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Hibernating substrate of ventricular tachycardia: a three-dimensional metabolic and electro-anatomic assessment

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Abstract

Purpose

Hibernating myocardium (HM) is associated with sudden cardiac death (SCD). Little is known about the electrophysiological properties of HM and the basis of its association with SCD. We aimed to electrophysiologically characterize HM in patients with ventricular tachycardia (VT).

Methods

Endocardial voltage mapping, metabolic 18FDG-positron emission tomography (PET) and perfusion 82Rb, 201Tl, or 99mTc scans were performed in 61 ischemic heart disease patients with VT. Hibernating areas were identified which was followed by three-dimensional PET reconstructions and integration with voltage maps to allow hybrid metabolic-electro-anatomic assessment of the arrhythmogenic substrate.

Results

Of 61 patients with ischemic heart disease and refractory VT, 7 were found to have hibernating myocardium (13%). A total of 303 voltage points were obtained within hibernating myocardium (8.2 points per 10 cm2) and displayed abnormal voltage in 48.5 and 78.3% of bipolar and unipolar recordings, respectively, with significant heterogeneity of bipolar (p < 0.0001) and unipolar voltage measurements (p = 0.0004). Hibernating areas in 6 of 7 patients contained all three categories of bipolar voltage-defined scar (<0.5 mV), border zone (0.5–1.5 mV), and normal myocardium (>1.5 mV). The characteristics of local electrograms were also assessed and found abnormal in most recordings (76.6, 10.2% fractionated, 5.3% isolated potentials). Exit sites of clinical VTs were determined in 6 patients, of which 3 were located within hibernating myocardium.

Conclusions

Hibernating myocardium displays abnormal and heterogeneous electrical properties and seems to contribute to the substrate of VT. These observations may underlie the vulnerability to reentry and SCD in patients with hypoperfused yet viable myocardium.

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Abbreviations

SCD:

Sudden cardiac death

HM:

Hibernating myocardium

VT:

Ventricular tachycardia

VF:

Ventricular fibrillation

IHD:

Ischemic heart disease

MI:

Myocardial infarction

PET:

Positron emission tomography

SPECT:

Single photon emission tomography

18FDG:

18-fluorodeoxyglucose

ICD:

Implantable cardioverter-defibrillator

PES:

Programmed electrical stimulation

LV:

Left ventricle

RV:

Right ventricle

ICE:

Intra-cardiac echocardiography

IQR:

Interquartile range

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Authors and Affiliations

  1. Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic, Cleveland, OH, USA

    Ayman A. Hussein

  2. Division of Cardiology, University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD, 21201, USA

    Michelle Niekoop, Yousra Ghzally, Mohammed Abdulghani, Ramazan Asoglu, Vincent See, Stephen R. Shorofsky & Timm-Michael Dickfeld

  3. Division of Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA

    Vasken Dilsizian, Wengen Chen & Mark Smith

Authors
  1. Ayman A. Hussein
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  2. Michelle Niekoop
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Maryland Arrhythmia and Cardiology Imaging Group (MACIG)

Corresponding author

Correspondence to Timm-Michael Dickfeld.

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Conflict of interest

Dr Dickfeld receives consulting and grant support from Biosense Webster and grant support from General Electric. All other authors declare that they have no conflicts of interest.

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Hussein, A.A., Niekoop, M., Dilsizian, V. et al. Hibernating substrate of ventricular tachycardia: a three-dimensional metabolic and electro-anatomic assessment. J Interv Card Electrophysiol 48, 247–254 (2017). https://doi.org/10.1007/s10840-016-0219-1

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  • DOI: https://doi.org/10.1007/s10840-016-0219-1

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