Circulation, Vol 88, 1647-1670, Copyright © 1993 by American Heart Association
WG Stevenson, H Khan, P Sager, LA Saxon, HR Middlekauff, PD Natterson and I Wiener
BACKGROUND. Ventricular tachycardia reentry circuits in chronic infarct
scars can contain slow conduction zones, which are difficult to distinguish
from bystander areas adjacent to the circuit during catheter mapping. This
study developed criteria for identifying reentry circuit sites using
computer simulations. These criteria then were tested during catheter
mapping in humans to predict sites at which radiofrequency current
application terminated ventricular tachycardia. METHODS AND RESULTS. In
computer simulations, effects of single stimuli and stimulus trains at
sites in and adjacent to reentry circuits were analyzed. Entrainment with
concealed fusion, defined as ventricular tachycardia entrainment with no
change in QRS morphology, could occur during stimulation in reentry circuit
common pathways and adjacent bystander sites. Pacing at reentry circuit
common pathway sites, the stimulus to QRS (S-QRS) interval equals the
electrogram to QRS interval (EG-QRS) during tachycardia. The postpacing
interval from the last stimulus to the following electrogram equals the
tachycardia cycle length. Pacing at bystander sites the S-QRS exceeds the
EG-QRS interval when the conduction time from the bystander site to the
circuit is short but may be less than or equal to the EG-QRS interval when
the conduction time to the circuit is long. The postpacing interval,
however, always exceeds the tachycardia cycle length. When conduction in
the circuit slows during pacing, the S-QRS and postpacing intervals
increase and the slowest stimulus train most closely reflects conduction
times during tachycardia. Endocardial catheter mapping and radiofrequency
ablation were performed during 31 monomorphic ventricular tachycardias in
15 patients with drug refractory ventricular tachycardia late after
myocardial infarction. During ventricular tachycardia, trains of electrical
stimuli or scanning single stimuli were evaluated before application of
radiofrequency current at the same site. Radiofrequency current terminated
ventricular tachycardia at 24 of 241 sites (10%) in 12 of 15 patients
(80%). Ventricular tachycardia termination occurred more frequently at
sites with entrainment with concealed fusion (odds ratio, 3.4; 95%
confidence interval [CI], 1.4 to 8.3), a postpacing interval approximating
the ventricular tachycardia cycle length (odds ratio, 4.6; 95% CI, 1.6 to
12.9) and an S-QRS interval during entrainment of more than 60 milliseconds
and less than 70% of the ventricular tachycardia cycle length (odds ratio,
4.9; 95% CI, 1.4 to 17.1). Ventricular tachycardia termination was also
predicted by the presence of isolated diastolic potentials or continuous
electrical activity (odds ratio, 5.2; 95% CI, 1.8 to 15.5), but these
electrograms were infrequent (8% of all sites). Combinations of entrainment
with concealed fusion, postpacing interval, S-QRS intervals, and isolated
diastolic potentials or continuous electrical activity predicted a more
than 35% incidence of ventricular tachycardia termination during
radiofrequency current application versus a 4% incidence when none
suggested that the site was in the reentry circuit. Analysis of the
postpacing interval and S-QRS interval suggested that 25% of the sites with
entrainment with concealed fusion were in bystander areas not within the
reentry circuit. At restudy 5 to 7 days later, 6 patients had no
monomorphic ventricular tachycardia inducible, and inducible ventricular
tachycardias were modified in 4 patients. None of these 10 patients have
suffered arrhythmia recurrences during a follow-up of 316 +/- 199 days,
although 4 continue to receive previously ineffective medications.
CONCLUSIONS. Regions giving rise to reentry after myocardial infarction are
complex and can include bystander areas, slow conduction zones, and
isthmuses for impulse propagation at which radiofrequency current lesions
can interrupt reentry.
ARTICLES
Identification of reentry circuit sites during catheter mapping and radiofrequency ablation of ventricular tachycardia late after myocardial infarction
Division of Cardiology, UCLA School of Medicine.
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K. Haberl and M. Allessie Differential Effects of a Segment of Slow Conduction on Reentrant Ventricular Tachycardia in the Rabbit Heart Circulation, February 23, 1999; 99(7): 949 - 962. [Abstract] [Full Text] [PDF]
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 D. S. Cannom and E. N. Prystowsky Management of Ventricular Arrhythmias: Detection, Drugs, and Devices JAMA, January 13, 1999; 281(2): 172 - 179. [Abstract] [Full Text] [PDF]
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C. Cabo, H. Schmitt, G. Masters, J. Coromilas, A. L. Wit, and M. M. Scheinman Location of Diastolic Potentials in Reentrant Circuits Causing Sustained Ventricular Tachycardia in the Infarcted Canine Heart : Relationship to Predicted Critical Ablation Sites Circulation, December 8, 1998; 98(23): 2598 - 2607. [Abstract] [Full Text] [PDF]
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M. J. Schalij, F. P. van Rugge, M. Siezenga, and E. T. van der Velde Endocardial Activation Mapping of Ventricular Tachycardia in Patients : First Application of a 32-Site Bipolar Mapping Electrode Catheter Circulation, November 17, 1998; 98(20): 2168 - 2179. [Abstract] [Full Text] [PDF]
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K. Ellison, P. Friedman, L. Ganz, and W. Stevenson Entrainment mapping and radiofrequency catheter ablation of ventricular tachycardia in right ventricular dysplasia J. Am. Coll. Cardiol., September 1, 1998; 32(3): 724 - 728. [Abstract] [Full Text] [PDF]
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R. J. Schilling, N. S. Peters, and D. W. Davies Simultaneous Endocardial Mapping in the Human Left Ventricle Using a Noncontact Catheter : Comparison of Contact and Reconstructed Electrograms During Sinus Rhythm Circulation, September 1, 1998; 98(9): 887 - 898. [Abstract] [Full Text] [PDF]
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H. Nakagawa, F. H. M. Wittkampf, W. S. Yamanashi, J. V. Pitha, S. Imai, B. Campbell, M. Arruda, R. Lazzara, and W. M. Jackman Inverse Relationship Between Electrode Size and Lesion Size During Radiofrequency Ablation With Active Electrode Cooling Circulation, August 4, 1998; 98(5): 458 - 465. [Abstract] [Full Text] [PDF]
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W. G. Stevenson, P. L. Friedman, D. Kocovic, P. T. Sager, L. A. Saxon, and B. Pavri Radiofrequency Catheter Ablation of Ventricular Tachycardia After Myocardial Infarction Circulation, July 28, 1998; 98(4): 308 - 314. [Abstract] [Full Text] [PDF]
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T. Nitta, R. B. Schuessler, M. Mitsuno, C. K. Rokkas, F. Isobe, C. S. Cronin, J. L. Cox, and J. P. Boineau Return Cycle Mapping After Entrainment of Ventricular Tachycardia Circulation, March 31, 1998; 97(12): 1164 - 1175. [Abstract] [Full Text] [PDF]
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A. A V de Paola, W. D S Melo, M. Z P Tavora, and E. E Martinez Angiographic and electrophysiological substrates for ventricular tachycardia mapping through the coronary veins Heart, January 1, 1998; 79(1): 59 - 63. [Abstract] [Full Text] [PDF]
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J. M. Ormaetxe, J. Almendral, J. D. Martinez-Alday, J. P. Villacastin, A. Arenal, A. Pastor, T. Echeverria, and J. L. Delcan Analysis of the Degree of QRS Fusion Necessary for Its Visual Detection : Importance for the Recognition of Transient Entrainment Circulation, November 18, 1997; 96(10): 3509 - 3516. [Abstract] [Full Text]
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M. Eldar, D. G. Ohad, J. J. Goldberger, Z. Rotstein, S. Hsu, D. K. Swanson, and A. J. Greenspon Transcutaneous Multielectrode Basket Catheter for Endocardial Mapping and Ablation of Ventricular Tachycardia in the Pig Circulation, October 7, 1997; 96(7): 2430 - 2437. [Abstract] [Full Text]
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S. A. Strickberger, K. C. Man, E. G. Daoud, R. Goyal, K. Brinkman, C. Hasse, F. Bogun, B. P. Knight, R. Weiss, M. Bahu, et al. A Prospective Evaluation of Catheter Ablation of Ventricular Tachycardia as Adjuvant Therapy in Patients With Coronary Artery Disease and an Implantable Cardioverter-Defibrillator Circulation, September 2, 1997; 96(5): 1525 - 1531. [Abstract] [Full Text]
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H. Kottkamp, G. Hindricks, E. Horst, T. Baal, C. Fechtrup, G. Breithardt, and M. Borggrefe Subendocardial and Intramural Temperature Response During Radiofrequency Catheter Ablation in Chronic Myocardial Infarction and Normal Myocardium Circulation, April 15, 1997; 95(8): 2155 - 2161. [Abstract] [Full Text]
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F. Bogun, M. Bahu, B. P. Knight, R. Weiss, W. Paladino, M. Harvey, R. Goyal, E. Daoud, K. C. Man, S. A. Strickberger, et al. Comparison of Effective and Ineffective Target Sites That Demonstrate Concealed Entrainment in Patients With Coronary Artery Disease Undergoing Radiofrequency Ablation of Ventricular Tachycardia Circulation, January 7, 1997; 95(1): 183 - 190. [Abstract] [Full Text]
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A. E. Epstein, W. M. Miles, D. G. Benditt, A. J. Camm, E. J. Darling, P. L. Friedman, A. Garson, J. C. Harvey, G. A. Kidwell, G. J. Klein, et al. Personal and Public Safety Issues Related to Arrhythmias That May Affect Consciousness: Implications for Regulation and Physician Recommendations: A Medical/Scientific Statement From the American Heart Association and the North American Society of Pacing and Electrophysiology Circulation, September 1, 1996; 94(5): 1147 - 1166. [Full Text]
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G. F. Van Hare and A. L. Waldo The Atrial Flutter Reentrant Circuit: Additional Pieces of the Puzzle Circulation, August 1, 1996; 94(3): 244 - 246. [Full Text]
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J. M. Kalman, J. E. Olgin, L. A. Saxon, W. G. Fisher, R. J. Lee, and M. D. Lesh Activation and Entrainment Mapping Defines the Tricuspid Annulus as the Anterior Barrier in Typical Atrial Flutter Circulation, August 1, 1996; 94(3): 398 - 406. [Abstract] [Full Text]
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H. Nakagawa, R. Lazzara, T. Khastgir, K. J. Beckman, J. H. McClelland, S. Imai, J. V. Pitha, A. E. Becker, M. Arruda, M. D. Gonzalez, et al. Role of the Tricuspid Annulus and the Eustachian Valve/Ridge on Atrial Flutter: Relevance to Catheter Ablation of the Septal Isthmus and a New Technique for Rapid Identification of Ablation Success Circulation, August 1, 1996; 94(3): 407 - 424. [Abstract] [Full Text]
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J. M. Kalman, G. F. VanHare, J. E. Olgin, L. A. Saxon, S. I. Stark, and M. D. Lesh Ablation of `Incisional' Reentrant Atrial Tachycardia Complicating Surgery for Congenital Heart Disease : Use of Entrainment to Define a Critical Isthmus of Conduction Circulation, February 1, 1996; 93(3): 502 - 512. [Abstract] [Full Text]
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B. Cauchemez, M. Haissaguerre, B. Fischer, O. Thomas, J. Clementy, and P. Coumel Electrophysiological Effects of Catheter Ablation of Inferior Vena Cava–Tricuspid Annulus Isthmus in Common Atrial Flutter Circulation, January 15, 1996; 93(2): 284 - 294. [Abstract] [Full Text]
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D. J. Wilber, D. E. Kopp, D. N. Glascock DO, C. A. Kinder, and J. G. Kall Catheter Ablation of the Mitral Isthmus for Ventricular Tachycardia Associated With Inferior Infarction Circulation, December 15, 1995; 92(12): 3481 - 3489. [Abstract] [Full Text]
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J. E. Olgin, J. M. Kalman, A. P. Fitzpatrick, and M. D. Lesh Role of Right Atrial Endocardial Structures as Barriers to Conduction During Human Type I Atrial Flutter : Activation and Entrainment Mapping Guided by Intracardiac Echocardiography Circulation, October 1, 1995; 92(7): 1839 - 1848. [Abstract] [Full Text]
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H. Kottkamp, G. Hindricks, X. Chen, J. Brunn, S. Willems, W. Haverkamp, M. Block, G. Breithardt, and M. Borggrefe Radiofrequency Catheter Ablation of Sustained Ventricular Tachycardia in Idiopathic Dilated Cardiomyopathy Circulation, September 1, 1995; 92(5): 1159 - 1168. [Abstract] [Full Text]
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J. M. Miller, G. S. Tyson, W. C. Hargrove III, J. A. Vassallo, M. E. Rosenthal, and M. E. Josephson Effect of Subendocardial Resection on Sinus Rhythm Endocardial Electrogram Abnormalities Circulation, May 1, 1995; 91(9): 2385 - 2391. [Abstract] [Full Text]
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 A. B. Wagshal, L. A. Pires, and S. K. Stephen Management of Cardiac Arrhythmias With Radiofrequency Catheter Ablation Arch Intern Med, January 23, 1995; 155(2): 137 - 147. [Abstract] [PDF]
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C. de Chillou, D. Lacroix, D. Klug, I. Magnin-Poull, C. Marquie, M. Messier, M. Andronache, C. Kouakam, N. Sadoul, J. Chen, et al. Isthmus Characteristics of Reentrant Ventricular Tachycardia After Myocardial Infarction Circulation, February 12, 2002; 105(6): 726 - 731. [Abstract] [Full Text] [PDF]
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