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Relationships between cardiac innervation/perfusion imbalance and ventricular arrhythmias: impact on invasive electrophysiological parameters and ablation procedures

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European Journal of Nuclear Medicine and Molecular Imaging Aims and scope Submit manuscript

Abstract

Purpose

To assess the relationship between regional myocardial perfusion and sympathetic innervation parameters at myocardial scintigraphy and intra-cavitary electrophysiological data in patients with ventricular arrhythmias (VA) submitted to invasive electrophysiological study and ablation procedure.

Methods

Sixteen subjects underwent invasive electrophysiological study with electroanatomical mapping (EAM) followed by trans-catheter ablations of VA. Before ablation all patients were studied with a combined evaluation of regional myocardial perfusion and sympathetic innervation by means of tomographic 99mTc-tetrofosmin and 123I- metaiodobenzylguanidine cadmium-zinc-telluride (CZT) scintigraphies, respectively. Off-line spatial co-registration of CZT perfusion and innervation data with the three-dimensional EAM reconstruction was performed in every patient.

Results

CZT revealed the presence of myocardial scar in 55 (20 %) segments. Of the viable myocardial segments, 131 (60 %) presented a preserved adrenergic innervation, while 86 (40 %) showed a significantly depressed innervation (i.e. innervation/perfusion mismatch). On EAM, the invasively measured intra-cavitary voltage was significantly lower in scarred segments than in viable ones (1.7 ± 1.5 mV vs. 4.0 ± 2.2 mV, P < 0.001). Interestingly, among the viable segments, those showing an innervation/perfusion mismatch presented a significantly lower intra-cavitary voltage than those with preserved innervation (1.9 ± 2.5 mV vs. 4.7 ± 2.3 mV, P < 0.001). Intra-cardiac ablation was performed in 63 (23 %) segments. On multivariate analysis, after correction for scar burden, the segments showing an innervation/perfusion mismatch remained the most frequent ablation targets (OR 5.6, 95 % CI 1.5–20.8; P = 0.009).

Conclusions

In patients with VA, intra-cavitary electrical abnormalities frequently originate at the level of viable myocardial segments with depressed sympathetic innervation that frequently represents the ultimate ablation target.

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References

  1. Priori SG, Blomström-Lundqvist C, Mazzanti A, Blom N, Borggrefe M, Camm J, et al. 2015 ESC guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: The Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC) Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J. 2015;36:2793–867.

    Article  PubMed  Google Scholar 

  2. Klein T, Dilsizian V, Cao Q, Chen W, Dickfeld TM. The potential role of iodine-123 metaiodobenzylguanidine imaging for identifying sustained ventricular tachycardia in patients with cardiomyopathy. Curr Cardiol Rep. 2013;15:359.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Paul M, Wichter T, Kies P, Gerss J, Wollmann C, Rahbar K, et al. Cardiac sympathetic dysfunction in genotyped patients with arrhythmogenic right ventricular cardiomyopathy and risk of recurrent ventricular tachyarrhythmias. J Nucl Med. 2011;52:1559–65.

    Article  CAS  PubMed  Google Scholar 

  4. Fallavollita JA, Heavey BM, Luisi Jr AJ, Michalek SM, Baldwa S, Mashtare Jr TL, et al. Regional myocardial sympathetic denervation predicts the risk of sudden cardiac arrest in ischemic cardiomyopathy. J Am Coll Cardiol. 2014;63:141–9.

    Article  PubMed  Google Scholar 

  5. Jacobson AF, Senior R, Cerqueira MD, Wong ND, Thomas GS, Lopez VA, et al. Myocardial iodine-123 meta-iodobenzylguanidine imaging and cardiac events in heart failure. Results of the prospective ADMIRE-HF (AdreView Myocardial Imaging for Risk Evaluation in Heart Failure) study. J Am Coll Cardiol. 2010;55:2212–21.

    Article  PubMed  Google Scholar 

  6. Dimitriu-Leen AC, Gimelli A, Al Younis I, Veltman CE, Verberne HJ, Wolterbeek R, et al. The impact of acquisition time of planar cardiac (123)I-MIBG imaging on the late heart to mediastinum ratio. Eur J Nucl Med Mol Imaging. 2016;43:326–32.

    Article  PubMed  Google Scholar 

  7. Clements IP, Garcia EV, Chen J, Folks RD, Butler J, Jacobson AF. Quantitative iodine-123-metaiodobenzylguanidine (MIBG) SPECT imaging in heart failure with left ventricular systolic dysfunction: development and validation of automated procedures in conjunction with technetium-99m tetrofosmin myocardial perfusion SPECT. J Nucl Cardiol. 2016;23:425–35.

    Article  PubMed  Google Scholar 

  8. Gimelli A, Liga R, Giorgetti A, Genovesi D, Marzullo P. Assessment of myocardial adrenergic innervation with a solid-state dedicated cardiac cadmium-zinc-telluride camera: first clinical experience. Eur Heart J Cardiovasc Imaging. 2014;15:575–85.

    Article  PubMed  Google Scholar 

  9. Zhou Y, Zhou W, Folks RD, Manatunga DN, Jacobson AF, Garcia EV, et al. I-123 mIBG and Tc-99m myocardial SPECT imaging to predict inducibility of ventricular arrhythmia on electrophysiology testing: a retrospective analysis. J Nucl Cardiol. 2014;21:913–20.

    Article  PubMed  Google Scholar 

  10. Bax JJ, Kraft O, Buxton AE, Fjeld JG, Parízek P, Agostini D, et al. 123 I-mIBG scintigraphy to predict inducibility of ventricular arrhythmias on cardiac electrophysiology testing: a prospective multicenter pilot study. Circ Cardiovasc Imaging. 2008;1:131–40.

    Article  PubMed  Google Scholar 

  11. Gimelli A, Liga R, Genovesi D, Giorgetti A, Kusch A, Marzullo P. Association between left ventricular regional sympathetic denervation and mechanical dyssynchrony in phase analysis: a cardiac CZT study. Eur J Nucl Med Mol Imaging. 2014;41:946–55.

    Article  PubMed  Google Scholar 

  12. Knackstedt C, Schauerte P, Kirchhof P. Electro-anatomic mapping systems in arrhythmias. Europace. 2008;10 Suppl 3:iii28–34.

    PubMed  Google Scholar 

  13. Robinson MR, Hutchinson MD. Use of imaging techniques to guide catheter ablation procedures. Curr Cardiol Rep. 2010;12:374–81.

    Article  PubMed  Google Scholar 

  14. Gimelli A, Masci PG, Liga R, Grigoratos C, Pasanisi EM, Lombardi M, et al. Regional heterogeneity in cardiac sympathetic innervation in acute myocardial infarction: relationship with myocardial oedema on magnetic resonance. Eur J Nucl Med Mol Imaging. 2014;41:1692–4.

    Article  PubMed  Google Scholar 

  15. Romero J, Lupercio F, Goodman-Meza D, Ruiz JC, Briceno DF, Fisher JD, et al. Electroanatomic mapping systems (CARTO/EnSite NavX) vs. conventional mapping for ablation procedures in a training program. J Interv Card Electrophysiol. 2016;45:71–80.

    Article  PubMed  Google Scholar 

  16. Heidbuchel H, Wittkampf FH, Vano E, Ernst S, Schilling R, Picano E, et al. Practical ways to reduce radiation dose for patients and staff during device implantations and electrophysiological procedures. Europace. 2014;16:946–64.

    Article  PubMed  Google Scholar 

  17. Marchlinski FE, Callans DJ, Gottlieb CD, Zado E. Linear ablation lesions for control of unmappable ventricular tachycardia in patients with ischemic and nonischemic cardiomyopathy. Circulation. 2000;101:1288–96.

    Article  CAS  PubMed  Google Scholar 

  18. Hsia HH, Lin D, Sauer WH, Callans DJ, Marchlinski FE. Anatomic characterization of endocardial substrate for hemodynamically stable reentrant ventricular tachycardia: identification of endocardial conducting channels. Heart Rhythm. 2006;3:503–12.

    Article  PubMed  Google Scholar 

  19. Sacher F, Lim HS, Derval N, Denis A, Berte B, Yamashita S, et al. Substrate mapping and ablation for ventricular tachycardia: the LAVA approach. J Cardiovasc Electrophysiol. 2015;26:464–71.

    Article  PubMed  Google Scholar 

  20. Kuteszko R, Pytkowski M, Farkowski MM, Maciag A, Sterlinski M, Jankowska A, et al. Utility of automated template matching for the interpretation of pace mapping in patients ablated due to outflow tract ventricular arrhythmias. Europace. 2015;17:1428–34.

    Article  PubMed  Google Scholar 

  21. Klein T, Abdulghani M, Smith M, Huang R, Asoglu R, Remo BF, et al. Three-dimensional 123I-meta-iodobenzylguanidine cardiac innervation maps to assess substrate and successful ablation sites for ventricular tachycardia: feasibility study for a novel paradigm of innervation imaging. Circ Arrhythm Electrophysiol. 2015;8:583–91.

    Article  PubMed  Google Scholar 

  22. Zhao C, Shuke N, Yamamoto W, Okizaki A, Sato J, Ishikawa Y, et al. Comparison of cardiac sympathetic nervous function with left ventricular function and perfusion in cardiomyopathies by 123I-MIBG SPECT and 99mTc-tetrofosmin electrocardiographically gated SPECT. J Nucl Med. 2001;42:1017–24.

    CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Fondazione Toscana Gabriele Monasterio, Via Moruzzi, 1, 56124, Pisa, Italy

    Alessia Gimelli & Paolo Marzullo

  2. Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy

    Francesca Menichetti, Ezio Soldati, Riccardo Liga, Andrea Vannozzi & Maria Grazia Bongiorni

  3. CNR, Institute of Clinical Physiology, Pisa, Italy

    Paolo Marzullo

Authors
  1. Alessia Gimelli
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  2. Francesca Menichetti
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  3. Ezio Soldati
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  4. Riccardo Liga
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  5. Andrea Vannozzi
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  6. Paolo Marzullo
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  7. Maria Grazia Bongiorni
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Correspondence to Alessia Gimelli.

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The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Alessia Gimelli and Francesca Menichetti shared first co-authorship.

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Gimelli, A., Menichetti, F., Soldati, E. et al. Relationships between cardiac innervation/perfusion imbalance and ventricular arrhythmias: impact on invasive electrophysiological parameters and ablation procedures. Eur J Nucl Med Mol Imaging 43, 2383–2391 (2016). https://doi.org/10.1007/s00259-016-3461-y

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  • DOI: https://doi.org/10.1007/s00259-016-3461-y

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