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Substrate mapping for scar-related ventricular tachycardia in patients with resynchronization therapy—the importance of the pacing mode

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Abstract

Purpose

Targets for substrate-based catheter ablation of scar-related ventricular tachycardia (VT) include sites with fractionated and late potentials (LPs). We hypothesized that in patients with cardiac resynchronization therapy (CRT), the pacing mode may influence the timing of abnormal electrograms (EGMs) relative to the surface QRS complex.

Methods

We assessed bipolar EGM characteristics in left ventricular low bipolar voltage areas (< 1.5 mV) from 10 patients with coronary disease and a CRT device undergoing catheter ablation for VT. EGMs at 81 sites were analyzed during three different pacing modes (biventricular (BiV), right ventricular (RV)-only, and left ventricular (LV)-only) pacing.

Results

Stimulus to end of local electrogram duration (Stim-to-eEGM) depended significantly on the stimulation site (BiV, LV, or RV, p = 0.032). Single-chamber pacing unmasked LPs, not present during BiV pacing, in three patients. In another three patients, a concomitant increase in stimulus to end of surface QRS duration caused by single-site pacing compensated for the increase in Stim-to-eEGM duration, thereby prohibiting LP unmasking.

Conclusion

The sequence of ventricular activation, as determined by the pacing site in patients with CRT devices, has a major influence on the detection of late potentials during substrate-guided ablation. Further study is warranted to define the optimal approaches, including the rhythm, for substrate mapping, but our findings suggest that BiV pacing may be most likely to obscure detection of late potentials as compared to single-site pacing.

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Funding

Dr. Baldinger received educational grants from the University Hospital of Bern, Switzerland, and the Swiss foundation for pacemakers and electrophysiology.

Dr. Epstein receives consulting fees from Boston Scientific, Medtronic, and Spectranetics. Dr. John receives consulting fees from St. Jude Medical. Dr. Michaud and Dr. Tedrow receive consulting fees from St. Jude Medical and research funding from Boston Scientific and Biosense Webster. Dr. Stevenson is co-holder of a patent for needle ablation that is consigned to Brigham and Women’s Hospital. Dr. Stevenson’s spouse receives research support from St. Jude Medical, Inc.

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Author notes

  1. Drs. Baldinger and Kumar contributed equally to this manuscript and share first authorship.

Authors and Affiliations

  1. Cardiac Arrhythmia Center, Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA, USA

    Samuel H. Baldinger, Saurabh Kumar, Akira Fujii, Jorge Romero, Laurence M. Epstein, Gregory F. Michaud, Usha B. Tedrow, Roy John & William G. Stevenson

  2. Department of Cardiology, Bern University Hospital and University of Bern, Bern, Switzerland

    Samuel H. Baldinger & Andreas Haeberlin

  3. Division of Cardiology, Vanderbilt University Medical Center, 2220 Pierce Avenue, Nashville, TN, 37232-6300, USA

    Gregory F. Michaud, Roy John & William G. Stevenson

Authors
  1. Samuel H. Baldinger
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  2. Saurabh Kumar
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  3. Akira Fujii
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  4. Andreas Haeberlin
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  5. Jorge Romero
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  6. Laurence M. Epstein
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  7. Gregory F. Michaud
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  8. Usha B. Tedrow
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  9. Roy John
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  10. William G. Stevenson
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Contributions

Samuel H. Baldinger: concept/design, data analysis/interpretation, drafting of manuscript

Saurabh Kumar: concept/design, data collection, critical revision

Akira Fujii: data collection, critical revision

Andreas Haeberlin: statistics, critical revision

Jorge Romero: critical revision

Laurence M. Epstein: critical revision

Gregory F. Michaud: critical revision

Roy John: critical revision

Usha B. Tedrow: critical revision

William G. Stevenson: concept/design, data interpretation, critical revision

Corresponding author

Correspondence to William G. Stevenson.

Ethics declarations

Data collection was performed according to protocols approved by the Human Research Committee of Brigham and Women’s Hospital. Each patient gave written informed consent for the electrophysiology procedure.

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Baldinger, S.H., Kumar, S., Fujii, A. et al. Substrate mapping for scar-related ventricular tachycardia in patients with resynchronization therapy—the importance of the pacing mode. J Interv Card Electrophysiol 55, 55–62 (2019). https://doi.org/10.1007/s10840-019-00548-5

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  • DOI: https://doi.org/10.1007/s10840-019-00548-5

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