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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