Author + information
- Received March 5, 2019
- Revision received July 1, 2019
- Accepted July 2, 2019
- Published online October 21, 2019.
- Marek Sramko, MD, PhDa,b,∗,
- Saif Abdel-Kafi, MDa,∗,
- Rob J. van der Geest, MD, PhDc,
- Marta de Riva, MDa,
- Claire A. Glashan, MDa,
- Hildo J. Lamb, MD, PhDc and
- Katja Zeppenfeld, MD, PhDa,∗ ()
- aDepartment of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
- bDepartment of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- cDepartment of Radiology, Leiden University Medical Center, Leiden, the Netherlands
- ↵∗Address for correspondence:
Dr. Katja Zeppenfeld, Department of Cardiology, Leiden University Medical Center, P.O. Box 9600, 2300 RC Leiden, the Netherlands.
Objectives This study sought to determine new reference cutoffs for normal unipolar voltage (UV) and bipolar voltage (BV) that would be adjusted for the LV remodeling.
Background The definition of “normal” left ventricular (LV) endocardial voltage in patients with post-infarct scar is still lacking. The reference voltage of the noninfarcted myocardium (NIM) may differ between patients depending on LV structural remodeling and the ensuing interstitial fibrosis.
Methods Electroanatomic voltage mapping was integrated with isotropic late gadolinium–enhanced cardiac magnetic resonance in 15 patients with nonremodeled LV and 12 patients with remodeled LV (end-systolic volume index >50 ml/m2 with ejection fraction <47% assessed by cardiac magnetic resonance). Reference voltages (fifth percentile values) were determined from pooled NIM segments without late gadolinium enhancement.
Results The cutoffs for normal BV and UV were ≥3.0 and ≥6.7 mV for nonremodeled LV and ≥2.1 and ≥6.4 mV for remodeled LV. Endocardial low-voltage area (LVA) defined by the adjusted cutoffs corresponded better to late gadolinium enhancement–detected scar than did LVA defined by uniform cutoffs. In 15 patients who underwent successful ablation of ventricular tachycardia, the LVA contained >97% of targeted evoked delayed potentials. Insights from whole-heart T1 mapping revealed more fibrotic NIM in patients with remodeled LV compared with nonremodeled LV.
Conclusions This study found substantial differences in endocardial voltage of NIM in post-infarct patients with remodeled versus nonremodeled LV. The new adjusted cutoffs for “normal” BV and UV enable a patient-tailored approach to electroanatomic voltage mapping of LV.
↵∗ Drs. Sramko and Abdel-Kafi contributed equally to the work.
The Leiden University Medical Center Department of Cardiology has received unrestricted grant support from Edwards Lifesciences, Medtronic, Biotronik, and Boston Scientific; and has received research grant support from Biosense Webster. Dr. Sramko was supported by the Research Fellowship of the European Society of Cardiology (2017/2018) and by a grant of the Czech Society of Cardiology. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The 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 March 5, 2019.
- Revision received July 1, 2019.
- Accepted July 2, 2019.
- 2019 American College of Cardiology Foundation
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