Author + information
- Received November 2, 2017
- Revision received January 28, 2018
- Accepted January 29, 2018
- Published online March 19, 2018.
- Marta de Riva, MDa,
- Yoshihisa Naruse, MD, PhDa,
- Micaela Ebert, MDa,
- Alexander F.A. Androulakis, MDa,
- Qian Tao, PhDb,
- Masaya Watanabe, MD, PhDa,
- Adrianus P. Wijnmaalen, MD, PhDa,
- Jeroen Venlet, MDa,
- Charlotte Brouwer, MDa,
- Serge A. Trines, MD, PhDa,
- Martin J. Schalij, MD, PhDa and
- Katja Zeppenfeld, MD, PhDb,∗ ()
- aDepartment of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
- bDepartment of Radiology, Division of Image Processing, Leiden University Medical Center, Leiden, the Netherlands
- ↵∗Address for correspondence:
Dr. Katja Zeppenfeld, Leiden University Medical Centre, Department of Cardiology, Postal Zone: C-05-P, P.O. Box 9600, 2300 RC Leiden, the Netherlands.
Objectives This study sought to determine whether ablation of hidden substrate unmasked by right ventricular extrastimulation (RVE) improves ablation outcome of post-myocardial infarction (MI) ventricular tachycardia (VT).
Background In patients with small or nontransmural scars after MI, part of the VT substrate may be functional and, in addition, masked by high-voltage far-field signals arising from adjacent normal myocardium.
Methods In 60 consecutive patients, systematic analysis of electrograms recorded from the presumed infarct area was performed during sinus rhythm, RV pacing at 500 ms, and during a short-coupled RV extrastimulus. Sites showing low-voltage, near-field potentials with evoked conduction delay in response to RVE were targeted.
Results In 37 (62%) patients, ablation target sites located in areas with normal voltage during sinus rhythm were unmasked by RVE (hidden substrate group). These patients had better left ventricular function (36 ± 11% vs. 26 ± 12%; p = 0.003), smaller electroanatomical scars (<1.5 mV), and smaller dense scars (<0.5 mV) (median 59 and 14 cm2 vs. 82 and 44 cm2; p = 0.044 and p = 0.003) than did those in whom no hidden substrate was identified (overt substrate group). During a median follow-up of 16 months, 13 (22%) patients had VT recurrence. Patients with hidden substrate had a lower incidence of VT recurrence (12-month VT-free survival 89% vs. 50% in patients with overt substrate; p = 0.005). Compared with a historical cohort of 90 post-MI patients matched for left ventricular function and electroanatomical scar area, in whom no RVE was performed, patients in the hidden substrate group had a higher 1-year VT-free survival (89% vs. 73%; p = 0.039).
Conclusions Hidden substrate ablation unmasked by RVE improves ablation outcome in post-MI patients with small or nontransmural scars.
The Department of Cardiology Leiden receives unrestricted research and fellowship grants from Edward Lifesciences, Boston Scientific, Medtronic, and Biotronik. Dr. Naruse was supported by an overseas research fellowship from the Japan Society for the Promotion of Science) and a 2014 to 2015 fellowship from the Japanese Heart Rhythm Society–European Heart Rhythm Association (sponsored by Biotronik). The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received November 2, 2017.
- Revision received January 28, 2018.
- Accepted January 29, 2018.
- 2018 American College of Cardiology Foundation
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