Mapping strategies for premature ventricular contractions—activation, voltage, and/or pace map

Mapping-Strategien bei ventrikulären Extrasystolen – Activation- Voltage- und/oder Pace-Map

Abstract

A high premature ventricular contraction (PVC) burden is associated with an increase in cardiovascular mortality and may become clinically apparent through palpitations, reduced physical capacity or PVC-induced cardiomyopathy. Catheter ablation has been shown to be a more effective tool to treat patients with a high PVC burden than medical therapy alone. Current recommendations list catheter ablation as a class I option in patients with symptomatic idiopathic outflow tract PVCs as well as in patients with suspected PVC-induced cardiomyopathy. Careful planning is necessary to maximize efficiency and outcome of the ablation procedure. Prediction of the most likely PVC origin by studying the 12-lead electrocardiogram (ECG) is important. A high burden of spontaneous PVCs is associated with a better outcome during and after the procedure; pharmacological provocation can be performed. Developments in high density mapping systems have greatly advanced accuracy and efficiency of arrhythmia mapping in recent years. Different systems are now available that allow the simultaneous use and integration of different mapping information in an automated manner. Voltage mapping, activation mapping and pace mapping are used in clinical practice today. Activation mapping is used to visualize the area of earliest activation. While it is a very accurate tool, it relies on a high burden of spontaneous PVCs. Pace mapping aims to find the target area by means of stimulation and comparison of paced QRS complexes with the clinical PVC. Today, mostly a combination of both methods is used to maximize procedure outcome and efficiency. While voltage mapping plays a primary role in the mapping of substrate-based sustained arrhythmias in patients with underlying structural heart disease, activation and pace mapping are the methods of choice for PVC mapping.

Zusammenfassung

Eine hohe Anzahl ventrikulärer Extrasystolen (VES) ist mit einer erhöhten kardiovaskulären Mortalität assoziiert und kann klinisch mit Palpitationen, reduzierter körperlicher Leistungsfähigkeit oder VES-assoziierter Kardiomyopathie imponieren. Dabei ist die Katheterablation ein wirksameres Behandlungsverfahren als die alleinige medikamentöse Therapie. Aktuell hat die Katheterablation bei Patienten mit symptomatischen, idiopathischen Ausflusstrakt-VES oder mit vermuteter VES-assoziierter Kardiomyopathie eine Klasse-I-Empfehlung. Vor einer VES-Ablation ist eine sorgfältige Planung notwendig, um Wirksamkeit und Outcome zu optimieren. Wichtig ist die Ermittlung der zu erwartenden Ursprungsregion der klinischen VES anhand eines 12-Kanal-EKGs. Dabei ist eine hohe Anzahl spontaner VES mit einem besseren Outcome während und nach Prozedur assoziiert. Medikamentöse Provokationsmanöver sind möglich. Mit der Weiterentwicklung hochauflösender Mapping-Systeme hat sich die Genauigkeit und Effizienz des Mappings in den letzten Jahren stark verbessert. Mittlerweile gibt es Systeme, die automatisiert eine gleichzeitige Nutzung und Integration verschiedener Mapping-Informationen ermöglichen. Voltage‑, Aktivierungs- und Pace-Maps finden heute in der klinischen Praxis Anwendung. Ziel des Aktivierungs-Mappings ist es, den Ort der frühesten Aktivierung zu identifizieren; dieses Verfahren ist sehr genau, ist aber von einer hohen Anzahl spontaner VES abhängig. Beim Pace-Mapping wird mittels Stimulation der Zielort identifiziert, an dem der stimulierte QRS-Komplex der klinischen VES gleicht. Zur VES-Ablation wird heute meist eine Kombination der beiden Verfahren genutzt. Während das Voltage-Mapping vor allem bei Patienten mit strukturellen Herzerkrankungen und substratassoziierten anhaltenden Tachykardien eine Rolle spielt, sind Aktivierungs- und Pace-Mapping die erste Wahl zum VES-Mapping.

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Correspondence to Sebastian Dittrich.

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S. Dittrich, A. Sultan, J. Lüker, and D. Steven declare that they have no competing interests.

For this article no studies with human participants or animals were performed by any of the authors. All studies performed were in accordance with the ethical standards indicated in each case.

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Dittrich, S., Sultan, A., Lüker, J. et al. Mapping strategies for premature ventricular contractions—activation, voltage, and/or pace map. Herzschr Elektrophys (2021). https://doi.org/10.1007/s00399-021-00743-w

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Keywords

  • Ventricular premature complexes
  • Catheter ablation
  • Cardiac arrhythmias
  • High-resolution mapping
  • Ventricular fibrillation

Schlüsselwörter

  • Ventrikuläre Extrasystolen
  • Katheterablation
  • Herzrhythmusstörungen
  • Hochauflösendes Mapping
  • Kammerflimmern