Endocardial mapping of ventricular tachycardia in the intact human ventricle: evidence for reentrant mechanisms

Department of Medicine, Toronto General Hospital, Ontario, Canada.

A balloon array of 112 electrodes was used to obtain simultaneous recordings of endocardial electrograms during intraoperative mapping studies of ventricular tachycardia. Introduction of the balloon through a left atriotomy and across the mitral valve allowed endocardial activation maps to be obtained in the intact left ventricle. Of 20 patients with coronary artery disease studied in this way, suggestive evidence of endocardial reentry was found in 6. Three separate reentrant mechanisms were observed. In two patients, a single broad wave front of continuous recirculating activation reminiscent of a vortex was initiated by the formation of a functional arc of block in response to premature stimuli. In five patients, premature stimuli again produced a functional arc of block, which was circumvented by two opposing wave fronts that united on the distal side. Retrograde penetration by a narrow isthmus of slow conduction through the block initiated the tachycardia, whose activation sequence was consistent with figure eight reentry. In one patient, premature stimuli produced a region of delayed potentials. Critical timing of these resulted in microreentry in an adjacent circumscribed site, which formed the site of origin of the ensuing tachycardia. The microreentrant signals were not detected by standard unipolar recordings, but were seen on simultaneously recorded high gain electrograms. In 14 patients, although mapping identified a site of origin, the activation patterns showed either radial spread or incomplete circles. Detection of reentrant mechanisms during intraoperative mapping required high density electrode arrays and refined high gain recordings. An intact ventricle may facilitate intraoperative initiation of tachycardia.

This article has been cited by other articles:

				E. M. Aliot, W. G. Stevenson, J. M. Almendral-Garrote, F. Bogun, C. H. Calkins, E. Delacretaz, P. D. Bella, G. Hindricks, P. Jais, M. E. Josephson, et al. EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias: Developed in a partnership with the European Heart Rhythm Association (EHRA), a Registered Branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA) Europace, June 1, 2009; 11(6): 771 - 817. [Full Text] [PDF]

				O. R. Segal, A. W.C. Chow, V. Markides, D. W. Davies, and N. S. Peters Characterization of the Effects of Single Ventricular Extrastimuli on Endocardial Activation in Human Infarct-Related Ventricular Tachycardia J. Am. Coll. Cardiol., March 27, 2007; 49(12): 1315 - 1323. [Abstract] [Full Text] [PDF]

				F. Bogun, E. Good, S. Reich, D. Elmouchi, P. Igic, K. Lemola, D. Tschopp, K. Jongnarangsin, H. Oral, A. Chugh, et al. Isolated Potentials During Sinus Rhythm and Pace-Mapping Within Scars as Guides for Ablation of Post-Infarction Ventricular Tachycardia J. Am. Coll. Cardiol., May 16, 2006; 47(10): 2013 - 2019. [Abstract] [Full Text] [PDF]

				V. S. Chauhan, E. Downar, K. Nanthakumar, J. D. Parker, H. J. Ross, W. Chan, and P. Picton Increased ventricular repolarization heterogeneity in patients with ventricular arrhythmia vulnerability and cardiomyopathy: a human in vivo study Am J Physiol Heart Circ Physiol, January 1, 2006; 290(1): H79 - H86. [Abstract] [Full Text] [PDF]

				L. L. Mickleborough Surgical Treatment of Ventricular Arrhythmias Card. Surg. Adult, January 1, 2003; 2(2003): 1287 - 1292. [Full Text]

				P. Della Bella, A. Pappalardo, S. Riva, C. Tondo, G. Fassini, and N. Trevisi Non-contact mapping to guide catheter ablation of untolerated ventricular tachycardia Eur. Heart J., May 1, 2002; 23(9): 742 - 752. [Abstract] [Full Text] [PDF]

				F. H Samie and J. Jalife Mechanisms underlying ventricular tachycardia and its transition to ventricular fibrillation in the structurally normal heart Cardiovasc Res, May 1, 2001; 50(2): 242 - 250. [Abstract] [Full Text] [PDF]

				H. Guo, S. Hecker, S. Levy, and B. Olshansky Ventricular tachycardia with QRS configuration similar to that in sinus rhythm and a myocardial origin: differential diagnosis with bundle branch reentry Europace, January 1, 2001; 3(2): 115 - 123. [Abstract] [PDF]

				S Furniss, R Anil-Kumar, J P Bourke, R Behulova, and E Simeonidou Radiofrequency ablation of haemodynamically unstable ventricular tachycardia after myocardial infarction Heart, December 1, 2000; 84(6): 648 - 652. [Abstract] [Full Text]

				M. E. Josephson Epicardial approach to the ablation of ventricular tachycardia in coronary artery disease: an alternative or ancillary approach J. Am. Coll. Cardiol., May 1, 2000; 35(6): 1450 - 1452. [Full Text] [PDF]

				S S FURNISS and R W F CAMPBELL Ventricular tachycardia: is it a burning issue? Heart, June 1, 1999; 81(6): 567 - 569. [Full Text]

				J. N. Weiss, A. Garfinkel, H. S. Karagueuzian, Z. Qu, and P.-S. Chen Chaos and the Transition to Ventricular Fibrillation : A New Approach to Antiarrhythmic Drug Evaluation Circulation, June 1, 1999; 99(21): 2819 - 2826. [Abstract] [Full Text] [PDF]

				K. Haberl and M. Allessie Differential Effects of a Segment of Slow Conduction on Reentrant Ventricular Tachycardia in the Rabbit Heart Circulation, February 23, 1999; 99(7): 949 - 962. [Abstract] [Full Text] [PDF]

				M. Zabel, T. Klingenheben, M. R. Franz, and S. H. Hohnloser Assessment of QT Dispersion for Prediction of Mortality or Arrhythmic Events After Myocardial Infarction : Results of a Prospective, Long-term Follow-up Study Circulation, June 30, 1998; 97(25): 2543 - 2550. [Abstract] [Full Text] [PDF]

				M. Eldar, A. P. Fitzpatrick, D. Ohad, M. F. Smith, S. Hsu, J. G. Whayne, Z. Vered, Z. Rotstein, T. Kordis, D. K. Swanson, et al. Percutaneous Multielectrode Endocardial Mapping During Ventricular Tachycardia in the Swine Model Circulation, September 1, 1996; 94(5): 1125 - 1130. [Abstract] [Full Text]

				D. J. Wilber, D. E. Kopp, D. N. Glascock DO, C. A. Kinder, and J. G. Kall Catheter Ablation of the Mitral Isthmus for Ventricular Tachycardia Associated With Inferior Infarction Circulation, December 15, 1995; 92(12): 3481 - 3489. [Abstract] [Full Text]

				J. M. Miller, G. S. Tyson, W. C. Hargrove III, J. A. Vassallo, M. E. Rosenthal, and M. E. Josephson Effect of Subendocardial Resection on Sinus Rhythm Endocardial Electrogram Abnormalities Circulation, May 1, 1995; 91(9): 2385 - 2391. [Abstract] [Full Text]

				R. A. Gray, J. Jalife, A. Panfilov, W. T. Baxter, C. Cabo, J. M. Davidenko, and A. M. Pertsov Nonstationary Vortexlike Reentrant Activity as a Mechanism of Polymorphic Ventricular Tachycardia in the Isolated Rabbit Heart Circulation, May 1, 1995; 91(9): 2454 - 2469. [Abstract] [Full Text]

				A. B. Wagshal, L. A. Pires, and S. K. Stephen Management of Cardiac Arrhythmias With Radiofrequency Catheter Ablation Arch Intern Med, January 23, 1995; 155(2): 137 - 147. [Abstract] [PDF]

				J. N. Weiss, K. Nademanee, W. G. Stevenson, and B. Singh Ventricular Arrhythmias in Ischemic Heart Disease Ann Intern Med, May 1, 1991; 114(9): 784 - 797. [Abstract] [PDF]