Targeted Ablation of Ventricular Tachycardia Guided by Wavefront Discontinuities During Sinus Rhythm A New Functional Substrate Mapping Strategy
Targeted Ablation of Ventricular Tachycardia Guided by Wavefront Discontinuities During Sinus Rhythm A New Functional Substrate Mapping Strategy
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DOI：
10.1161/circulationaha.119.042423
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发表时间：
2019-10-22
期刊：
影响因子：
37.8
通讯作者：
Tung, Roderick
中科院分区：
文献类型：
--
作者：
Aziz, Zaid;Shatz, Dalise;Tung, Roderick
背景：需要准确和快速识别最容易折返的瘢痕区域以指导室性心动过速（VT）消融。我们的目的是前瞻性评估主要通过窦性心律期间心室激动的传播分析确定的减速区（DZ）靶向引导的VT消融术的结局。方法：2016年至2018年，前瞻性入组芝加哥大学室性心动过速消融登记研究的瘢痕相关室性心动过速患者。使用高密度多电极标测导管创建注释到最新局部电描记图偏转的等时晚期激动标测图。对DZ进行靶向消融（1 cm半径内>3个等时线），优先考虑具有最大等时线拥挤的较晚激活区域。如果可能，进行室性心动过速的激动标测，并将成功消融部位与DZ部位进行比较，以确定机制相关性。前瞻性随访患者的室性心动过速复发和死亡率。结果如下：120例患者（中位年龄65岁[59-71]，15%为女性，50%为非缺血性，中位射血分数31%）接受了144次瘢痕相关VT消融术。57%的患者既往进行过消融，59%的病例采用了心外膜入路。在基线心律期间进行了高密度标测（心内膜2518点[1615-3752]，心外膜5049 +/- 2580点），并确定了平均2 +/- 1 DZ，在95%的病例中共定位于成功终止部位。中位总射频应用持续时间为29分钟（21-38分钟）至靶DZ，代表消融18%的低压区域。在12 +/- 10个月时，实现了70%的室性心动过速复发率（缺血性心肌病为80%，非缺血性心肌病为63%）。总生存率为87%。结论：一种新型的电压无关高密度标测显示器可以识别窦性心律期间VT的功能基底，并指导靶向消融，从而避免了广泛的射频输送。基线节律期间等时拥挤的区域可预测VT终止部位，提供了减速区高度致心律失常的机制证据，作为折返的病灶。
Background: Accurate and expedited identification of scar regions most prone to reentry is needed to guide ventricular tachycardia (VT) ablation. We aimed to prospectively assess outcomes of VT ablation guided primarily by the targeting of deceleration zones (DZ) identified by propagational analysis of ventricular activation during sinus rhythm. Methods: Patients with scar-related VT were prospectively enrolled in the University of Chicago VT Ablation Registry between 2016 and 2018. Isochronal late activation maps annotated to the latest local electrogram deflection were created with high-density multielectrode mapping catheters. Targeted ablation of DZ (>3 isochrones within 1cm radius) was performed, prioritizing later activated regions with maximal isochronal crowding. When possible, activation mapping of VT was performed, and successful ablation sites were compared with DZ locations for mechanistic correlation. Patients were prospectively followed for VT recurrence and mortality. Results: One hundred twenty patients (median age 65 years [59-71], 15% female, 50% nonischemic, median ejection fraction 31%) underwent 144 ablation procedures for scar-related VT. 57% of patients had previous ablation and epicardial access was employed in 59% of cases. High-density mapping during baseline rhythm was performed (2518 points [1615-3752] endocardial, 5049 +/- 2580 points epicardial) and identified an average of 2 +/- 1 DZ, which colocalized to successful termination sites in 95% of cases. The median total radiofrequency application duration was 29 min (21-38 min) to target DZ, representing ablation of 18% of the low-voltage area. At 12 +/- 10 months, 70% freedom from VT recurrence (80% in ischemic cardiomyopathy and 63% in nonischemic cardiomyopathy) was achieved. The overall survival rate was 87%. Conclusions: A novel voltage-independent high-density mapping display can identify the functional substrate for VT during sinus rhythm and guide targeted ablation, obviating the need for extensive radiofrequency delivery. Regions with isochronal crowding during the baseline rhythm were predictive of VT termination sites, providing mechanistic evidence that deceleration zones are highly arrhythmogenic, functioning as niduses for reentry.