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Localizing the critical isthmus of postinfarct ventricular tachycardia: The value of pace-mapping during sinus rhythm

Abstract : BACKGROUND: Most postinfarct ventricular tachycardias (VTs) are sustained by a reentrant mechanism. The "protected isthmus" of the reentrant circuit is critical for the maintenance of VTs and the target for catheter ablation. Various techniques based on conventional electrophysiology and/or detailed three-dimensional (3D) reconstruction of the VT circuit are used to unmask this isthmus. OBJECTIVE: The purpose of this study was to assess pace-maps (PMs) to identify postinfarct VT isthmuses. We hypothesized that an abrupt change in paced QRS morphology may be used to identify a VT isthmus and be targeted for successful ablation. METHODS: High-density 3D PMs were matched to the subsequent 3D endocardial reentrant VT activation mapping in 10 patients (8 men; age 70.7 ± 10.8 years) who underwent successful postinfarct VT ablation. At each pacing site in a given patient, the 12-lead ECG recorded during pacing was compared to that of VT, with the resulting matching percentage (up to 100% for perfect matches) allocated to this point to generate color-coded PMs. RESULTS: With respect to VT isthmuses, the best percentages of matching were found in the exit zones and isthmus exit part (89% ± 8% and 84% ± 7%, respectively) and the poorest adjacent to scar border in the outer entrance zones (23% ± 28%), in the entrance zones (39% ± 34%), and in the entrance part of the isthmus (32% ± 26%). The color-coded sequence (from the best to the poorest matching sites) on the PMs revealed figure-of-eight pictures matching the VT activation time maps and identifying VT isthmuses. CONCLUSION: Pace-mapping is useful for unmasking VT isthmuses in patients with well-tolerated postinfarct endocardial reentrant VTs.
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Submitted on : Friday, March 9, 2018 - 11:33:39 AM
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Christian de Chillou, Laurent Groben, Isabelle Magnin-Poull, Marius Andronache, Mohamed Magdi Abbas, et al.. Localizing the critical isthmus of postinfarct ventricular tachycardia: The value of pace-mapping during sinus rhythm. Heart Rhythm, Elsevier, 2014, 11 (2), pp.175 - 181. ⟨10.1016/j.hrthm.2013.10.042⟩. ⟨hal-01727527⟩



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