Predictors of ventricular ablation’s success: Viability, innervation, or mismatch?

  • Alessia GimelliEmail author
  • Francesca Menichetti
  • Ezio Soldati
  • Riccardo Liga
  • Nicola Scelza
  • Giulio Zucchelli
  • Andrea Di Cori
  • Luca Segreti
  • Andrea Vannozzi
  • Maria Grazia Bongiorni
  • Paolo Marzullo
Original Article



Sympathetic dys-innervation may play an important role in the development of post-ischemic ventricular arrhythmias (VA). Aim of this study was to prove that perfusion/innervation mismatch (PIM) evaluated by SPECT can identify areas of local abnormal ventricular activities (LAVA) on electroanatomic mapping (EAM).


Sixteen patients referred to post-ischemic VA catheter ablation underwent pre-procedural and 1-month post-ablation 123I-MIBG/99mTc-tetrofosmin rest SPECT myocardial imaging. PIM was defined according to the segmental distributions of 99mTc-tetrofosmin and 123I-MIBG. A 17-segment LV analysis was used for either SPECT or LV EAM voltage map. All patients were followed up clinically for at least 1 year.


Before ablation, the mean voltage in the PIM segments was higher than in the scarred ones but lower than in the normal regions. The presence of PIM in a specific LV zone was an independent predictor of LAVA. After ablation, PIM value was significantly reduced, mainly due to an increase in perfusion summed rest score, in particular in patients that were responders to ablation.


PIM may associate with VA substrate expressed by LAVA and might provide a novel guide for substrate ablation. A significant reduction of PIM could predict a positive clinical response to ablation.


Intervention tracers image-guided application diagnostic and prognostic application cardiac innervation multimodality 



Ischemic heart disease


Ventricular arrhythmias


Implantable cardioverter-defibrillator


Electro-anatomical mapping


Ventricular tachycardia


Local abnormal ventricular activities


Sympathetic nervous system




Perfusion/innervations mismatch



The authors have nothing to disclose.

Supplementary material

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Supplementary material 1 (DOC 32 kb)
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Supplementary material 3 (PPT 947 kb)
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Supplementary material 4 (DOC 23 kb)


  1. 1.
    John RM, Tedrow UB, Koplan BA, Albert CM, Epstein LM, Sweeney MO, et al. Ventricular arrhythmias and sudden cardiac death. Lancet 2012;380:1520-9.CrossRefGoogle Scholar
  2. 2.
    Zaman S, Kovoor P. Sudden cardiac death early after myocardial infarction: Pathogenesis, risk stratification, and primary prevention. Circulation 2014;129:2426-35.CrossRefGoogle Scholar
  3. 3.
    Bunch TJ, Weiss JP, Crandall BG, Day JD, May HT, Bair TL, et al. Patients treated with catheter ablation for ventricular tachycardia after an ICD shock have lower long-term rates of death and heart failure hospitalization than do patients treated with medical management only. Heart Rhythm 2014;11:533-40.CrossRefGoogle Scholar
  4. 4.
    Maskoun W, Saad M, Abualsuod A, Nairooz R, Miller JM. Outcome of catheter ablation for ventricular tachycardia in patients with ischemic cardiomyopathy: A systematic review and meta-analysis of randomized clinical trials. Int J Cardiol 2018. Scholar
  5. 5.
    Stevenson WG, Wilber DJ, Natale A, Jackman WM, Marchlinski FE, Talbert T, Multicenter Thermocool VT Ablation Trial Investigators, et al. Irrigated radiofrequency catheter ablation guided by electroanatomic mapping for recurrent ventricular tachycardia after myocardial infarction: The multicenter thermocool ventricular tachycardia ablation trial. Circulation 2008;118:2773-82.CrossRefGoogle Scholar
  6. 6.
    Acosta J, Penela D, Andreu D, Cabrera M, Carlosena A, Vassanelli A, et al. Elucidation of hidden slow conduction by double ventricular extrastimuli: A method for further arrhythmic substrate identification in ventricular tachycardia ablation procedures. Europace 2018;1:337-46.CrossRefGoogle Scholar
  7. 7.
    Di Biase L, Burkhardt JD, Lakkireddy D, Carbucicchio C, Tondo C, Natale A, et al. Ablation of stable VTs versus substrate ablation in ischemic cardiomyopathy: The VISTA Randomized Multicenter Trial. J Am Coll Cardiol 2015;29:2872-82.CrossRefGoogle Scholar
  8. 8.
    Fernández-Armenta J, Penela D, Acosta J, Andreu D, Evertz R, Cabrera M, et al. Substrate modification or ventricular tachycardia induction, mapping, and ablation as the first step? A randomized study. Heart Rhythm 2016;13:1589-95.CrossRefGoogle Scholar
  9. 9.
    Jais P, Maury P, Khairy P, Sacher F, Nault I, Komatsu Y, et al. Elimination of local abnormal ventricular activities:a new endpoint for substrate modification in patients with scar related ventricular tachycardia. Circulation 2012;125:2184-96.CrossRefGoogle Scholar
  10. 10.
    Wolf M, Sacher F, Cochet H, Kitamura T, Takigawa M, Yamashita S, et al. Long-term outcome of substrate modification in ablation of post-myocardial infarction ventricular tachycardia. Circ Arrhythm Electrophysiol 2018;11:e005635. Scholar
  11. 11.
    Gimelli A, Menichetti F, Soldati E, Liga R, Vannozzi A, Marzullo P, 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 2016;43:2383-91.CrossRefGoogle Scholar
  12. 12.
    Abdulghani M, Duell J, Smith M, Chen W, Bentzen SM, Asoglu R, et al. Global and regional myocardial innervation before and after ablation of drug-refractory ventricular tachycardia assessed with 123I-MIBG. J Nucl Med 2015;56:52S-8S.CrossRefGoogle Scholar
  13. 13.
    Zhou Y, Zhou W, Folks RD, Manatunga DN, Jacobson AF, Bax J, et al. I-123 mIBG and Tc-99 m myocardial SPECT imaging to predict inducibility of ventricular arrhythmia on electrophysiology testing: A retrospective analysis. J Nucl Cardiol 2014;21:913-20.CrossRefGoogle Scholar
  14. 14.
    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.CrossRefGoogle Scholar
  15. 15.
    Romero J, Lupercio F, Goodman-Meza D, Ruiz JC, Briceno DF, Fisher JD, et al. Electroanatomicmapping systems (CARTO/EnSite NavX) vs conventional mapping for ablation procedures in a training program. J Interv Card Electrophysiol 2016;45:71-80.CrossRefGoogle Scholar
  16. 16.
    Hussein A, Jimenez A, Ahmad G, Mesubi O, Klein T, Gurm G, et al. Assessment of ventricular tachycardia scar substrate by intracardiac echocardiography. Pacing Clin Electrophysiol 2014;37:412-21.CrossRefGoogle Scholar
  17. 17.
    Heidbuchel H, Wittkampf FH, Vano E, Ernst S, Schillin 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.CrossRefGoogle Scholar
  18. 18.
    Jesel L, Sacher F, Komatsu Y, Daly M, Zellerhoff S, Lim HS, et al. Characterization of contact force during endocardial and epicardial ventricular mapping. Circ Arrhythm Electrophysiol 2014;7:1168-73.CrossRefGoogle Scholar
  19. 19.
    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.CrossRefGoogle Scholar
  20. 20.
    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.CrossRefGoogle Scholar
  21. 21.
    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.CrossRefGoogle Scholar
  22. 22.
    Chen PS, Chen LS, Cao JM, Sharifi B, Karagueuzian HS, Fishbein MC. Sympathetic nerve sprouting, electrical remodeling and the mechanisms of sudden cardiac death. Cardiovasc Res 2001;50:409-16.CrossRefGoogle Scholar
  23. 23.
    Kammerling JJ, Green FJ, Watanabe AM, Inoue H, Barber MJ, Henry DP, et al. Denervation supersensitivity of refractoriness in Non infarcted areas apical to transmural myocardial infarction. Circulation 1987;76:383-93.CrossRefGoogle Scholar

Copyright information

© American Society of Nuclear Cardiology 2019

Authors and Affiliations

  • Alessia Gimelli
    • 1
    Email author
  • Francesca Menichetti
    • 2
    • 3
  • Ezio Soldati
    • 2
  • Riccardo Liga
    • 2
  • Nicola Scelza
    • 2
  • Giulio Zucchelli
    • 2
  • Andrea Di Cori
    • 2
  • Luca Segreti
    • 2
  • Andrea Vannozzi
    • 2
  • Maria Grazia Bongiorni
    • 2
  • Paolo Marzullo
    • 1
    • 4
  1. 1.Fondazione Toscana G. MonasterioPisaItaly
  2. 2.Cardio-Thoracic and Vascular DepartmentUniversity Hospital of PisaPisaItaly
  3. 3.Sant’Anna, School of Advanced StudiesPisaItaly
  4. 4.CNR, Institute of Clinical PhysiologyPisaItaly

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