeitos adversos , Técnicas Eletrofisiológicas Cardíacas , Estudos de Viabilidade , Feminino , Ventrículos do Coração/diagnóstico por imagem , Ventrículos do Coração/inervação , Ventrículos do Coração/cirurgia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Prospectivos , Cintilografia , Sistema Nervoso Simpático/fisiopatologia , Taquicardia Ventricular/fisiopatologia , Resultado do TratamentoRESUMO
OBJECTIVES: This study sought to assess the feasibility of deriving 3-dimensional (3D) scar maps from positron emission tomography (PET)/computed tomography (CT) hybrid imaging and to integrate those into clinical mapping systems to assist in ventricular tachycardia (VT) ablations. BACKGROUND: Ablation strategies for nonidiopathic VT are increasingly based on the anatomic information of the scar and its border zone. However, the current "gold standard" of voltage mapping is limited by its inability to accurately describe a complex 3D scar morphology, its imperfect spatial resolution, and prolonged procedure times. METHODS: Fourteen patients underwent PET/CT multimodality imaging before the VT ablation. We used PET/CT-derived scar maps to characterize myocardial scar using a 17-segment analysis and surface reconstruction. In 10 patients, reconstructed 3D metabolic scar maps were integrated into a clinical mapping system and compared with high-resolution voltage maps. RESULTS: A good correlation was found between the voltage maps and PET/CT-derived scar maps (r = 0.89; r < 0.05). In addition, 3D metabolic scar maps accurately displayed endocardial and epicardial surface and could be successfully integrated with a registration error of 3.7 +/- 0.7 mm. A combination of visual alignment and surface registration was most accurate for myocardial scar accounting for =15% of the left ventricular surface. Scar size, location, and border zone accurately predicted high-resolution voltage map findings (r = 0.87; p < 0.05). Integrated scar maps revealed metabolically active channels within the myocardial scar not detected by voltage mapping and correctly predicted non-transmural scar despite normal endocardial voltage recordings. Areas of low voltage within wall segments displaying preserved metabolic activity were shown to be due to suboptimal catheter contact and prevented unnecessary ablation lesions. CONCLUSIONS: We found that PET/CT fusion imaging is able to accurately assess left ventricular scar and its border zone. The integration of a 3D scar map into a clinical mapping system is feasible and may allow supplementary scar characterization that is not available from voltage maps. This technique could significantly facilitate substrate-based VT ablations.