How to use pace mapping for ventricular tachycardia ablation in postinfarct patients.

We aim to describe the technical aspects of pace mapping (PM), as well as the two typical patterns of pacing correlation maps during ventricular tachycardia (VT) ablation. The first main pattern is focal, with a gradual and eccentric decrease of the QRS correlation from the area with the best PM correlation. This focal pattern may be associated with two clinical situations: (1) with some endocardial points showing a good correlation compared to VT morphology: true endocardial exit of VT or endocardial breakthrough of either an intramural or an epicardial circuit; (2) without any endocardial points showing a good correlation compared to VT morphology: the VT may originate from the other ventricle, but the presence of an intramural or an epicardial circuit should be considered in patients with a structural heart disease. The second pattern is the presence of PM points exhibiting a good correlation close to other PM points showing a poor correlation compared to VT morphology: this abrupt change in paced QRS morphology over a short distance indicates divergence of activation wavefronts between these sites and suggests the presence of a slow conduction channel: the VT isthmus.

An efficient algorithm based on electrograms characteristics to identify ventricular tachycardia isthmus entrance in post-infarct patients.

AIMS: Our study assesses the value of electrograms (EGMs) characteristics to identify a ventricular tachycardia (VT) isthmus entrance in patients with post-infarct VT. Post-infarct VTs are mostly due to a re-entrant circuit. A pacemapping (PM) approach is able to localize the VT isthmus during sinus rhythm. Limited data are available about the role of local EGMs in defining VT isthmus location. METHODS AND RESULTS: Twenty consecutive patients (70% male) referred for post-infarct VT catheter ablation were included in the present study. The VT isthmus was defined according to the PM method. At each recording site, 10 characteristics of the local EGM were assessed to predict the location of the VT isthmus entrance. In total, 924 EGMs were acquired, of which 127 were located in the VT isthmus entrance. Logistic regression analysis showed that bipolar voltage, number of EGM positive peaks, and sQRS interval were independently associated with VT isthmus entrance location. The ROC curve best fitted the model at the cut-off 0.1641 (sensitivity 72%, specificity 75.2%, positive predictive value 31.3%, negative predictive value 94.4%, area under the curve 0.78, P < 0.001). Based upon these results, we developed an algorithm implemented in an automatic calculator to determine the likelihood that an EGM is located at a VT isthmus entrance. CONCLUSION: Our study suggests that three EGM characteristics: bipolar voltage, number of positive peaks, and sQRS interval can successfully identify a VT isthmus entrance in post-infarct patients.

Radio-frequency ablation as primary management of well-tolerated sustained monomorphic ventricular tachycardia in patients with structural heart disease and left ventricular ejection fraction over 30%.

AIMS: Patients with well-tolerated sustained monomorphic ventricular tachycardia (SMVT) and left ventricular ejection fraction (LVEF) over 30% may benefit from a primary strategy of VT ablation without immediate need for a 'back-up' implantable cardioverter-defibrillator (ICD). METHODS AND RESULTS: One hundred and sixty-six patients with structural heart disease (SHD), LVEF over 30%, and well-tolerated SMVT (no syncope) underwent primary radiofrequency ablation without ICD implantation at eight European centres. There were 139 men (84%) with mean age 62 ± 15 years and mean LVEF of 50 ± 10%. Fifty-five percent had ischaemic heart disease, 19% non-ischaemic cardiomyopathy, and 12% arrhythmogenic right ventricular cardiomyopathy. Three hundred seventy-eight similar patients were implanted with an ICD during the same period and serve as a control group. All-cause mortality was 12% (20 patients) over a mean follow-up of 32 ± 27 months. Eight patients (40%) died from non-cardiovascular causes, 8 (40%) died from non-arrhythmic cardiovascular causes, and 4 (20%) died suddenly (SD) (2.4% of the population). All-cause mortality in the control group was 12%. Twenty-seven patients (16%) had a non-fatal recurrence at a median time of 5 months, while 20 patients (12%) required an ICD, of whom 4 died (20%). CONCLUSION: Patients with well-tolerated SMVT, SHD, and LVEF > 30% undergoing primary VT ablation without a back-up ICD had a very low rate of arrhythmic death and recurrences were generally non-fatal. These data would support a randomized clinical trial comparing this approach with others incorporating implantation of an ICD as a primary strategy.

Molecular genetic screening after non-ischaemic sudden cardiac arrest and no overt cardiomyopathy in real life: A major tool for the aetiological diagnostic work-up.

BACKGROUND: With the development of advanced sequencing techniques, genetic testing has emerged as a valuable tool for the work-up of non-ischaemic sudden cardiac arrest (SCA). AIMS: To evaluate the effectiveness of genetic testing in patients with unexplained SCA, according to clinical phenotype. METHODS: All patients who underwent molecular genetic testing for non-ischaemic SCA with no left ventricular cardiomyopathy between 2012 and 2021 in two French university hospitals were included. RESULTS: Of 66 patients (mean age 36.7±11.9years, 54.5% men), 21 (31.8%; 95% confidence interval 22.4-45.3%) carried a genetic variant: eight (12.1%) had a pathogenic or likely pathogenic (P/LP) variant and 13 (19.7%) had a variant of uncertain significance (VUS). Among 37 patients (56.1%) with no phenotypic clues, genetic testing identified a P/LP variant in five (13.5%), mainly in RYR2 (n=3) and SCN5A (n=2), and a VUS in nine (24.3%). None of the nine patients with phenotypic evidence of channelopathies had P/LP variants, but two had VUS in RYR2 and NKX2.5. Among the 20 patients with suspected arrhythmogenic cardiomyopathy, three P/LP variants (15.0%) and two VUS (10.0%) were found in DSC2, PKP2, SCN5A and DSG2, TRPM4, respectively. Genetic testing was performed sooner after cardiac arrest (P<0.001) and results were obtained more rapidly (P=0.02) after versus before 2016. CONCLUSION: This study highlights the utility of molecular genetic testing with a genetic variant of interest identified in one-third of patients with unexplained SCA. Genetic testing was beneficial even in patients without phenotypic clues, with one-fourth of patients carrying a P/LP variant that could have direct implications.

Systematic analysis of SCN5A variants associated with inherited cardiac diseases.

BACKGROUND: SCN5A variants are associated with a spectrum of cardiac electrical disorders with clear phenotypes. However, they may also be associated with complex phenotypic traits like overlap syndromes or pleiotropy, which have not been systematically described. In addition, the involvement of SCN5A in dilated cardiomyopathies (DCMs) remains controversial. OBJECTIVE: We aimed to evaluate the different phenotypes associated with pathogenic (P)/likely pathogenic (LP) SCN5A variants and to determine the prevalence of pleiotropy in a large multicentric cohort of P/LP SCN5A variant carriers. METHODS: The DNA of 13,510 consecutive probands (9960 with cardiomyopathies) was sequenced with a custom panel of genes. Individuals carrying a heterozygous single P/LP SCN5A variant were selected and phenotyped. RESULTS: The study included 170 P/LP variants found in 495 patients. Of them, 119 (70%) were exclusively associated with a single well-established phenotype: 91 with Brugada syndrome, 15 with type 3 long QT syndrome, 6 with progressive cardiac conduction disease, 4 with multifocal ectopic Purkinje-related premature contractions, and 3 with sick sinus syndrome. Thirty-two variants (19%) were associated with overlap syndromes or pleiotropy. The 19 remaining variants (11%) were associated with atypical or unclear phenotypes. Of those, 8 were carried by 8 patients presenting with DCM with a debatable causative genotype/phenotype link. CONCLUSION: Most P/LP SCN5A variants were found in patients with primary electrical disorders, mainly Brugada syndrome. Nearly 20% were associated with overlap syndromes or pleiotropy, underscoring the need for comprehensive phenotypic evaluation. The concept of SCN5A variants causing DCM is extremely rare (8/9960) if not questionable.

Impact of pulmonary veins anatomy on the outcomes of radiofrequency ablation for paroxysmal atrial fibrillation in the era of contact force-sensing ablation catheters.

BACKGROUND: Pulmonary vein (PV) isolation (PVI) has become the cornerstone of atrial fibrillation (AF) ablation in patients with paroxysmal AF (PAF). PVI durability is influenced by many factors including PVs anatomy. Data regarding the influence of PVs anatomical variations on the outcomes of PAF ablation in the era of contact force-sensing ablation catheters are scarce and contradictory. METHODS: Consecutive patients referred to our center for a first ablation of PAF using radiofrequency (RF) were included. PVs anatomy was classified into 3 groups: typical anatomy (4 distinct veins), left common ostium (LCO), and right accessory PV (RAPV). The primary outcome was recurrence of atrial arrhythmia episode during a 12-month follow-up after ablation. RESULTS: Two hundred twenty-three patients were included (mean age 58.4 ± 10.8 years and 70.9% male). Among this cohort, 141 patients (63.2%) had typical PV anatomy, 53 (23.8%) had a LCO, and 29 (13.0%) had a RAPV. The existence of a RAPV was not associated with a higher rate of AF recurrences (22 (14.3%) vs. 7 (10.1%), p = 0.519). After multivariate analysis, the presence of an LCO did not appear to be associated with the AF recurrence rate at 12 months (OR = 1.69, 95%CI 0.95-2.49, p = 0.098). Maintenance of antiarrhythmic drugs after ablation was the only factor independently associated with a decreased risk of AF recurrence at 12 months (OR = 0.76, 95%CI 0.60-0.97, p = 0.046). CONCLUSION: This study suggests that the presence of an LCO or a RAPV is not associated with a higher rate of AF recurrence at 12 months after radiofrequency PVI using contact force-sensing catheters in PAF patients.

Showing up channels for postinfarct ventricular tachycardia ablation.

The number of scar-related ventricular tachycardia (VT) ablation procedures is increasing worldwide. This is certainly due to the ever growing number of patients implanted with an implantable cardioverter defibrillator in whom an ablation procedure may be required to better control the ventricular arrhythmia burden, but is also likely related to our better understanding of the arrhythmias mechanisms as well as the improvement of the mapping techniques during the last 15 years. Most VTs, especially those arising after myocardial infarction, depend on a critical isthmus. Defining precisely the critical isthmus of postinfarct VT may be challenging, particularly when the arrhythmia is poorly tolerated. In the literature, there are extensive data concerning the value of conventional electrophysiological techniques, especially entrainment mapping in association with postpacing interval measurements, regarding the identification of postinfarct VT isthmuses. There are, however, other--sometimes emerging--approaches to image critical postinfarct VT channels. We have summarized these, reviewing data from the published literature as well as our own experience.

Running after Activated Clotting Time Values in Patients Receiving Direct Oral Anticoagulants: A Potentially Dangerous Race. Results from a Prospective Study in Atrial Fibrillation Catheter Ablation Procedures.

BACKGROUND: Activated Clotting Time (ACT) guided heparinization is the gold standard for titrating unfractionated heparin (UFH) administration during atrial fibrillation (AF) ablation procedures. The current ACT target (300 s) is based on studies in patients receiving a vitamin K antagonist (VKA). Several studies have shown that in patients receiving Direct Oral Anticoagulants (DOACs), the correlation between ACT values and UFH delivered dose is weak. OBJECTIVE: To assess the relationship between ACT and real heparin anticoagulant effect measured by anti-Xa activity in patients receiving different anticoagulant treatments. METHODS: Patients referred for AF catheter ablation in our centre were prospectively included depending on their anticoagulant type. RESULTS: 113 patients were included, receiving rivaroxaban (n = 30), apixaban (n = 30), dabigatran (n = 30), and VKA (n = 23). To meet target ACT, a higher UFH dose was required in DOAC than VKA patients (14,077.8 IU vs. 9565.2 IU, p < 0.001), leading to a longer time to achieve target ACT (46.5 min vs. 27.3 min, p = 0.001). The correlation of ACT and anti-Xa activity was tighter in the VKA group (Spearman correlation ρ = 0.53), compared to the DOAC group (ρ = 0.19). Despite lower ACT values in the DOAC group, this group demonstrated a higher mean anti-Xa activity compared to the VKA group (1.56 ± 0.39 vs. 1.14 ± 0.36; p = 0.002). CONCLUSION: Use of a conventional ACT threshold at 300 s during AF ablation procedures leads to a significant increase in UFH administration in patients treated with DOACs. This increase corresponds more likely to an overdosing than a real increase in UFH requirement.

Efficacy and Safety of Second and Third-Generation Laser Balloon for Paroxysmal Atrial Fibrillation Ablation Compared to Radiofrequency Ablation: A Matched-Cohort.

Laser balloon (LB) has emerged as an interesting strategy for pulmonary vein isolation in paroxysmal atrial fibrillation (AF). A third-generation LB has recently been developed, allowing a continuous ablation set. We aimed to compare the results from our center's experience with second and third-generation LBs to a cohort of matched patients who had undergone radiofrequency ablation (RFA) with contact-force catheters. This retrospective monocenter case-control study included our first 50 LB paroxysmal AF ablations (26 second and 24 third-generation LB) and 50 RFA controls, matched on age, sex and left atrial dilation. The two groups had similar baseline parameters. LB procedures were significantly shorter than RFA (129 (110-160) vs. 160 (119-198) min, p = 0.007). During AF ablation, two major complications occurred in each group. At the one-year follow-up, AF recurrence was diagnosed in 7 (14%) of the LB group vs. 14 (28%) of the RFA group (p = 0.14). Moreover, we observed that third-generation LB procedures were associated with shorter laser applications (22 (19-29) vs. 69 (55-76) min, p < 0.001) and procedural durations (111 (100-128) vs. 151.5 (128.5-167) min, p < 0.001) compared to second-generation LB procedures. In the context of the major increase in the number of AF ablations, LB demonstrated consistent results in terms of clinical success, complications and also reduced procedure durations compared to RFA.

Is There an Association between Epicardial Adipose Tissue and Outcomes after Paroxysmal Atrial Fibrillation Catheter Ablation?

BACKGROUND: In patients undergoing paroxysmal atrial fibrillation (PAF) ablation, pulmonary vein isolation (PVI) alone fails in maintaining sinus rhythm in up to one third of patients after a first catheter ablation. Epicardial adipose tissue (EAT), as an endocrine-active organ, could play a role in the recurrence of AF after catheter ablation. OBJECTIVE: To evaluate the predictive value of clinical, echocardiographic, biological parameters and epicardial fat density measured by computed tomography scan (CT-scan) on AF recurrence in PAF patients who underwent a first pulmonary vein isolation procedure using radiofrequency (RF). METHODS: This monocentric retrospective study included all patients undergoing first-time RF PAF ablation at the Nancy University Hospital between March 2015 and December 2018 with one-year follow-up. RESULTS: 389 patients were included, of whom 128 (32.9%) had AF recurrence at one-year follow-up. Neither total-EAT volume (88.6 ± 37.2 cm3 vs. 91.4 ± 40.5 cm3, p = 0.519), nor total-EAT radiodensity (-98.8 ± 4.1 HU vs. -98.8 ± 3.8 HU, p = 0.892) and left atrium-EAT radiodensity (-93.7 ± 4.3 HU vs. -93.4 ± 6.0 HU, p = 0.556) were significantly associated with AF recurrence after PAF ablation. In multivariate analysis, previous cavo-tricuspid isthmus (CTI) ablation, ablation procedure duration, BNP and triglyceride levels remained independently associated with AF recurrence after catheter ablation at 12-months follow-up. CONCLUSION: Contrary to persistent AF, EAT parameters are not associated with AF recurrence after paroxysmal AF ablation. Thus, the role of the metabolic atrial substrate in PAF pathophysiology appears less obvious than in persistent AF.

Imaging in cardiac resynchronization therapy: what does the clinician need?

In the guidelines, criteria to select patients for cardiac resynchronization therapy (CRT) are based only on the QRS duration on surface electrocardiogram (ECG) as a marker of cardiac dyssynchrony. From a theoretical point, imaging techniques would be useful to improve patient's selection with an analysis of the atrio-ventricular, interventricular and intraventricular dyssynchrony. Imaging techniques may also identify physiopathological issues such as the presence of scar, right ventricular dysfunction, or severe pulmonary hypertension. New echocardiographic techniques appear promising, but the role of echocardiography in the identification of mechanical dyssynchrony remains to be clearly defined in prospective multicentre trials. The positioning of left ventricular lead could be optimized using different imaging techniques to assess the site of latest activation and the coronary sinus anatomy. Finally, imaging techniques may have an important role to optimize the programming of the device, especially the different cardiac timings. In the present article, we focused on echocardiography, multislices-computed tomography, and magnetic resonance imaging being discussed elsewhere.

Evaluation of 3D guided electroanatomic mapping for ablation of atrial fibrillation in reference to CT-Scan image integration.

BACKGROUND: Anatomical guided atrial fibrillation (AF) catheter ablation relies on the assumption that the left atrium reconstruction anatomy (LARA) using a 3D mapping system precisely matches the patient's CT scan anatomy (real anatomy). This study investigates whether this postulation is accurate using CT scan image integration. PATIENTS AND METHODS: Thirty consecutive patients (23 men, mean age = 51.9 +/- 9.9 years) with symptomatic drug-refractory paroxysmal (n = 21) or persistent (n = 9) AF underwent a circumferential, 2 x 2, pulmonary vein (PV) radiofrequency (RF) ablation using the CARTOMERGE system. Left atrium (LA) anatomy was first reconstructed and RF design lines drawn on this LARA. After a CT-scan image of the LA was integrated into the 3D system, RF lesions were deployed 10 +/- 5 mm outside the PV ostia (PVO) onto the CT-scan LA surface. The match between the actual RF lines and the RF design lines was analyzed off-line after catheter withdrawal. RESULTS: Circumferential RF design lines were divided into four segments encircling both the right and left PVs. Design segments matched the actual RF segments in a proportion varying from 23% up to 83%. A mean of 2.8 +/- 1.6 segments per patient were inaccurately designed that extended a mean of 3.8 +/- 2.3mm inside the adjacent PV or 6.7 +/- 1.8mm inside the left atrial appendage (LAA). Seven patients (23%) had four or more segments incorrectly designed. CONCLUSIONS: Our study reveals the inaccuracy of 3D anatomic guided RF ablation with respect to the LA anatomical structures that could be possibly improved when combined with CT-scan image integration.

Pace Mapping to Localize the Critical Isthmus of Ventricular Tachycardia.

Most postinfarct ventricular tachycardias (VT) are sustained by a reentrant mechanism. The "protected isthmus" of the reentrant circuit is critical for the maintenance of VTs and the target for catheter ablation. In this article, the authors describe the technique of pace-mapping during sinus rhythm to unmask postinfarct VT isthmuses. A pace-mapping map should be considered as the surrogate of an activation map during VT, in both patients with a normal heart and patients with a structural heart disease. Pace mapping is useful to unmask VT isthmuses in patients with postinfarct reentrant VTs.

Isthmus characteristics of reentrant ventricular tachycardia after myocardial infarction.

BACKGROUND: The reentrant mechanism of postinfarct ventricular tachycardia (VT) has been documented by surgical mapping analysis, but little is known about postinfarct VT circuits and the characteristics of their related protected isthmus with the use of 3D catheter mapping systems. METHODS AND RESULTS: A 3D electroanatomic mapping was performed in 21 patients with well-tolerated, postinfarct, sustained VT. In total, 33 episodes of tachycardia (mean cycle length 432+/-74 ms) were induced and mapped. Complete maps demonstrated macroreentrant circuits with 1 loop (n=8) or 2 loops (n=25) rotating around a protected isthmus bounded by 2 approximately parallel conduction barriers that consisted of a line of double potentials, a scar area, or the mitral annulus. A total of 26 critical isthmi were identified for the 33 VTs mapped, with the same isthmus being shared by 2 to 4 different tachycardic morphologies in 5 patients. On average, isthmi were 31+/-7 mm long (ranging from 18 to 41 mm) and 16+/-8 mm wide (ranging from 6 to 36 mm) and harbored diastolic electrograms. The isthmus axis was oriented parallel to the mitral annulus plane in perimitral circuits and perpendicular to the mitral annulus plane in all other circuits. Linear radiofrequency ablation performed across the most accessible part of the isthmus prevented the recurrence of tachycardia in 19 patients (90%) with a follow-up at 16+/-8 months. CONCLUSIONS: Detailed 3D electroanatomic mapping is helpful in reconstructing postinfarct VT circuits and in defining the characteristics of their related protected isthmi. The wide range of isthmus width values supports the need of linear radiofrequency lesions to eliminate the reentrant substrate of postinfarct VTs.

Identification of extremely slow conduction in the cavotricuspid isthmus during common atrial flutter ablation.

INTRODUCTION: Complete isthmus block has been used as an endpoint for radiofrequency ablation for common atrial flutter (AF). We sought to systematically evaluate extremely slow conduction (ESC), which is easily misinterpreted as complete block. METHODS AND RESULTS: We studied 107 consecutive patients (92 men, 15 women, 58 +/- 11 years) who had undergone a successful AF ablation procedure. A 24-pole catheter was positioned along the tricuspid annulus spanning the isthmus. Complete isthmus block was defined as the presence of a complete corridor of double potentials along the ablation line. Activation delay time (AT), activation difference (deltaA) between two adjacent dipoles, maximum activation difference (deltaA(max)), change in polarity (CP) and change in amplitude (CA) of the bipolar atrial electrogram were recorded and P-wave morphology in the surface electrocardiogram was analyzed. ESC was observed in 16 patients. Between ESC and complete block, differences were found on the two lateral dipoles adjacent to the ablation line (AT: 148 +/- 17 vs. 183 +/- 27 ms and 155 +/- 18 vs. 170 +/- 28 ms, P < 0.01; deltaA: -91 +/- 22 vs. -126 +/- 28 ms and -7 +/- 13 vs. 13 +/- 6 ms, P < 0.01). Statistically significant differences in CP were detected on the relevant dipoles (7/16 vs. 14/16 and 6/16 vs.13/16, P < 0.05). No significant difference was found either in CA or in terminal P wave positivity. Mean deltaA(max) were 13.8 +/- 5.0 and 27.8 +/- 9.5 ms (P < 0.001) respectively in ESC and complete block. Two types of ESC, regular and irregular, were demonstrated during the ablation procedure. CONCLUSIONS: (1) ESC was observed in 15% of the patients during the AF ablation procedure. (2) The parameters of AT, deltaA, and CP may help to differentiate ESC from complete block. DeltaA(max) might be the most powerful indicator. (3) To verify complete block, it is essential to position the mapping catheter across the CTI in order to demonstrate the activation sequence up to the ablation line.

Localizing the critical isthmus of postinfarct ventricular tachycardia: the value of pace-mapping during sinus rhythm.

BACKGROUND: Most postinfarct ventricular tachycardias (VTs) are sustained by a reentrant mechanism. The "protected isthmus" of the reentrant circuit is critical for the maintenance of VTs and the target for catheter ablation. Various techniques based on conventional electrophysiology and/or detailed three-dimensional (3D) reconstruction of the VT circuit are used to unmask this isthmus. OBJECTIVE: The purpose of this study was to assess pace-maps (PMs) to identify postinfarct VT isthmuses. We hypothesized that an abrupt change in paced QRS morphology may be used to identify a VT isthmus and be targeted for successful ablation. METHODS: High-density 3D PMs were matched to the subsequent 3D endocardial reentrant VT activation mapping in 10 patients (8 men; age 70.7 ± 10.8 years) who underwent successful postinfarct VT ablation. At each pacing site in a given patient, the 12-lead ECG recorded during pacing was compared to that of VT, with the resulting matching percentage (up to 100% for perfect matches) allocated to this point to generate color-coded PMs. RESULTS: With respect to VT isthmuses, the best percentages of matching were found in the exit zones and isthmus exit part (89% ± 8% and 84% ± 7%, respectively) and the poorest adjacent to scar border in the outer entrance zones (23% ± 28%), in the entrance zones (39% ± 34%), and in the entrance part of the isthmus (32% ± 26%). The color-coded sequence (from the best to the poorest matching sites) on the PMs revealed figure-of-eight pictures matching the VT activation time maps and identifying VT isthmuses. CONCLUSION: Pace-mapping is useful for unmasking VT isthmuses in patients with well-tolerated postinfarct endocardial reentrant VTs.

A stepwise approach to the management of postinfarct ventricular tachycardia using catheter ablation as the first-line treatment: a single-center experience.

BACKGROUND: The occurrence of ventricular tachycardia (VT) after myocardial infarction is associated with poorer prognosis. In such patients, implantable cardioverter-defibrillators are recommended. Catheter ablation of VT is currently recommended only as an adjunctive therapy. Whether a successful VT ablation alone might be a viable strategy in some of these patients, however, remains unknown. The aim of the present study was to evaluate this strategy. METHODS AND RESULTS: Between January 2002 and December 2011, 189 patients with cardiomyopathy underwent 259 VT ablations in our center. Forty-five patients (mean age, 65.2±9.6 years; 91% men) with a history of myocardial infarction and mean left ventricular ejection fraction of 39.7±9.7% matched the study criteria and were included in this analysis. Acute success was obtained in 40 of 45 patients (88.9%). During a follow-up, on the basis of our stepwise algorithm (using acute success, repeat electrophysiological study, and recurrence of VT), 19 of 45 patients (42.2%) underwent implantable cardioverter-defibrillators implantation. During a median follow-up of 4.5 (interquartile range, 2.1-7.0) years, all-cause mortality occurred in 14 of 45 patients (31.1%). Using multivariate Cox regression analysis, age (hazard ratio, 1.13; 95% confidence interval, 1.03-1.22; P=0.007) was the only independent predictor of mortality, whereas implantable cardioverter-defibrillators implantation was not (hazard ratio, 0.54; 95% confidence interval, 0.18-1.64; P=0.28) CONCLUSIONS: Our results suggest that a stepwise approach to the management of VT with ablation as a first-line treatment in postinfarct patients presenting with VT might be a reasonable option. Further studies are required to confirm these results.

Electroanatomic characterization of post-infarct scars comparison with 3-dimensional myocardial scar reconstruction based on magnetic resonance imaging.

OBJECTIVES: This study was designed to compare electroanatomic mapping (EAM) and magnetic resonance imaging (MRI) with delayed contrast enhancement (DCE) data for delineation of post-infarct scars. BACKGROUND: Electroanatomic substrate mapping is an important step in the post-infarct ventricular tachycardia (VT) ablation strategy, but this technique has not yet been compared with a gold-standard noninvasive tool informing on the topography and transmural extent of myocardial scars in humans. METHODS: Ten patients (9 men, age 71 +/- 10 years) admitted for post-infarct VT ablation underwent both a left ventricle DCE MRI and a sinus-rhythm 3-dimensional (3D) (CARTO) EAM (Biosense Webster, Johnson & Johnson, Diamond Bar, California). A 3D color-coded MRI-reconstructed left ventricular endocardial shell was generated to display scar data (intramural location and transmural extent). A matching process allocated any CARTO point to its corresponding position on the MRI map. Electrogram (EGM) characteristics were then evaluated in relation to scar data. RESULTS: A spiky EGM morphology, a reduced unipolar or bipolar EGM voltage amplitude (<6.52 and <1.54 mV, respectively), as well as a longer bipolar EGM duration (>56 ms) independently correlated with the presence of scar whatever its intramural position. Endocardial scars had a larger degree of signal reduction than intramural or epicardial scars. None of the parameters was correlated with transmural scar depth. A clear mismatch in infarct surface between CARTO and MRI maps was observed in one-third of infarct zones. CONCLUSIONS: Sinus-rhythm EAM helps identify the limits of post-infarct scars. However, the accuracy of EAM for precise scar delineation is limited. This limit might be circumvented using anatomical information provided by 3D MRI data.