Identification of Human Ventricular Tachycardia Demarcated by Fixed Lines of Conduction Block in a 3-Dimensional Hyperboloid Circuit
Identification of Human Ventricular Tachycardia Demarcated by Fixed Lines of Conduction Block in a 3-Dimensional Hyperboloid Circuit
复制标题
3 维双曲面电路中传导块固定线划分的人体室性心动过速的识别
作者：
T. Nishimura;Nathan Shatz;P. Weiss;M. Zawaneh;Rong Bai;Andrew D. Beaser;G. Upadhyay;Zaid A. Aziz;H. Nayak;Dalise Y. Shatz;S. Miyazaki;M. Goya;T. Sasano;W. Su;M. Raiman;Roderick Tung
背景：折返性室性心动过速（VT）的回路边界历来是在二维（2D）结构中概念化的，其固定或功能性质尚未解决。本研究旨在检查基线节律期间明显的局部传导阻滞线 (LOB) 与横向峡部边界之间的相关性，横向峡部边界在 3 维上将 VT 峡部限制为双曲面结构。方法：来自 3 个中心的 106 名患者（42% 为非缺血性心肌病）因疤痕相关 VT 接受导管消融术，总共 175 个 VT 激活图与基线节律期间的等时晚激活图相关。明显的 LOB 是由基线节律期间具有分裂电位（≥20 ms 等电段）的减速区定义的。减速区内起搏（≥600 ms）的新颖应用被用来揭示基线节律期间不明显的隐藏 LOB。在基线节律或起搏期间识别的 LOB 与 VT 期间的峡部边界相关。结果：在基线节律期间分析的 202 个减速区中，47% 存在明显的 LOB。当在 38 个没有明显 LOB 的减速区进行差异起搏时，84% 的潜在隐藏 LOB 被暴露。在 152 个 VT 激活图（2D=53，3 维 [3D]=99）中，69% 的横向边界与 2D 激活模式中的 LOB 共定位，3D VT 期间的深度边界与 LOB 共定位（79%）。在具有与 U 形 LOB 共定位的峡部区域的 VT 回路中 (n=28)，边界总是充当 2D 和 3D 中的两个横向边界。总体而言，在基线节律或差异起搏期间，74% 的峡部边界可被识别为固定 LOB。结论：大多数 VT 回路边界可被识别为窦性心律期间内在或起搏激活的固定 LOB。在疤痕基质内起搏时分析激活是一种新技术，可以揭示隐藏的 LOB，而以前被解释为具有功能性。从心肌表面的角度来看，LOB 通常与壁内传导相关，支持 3D 双曲面 VT 电路结构的存在。导管消融可以简化为在窦性心律期间针对已识别的 LOB 周围的两侧。
BACKGROUND: The circuit boundaries for reentrant ventricular tachycardia (VT) have been historically conceptualized within a 2-dimensional (2D) construct, with their fixed or functional nature unresolved. This study aimed to examine the correlation between localized lines of conduction block (LOB) evident during baseline rhythm with lateral isthmus boundaries that 3-dimensionally constrain the VT isthmus as a hyperboloid structure. METHODS: A total of 175 VT activation maps were correlated with isochronal late activation maps during baseline rhythm in 106 patients who underwent catheter ablation for scar-related VT from 3 centers (42% nonischemic cardiomyopathy). An overt LOB was defined by a deceleration zone with split potentials (≥20 ms isoelectric segment) during baseline rhythm. A novel application of pacing within deceleration zone (≥600 ms) was implemented to unmask a concealed LOB not evident during baseline rhythm. LOB identified during baseline rhythm or pacing were correlated with isthmus boundaries during VT. RESULTS: Among 202 deceleration zones analyzed during baseline rhythm, an overt LOB was evident in 47%. When differential pacing was performed in 38 deceleration zones without overt LOB, an underlying concealed LOB was exposed in 84%. In 152 VT activation maps (2D=53, 3-dimensional [3D]=99), 69% of lateral boundaries colocalized with an LOB in 2D activation patterns, and the depth boundary during 3D VT colocalized with an LOB in 79%. In VT circuits with isthmus regions that colocalized with a U-shaped LOB (n=28), the boundary invariably served as both lateral boundaries in 2D and 3D. Overall, 74% of isthmus boundaries were identifiable as fixed LOB during baseline rhythm or differential pacing. CONCLUSIONS: The majority of VT circuit boundaries can be identified as fixed LOB from intrinsic or paced activation during sinus rhythm. Analysis of activation while pacing within the scar substrate is a novel technique that may unmask concealed LOB, previously interpreted to be functional in nature. An LOB from the perspective of a myocardial surface is frequently associated with intramural conduction, supporting the existence of a 3D hyperboloid VT circuit structure. Catheter ablation may be simplified to targeting both sides around an identified LOB during sinus rhythm.