Characterization of trans-septal activation during septal pacing criteria for identification of intramural ventricular tachycardia substrate in nonischemic cardiomyopathy

Brian P. Betensky, Suraj Kapa, Benoit Desjardins, Fermin C. Garcia, David J. Callans, Sanjay Dixit, David S. Frankel, Mathew D. Hutchinson, Gregory E. Supple, Erica S. Zado, Francis E. Marchlinski

Research output: Contribution to journalArticle

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Abstract

Background-Identification of intramural basal-septal ventricular tachycardia (VT) substrate is challenging in nonischemic cardiomyopathy. We sought to (1) characterize normal/abnormal trans-septal right ventricular (RV) to left ventricular activation; (2) assess the effect of opposite RV pacing on left ventricular septal bipolar electrograms (EGMs); and (3) establish criteria for the identification of intramural septal VT substrate. Methods and Results-Endocardial activation mapping and local EGM assessment of the left interventricular septum was performed during RV basal septal pacing in 40 patients undergoing VT ablation with no evidence of septal scar (group 1, n=14) and with septal scar (group 2, n=26) defined by low septal unipolar voltage (<8.3 mV) and delayed enhancement on cardiac MRI with/without abnormal bipolar voltage (<1.5 mV) in sinus rhythm. Left ventricular trans-septal activation time was prolonged in Group 2 compared with Group 1 (55.3±33.0 versus 25.7±8.8 ms; P=0.003). In 6 group 2 patients, left ventricular septal breakthrough was displaced to the scar border. During RV pacing, group 2 had fractionated (8.8%), late (2.8%), and split (5.7%) EGMs not seen in group 1. Trans-septal activation >40 ms (sensitivity 60%, specificity 100%; P<0.001) and EGM duration >95 ms during pacing (sensitivity 22%, specificity 91%; P<0.001) identified septal scar (13/26 pts). Conclusions-In patients with nonischemic cardiomyopathy, VT and septal scar, delayed transmural conduction time (>40 ms) and fractionated, late, split, and wide (>95 ms) bipolar EGMs during RV basal pacing identify intramural VT substrate. In select cases, the basal septum appears compartmentalized as the stimulated wavefront is rerouted to the scar border.

Original languageEnglish (US)
Pages (from-to)1123-1130
Number of pages8
JournalCirculation: Arrhythmia and Electrophysiology
Volume6
Issue number6
DOIs
StatePublished - Dec 1 2013

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Ventricular Tachycardia
Cardiomyopathies
Cicatrix
Sensitivity and Specificity

Keywords

  • Mapping
  • Tachycardia
  • Ventricular

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Physiology (medical)

Cite this

Characterization of trans-septal activation during septal pacing criteria for identification of intramural ventricular tachycardia substrate in nonischemic cardiomyopathy. / Betensky, Brian P.; Kapa, Suraj; Desjardins, Benoit; Garcia, Fermin C.; Callans, David J.; Dixit, Sanjay; Frankel, David S.; Hutchinson, Mathew D.; Supple, Gregory E.; Zado, Erica S.; Marchlinski, Francis E.

In: Circulation: Arrhythmia and Electrophysiology, Vol. 6, No. 6, 01.12.2013, p. 1123-1130.

Research output: Contribution to journalArticle

Betensky, Brian P. ; Kapa, Suraj ; Desjardins, Benoit ; Garcia, Fermin C. ; Callans, David J. ; Dixit, Sanjay ; Frankel, David S. ; Hutchinson, Mathew D. ; Supple, Gregory E. ; Zado, Erica S. ; Marchlinski, Francis E. / Characterization of trans-septal activation during septal pacing criteria for identification of intramural ventricular tachycardia substrate in nonischemic cardiomyopathy. In: Circulation: Arrhythmia and Electrophysiology. 2013 ; Vol. 6, No. 6. pp. 1123-1130.
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title = "Characterization of trans-septal activation during septal pacing criteria for identification of intramural ventricular tachycardia substrate in nonischemic cardiomyopathy",
abstract = "Background-Identification of intramural basal-septal ventricular tachycardia (VT) substrate is challenging in nonischemic cardiomyopathy. We sought to (1) characterize normal/abnormal trans-septal right ventricular (RV) to left ventricular activation; (2) assess the effect of opposite RV pacing on left ventricular septal bipolar electrograms (EGMs); and (3) establish criteria for the identification of intramural septal VT substrate. Methods and Results-Endocardial activation mapping and local EGM assessment of the left interventricular septum was performed during RV basal septal pacing in 40 patients undergoing VT ablation with no evidence of septal scar (group 1, n=14) and with septal scar (group 2, n=26) defined by low septal unipolar voltage (<8.3 mV) and delayed enhancement on cardiac MRI with/without abnormal bipolar voltage (<1.5 mV) in sinus rhythm. Left ventricular trans-septal activation time was prolonged in Group 2 compared with Group 1 (55.3±33.0 versus 25.7±8.8 ms; P=0.003). In 6 group 2 patients, left ventricular septal breakthrough was displaced to the scar border. During RV pacing, group 2 had fractionated (8.8{\%}), late (2.8{\%}), and split (5.7{\%}) EGMs not seen in group 1. Trans-septal activation >40 ms (sensitivity 60{\%}, specificity 100{\%}; P<0.001) and EGM duration >95 ms during pacing (sensitivity 22{\%}, specificity 91{\%}; P<0.001) identified septal scar (13/26 pts). Conclusions-In patients with nonischemic cardiomyopathy, VT and septal scar, delayed transmural conduction time (>40 ms) and fractionated, late, split, and wide (>95 ms) bipolar EGMs during RV basal pacing identify intramural VT substrate. In select cases, the basal septum appears compartmentalized as the stimulated wavefront is rerouted to the scar border.",
keywords = "Mapping, Tachycardia, Ventricular",
author = "Betensky, {Brian P.} and Suraj Kapa and Benoit Desjardins and Garcia, {Fermin C.} and Callans, {David J.} and Sanjay Dixit and Frankel, {David S.} and Hutchinson, {Mathew D.} and Supple, {Gregory E.} and Zado, {Erica S.} and Marchlinski, {Francis E.}",
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T1 - Characterization of trans-septal activation during septal pacing criteria for identification of intramural ventricular tachycardia substrate in nonischemic cardiomyopathy

AU - Betensky, Brian P.

AU - Kapa, Suraj

AU - Desjardins, Benoit

AU - Garcia, Fermin C.

AU - Callans, David J.

AU - Dixit, Sanjay

AU - Frankel, David S.

AU - Hutchinson, Mathew D.

AU - Supple, Gregory E.

AU - Zado, Erica S.

AU - Marchlinski, Francis E.

PY - 2013/12/1

Y1 - 2013/12/1

N2 - Background-Identification of intramural basal-septal ventricular tachycardia (VT) substrate is challenging in nonischemic cardiomyopathy. We sought to (1) characterize normal/abnormal trans-septal right ventricular (RV) to left ventricular activation; (2) assess the effect of opposite RV pacing on left ventricular septal bipolar electrograms (EGMs); and (3) establish criteria for the identification of intramural septal VT substrate. Methods and Results-Endocardial activation mapping and local EGM assessment of the left interventricular septum was performed during RV basal septal pacing in 40 patients undergoing VT ablation with no evidence of septal scar (group 1, n=14) and with septal scar (group 2, n=26) defined by low septal unipolar voltage (<8.3 mV) and delayed enhancement on cardiac MRI with/without abnormal bipolar voltage (<1.5 mV) in sinus rhythm. Left ventricular trans-septal activation time was prolonged in Group 2 compared with Group 1 (55.3±33.0 versus 25.7±8.8 ms; P=0.003). In 6 group 2 patients, left ventricular septal breakthrough was displaced to the scar border. During RV pacing, group 2 had fractionated (8.8%), late (2.8%), and split (5.7%) EGMs not seen in group 1. Trans-septal activation >40 ms (sensitivity 60%, specificity 100%; P<0.001) and EGM duration >95 ms during pacing (sensitivity 22%, specificity 91%; P<0.001) identified septal scar (13/26 pts). Conclusions-In patients with nonischemic cardiomyopathy, VT and septal scar, delayed transmural conduction time (>40 ms) and fractionated, late, split, and wide (>95 ms) bipolar EGMs during RV basal pacing identify intramural VT substrate. In select cases, the basal septum appears compartmentalized as the stimulated wavefront is rerouted to the scar border.

AB - Background-Identification of intramural basal-septal ventricular tachycardia (VT) substrate is challenging in nonischemic cardiomyopathy. We sought to (1) characterize normal/abnormal trans-septal right ventricular (RV) to left ventricular activation; (2) assess the effect of opposite RV pacing on left ventricular septal bipolar electrograms (EGMs); and (3) establish criteria for the identification of intramural septal VT substrate. Methods and Results-Endocardial activation mapping and local EGM assessment of the left interventricular septum was performed during RV basal septal pacing in 40 patients undergoing VT ablation with no evidence of septal scar (group 1, n=14) and with septal scar (group 2, n=26) defined by low septal unipolar voltage (<8.3 mV) and delayed enhancement on cardiac MRI with/without abnormal bipolar voltage (<1.5 mV) in sinus rhythm. Left ventricular trans-septal activation time was prolonged in Group 2 compared with Group 1 (55.3±33.0 versus 25.7±8.8 ms; P=0.003). In 6 group 2 patients, left ventricular septal breakthrough was displaced to the scar border. During RV pacing, group 2 had fractionated (8.8%), late (2.8%), and split (5.7%) EGMs not seen in group 1. Trans-septal activation >40 ms (sensitivity 60%, specificity 100%; P<0.001) and EGM duration >95 ms during pacing (sensitivity 22%, specificity 91%; P<0.001) identified septal scar (13/26 pts). Conclusions-In patients with nonischemic cardiomyopathy, VT and septal scar, delayed transmural conduction time (>40 ms) and fractionated, late, split, and wide (>95 ms) bipolar EGMs during RV basal pacing identify intramural VT substrate. In select cases, the basal septum appears compartmentalized as the stimulated wavefront is rerouted to the scar border.

KW - Mapping

KW - Tachycardia

KW - Ventricular

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