TY - JOUR
T1 - High-resolution structural-functional substrate-trigger characterization
T2 - Future roadmap for catheter ablation of ventricular tachycardia
AU - Stoks, Job
AU - Hermans, Ben J. M.
AU - Boukens, Bas J. D.
AU - Holtackers, Robert J.
AU - Gommers, Suzanne
AU - Kaya, Yesim S.
AU - Vernooy, Kevin
AU - Cluitmans, Matthijs J. M.
AU - Volders, Paul G. A.
AU - ter Bekke, Rachel M. A.
N1 - Funding Information: This study was supported by the Special Research Fund (BOF) of Hasselt University (BOF17DOCMA15) and the Maastricht University Medical Center (MUMC+) to JS, the Hein Wellens Foundation, Health Foundation Limburg (Maastricht, The Netherlands), and a Veni grant from the Netherlands Organization for Scientific Research (TTW16772) to MC, the Netherlands CardioVascular Research Initiative (CVON2017-13 VIGILANCE and CVON2018B030 PREDICT2), Den Haag, The Netherlands to PV, and a Veni grant from the Netherlands Organization for Scientific Research (NWO/ZonMw 0915016181013) to RTB. Publisher Copyright: Copyright © 2023 Stoks, Hermans, Boukens, Holtackers, Gommers, Kaya, Vernooy, Cluitmans, Volders and ter Bekke.
PY - 2023/2/16
Y1 - 2023/2/16
N2 - Introduction: Patients with ventricular tachyarrhythmias (VT) are at high risk of sudden cardiac death. When appropriate, catheter ablation is modestly effective, with relatively high VT recurrence and complication rates. Personalized models that incorporate imaging and computational approaches have advanced VT management. However, 3D patient-specific functional electrical information is typically not considered. We hypothesize that incorporating non-invasive 3D electrical and structural characterization in a patient-specific model improves VT-substrate recognition and ablation targeting. Materials and methods: In a 53-year-old male with ischemic cardiomyopathy and recurrent monomorphic VT, we built a structural-functional model based on high-resolution 3D late-gadolinium enhancement (LGE) cardiac magnetic resonance imaging (3D-LGE CMR), multi-detector computed tomography (CT), and electrocardiographic imaging (ECGI). Invasive data from high-density contact and pace mapping obtained during endocardial VT-substrate modification were also incorporated. The integrated 3D electro-anatomic model was analyzed off-line. Results: Merging the invasive voltage maps and 3D-LGE CMR endocardial geometry led to a mean Euclidean node-to-node distance of 5 ± 2 mm. Inferolateral and apical areas of low bipolar voltage (<1.5 mV) were associated with high 3D-LGE CMR signal intensity (>0.4) and with higher transmurality of fibrosis. Areas of functional conduction delay or block (evoked delayed potentials, EDPs) were in close proximity to 3D-LGE CMR-derived heterogeneous tissue corridors. ECGI pinpointed the epicardial VT exit at ∼10 mm from the endocardial site of origin, both juxtaposed to the distal ends of two heterogeneous tissue corridors in the inferobasal left ventricle. Radiofrequency ablation at the entrances of these corridors, eliminating all EDPs, and at the VT site of origin rendered the patient non-inducible and arrhythmia-free until the present day (20 months follow-up). Off-line analysis in our model uncovered dynamic electrical instability of the LV inferolateral heterogeneous scar region which set the stage for an evolving VT circuit. Discussion and conclusion: We developed a personalized 3D model that integrates high-resolution structural and electrical information and allows the investigation of their dynamic interaction during arrhythmia formation. This model enhances our mechanistic understanding of scar-related VT and provides an advanced, non-invasive roadmap for catheter ablation.
AB - Introduction: Patients with ventricular tachyarrhythmias (VT) are at high risk of sudden cardiac death. When appropriate, catheter ablation is modestly effective, with relatively high VT recurrence and complication rates. Personalized models that incorporate imaging and computational approaches have advanced VT management. However, 3D patient-specific functional electrical information is typically not considered. We hypothesize that incorporating non-invasive 3D electrical and structural characterization in a patient-specific model improves VT-substrate recognition and ablation targeting. Materials and methods: In a 53-year-old male with ischemic cardiomyopathy and recurrent monomorphic VT, we built a structural-functional model based on high-resolution 3D late-gadolinium enhancement (LGE) cardiac magnetic resonance imaging (3D-LGE CMR), multi-detector computed tomography (CT), and electrocardiographic imaging (ECGI). Invasive data from high-density contact and pace mapping obtained during endocardial VT-substrate modification were also incorporated. The integrated 3D electro-anatomic model was analyzed off-line. Results: Merging the invasive voltage maps and 3D-LGE CMR endocardial geometry led to a mean Euclidean node-to-node distance of 5 ± 2 mm. Inferolateral and apical areas of low bipolar voltage (<1.5 mV) were associated with high 3D-LGE CMR signal intensity (>0.4) and with higher transmurality of fibrosis. Areas of functional conduction delay or block (evoked delayed potentials, EDPs) were in close proximity to 3D-LGE CMR-derived heterogeneous tissue corridors. ECGI pinpointed the epicardial VT exit at ∼10 mm from the endocardial site of origin, both juxtaposed to the distal ends of two heterogeneous tissue corridors in the inferobasal left ventricle. Radiofrequency ablation at the entrances of these corridors, eliminating all EDPs, and at the VT site of origin rendered the patient non-inducible and arrhythmia-free until the present day (20 months follow-up). Off-line analysis in our model uncovered dynamic electrical instability of the LV inferolateral heterogeneous scar region which set the stage for an evolving VT circuit. Discussion and conclusion: We developed a personalized 3D model that integrates high-resolution structural and electrical information and allows the investigation of their dynamic interaction during arrhythmia formation. This model enhances our mechanistic understanding of scar-related VT and provides an advanced, non-invasive roadmap for catheter ablation.
KW - CMR
KW - CT
KW - ECGI
KW - VT
KW - electroanatomical mapping
KW - image integration
KW - multi-modality
KW - personalized medicine
UR - http://www.scopus.com/inward/record.url?scp=85149967598&partnerID=8YFLogxK
U2 - https://doi.org/10.3389/fcvm.2023.1112980
DO - https://doi.org/10.3389/fcvm.2023.1112980
M3 - Article
C2 - 36873402
SN - 2297-055X
VL - 10
JO - Frontiers in cardiovascular medicine
JF - Frontiers in cardiovascular medicine
M1 - 1112980
ER -