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CLINICAL RESEARCH: HEART RHYTHM DISORDER

Endocardial and Epicardial Repolarization Alternans in Human Cardiomyopathy

Evidence for Spatiotemporal Heterogeneity and Correlation With Body Surface T-Wave Alternans

Division of Cardiology, University Health Network and Mount Sinai Hospital, Toronto, Canada.

Manuscript received May 23, 2006; revised manuscript received July 24, 2006, accepted August 14, 2006.

^_* Reprint requests and correspondence: Dr. Vijay S. Chauhan, PMCC 3-503, Toronto General Hospital, 150 Gerrard Street West, Toronto, Ontario, M5G 2C4 Canada. (Email: vijay.chauhan{at}uhn.on.ca).

OBJECTIVES: The aim of this study was to define the spatiotemporal distribution of intracardiac alternans and its relationship to body surface alternans in humans.

BACKGROUND: Spatial heterogeneity of alternans exists in the animal heart owing to nonuniform calcium cycling and restitution kinetics. Patients with cardiomyopathy manifest similar myocardial substrate, which might influence the distribution of intracardiac alternans and its projection onto the body surface.

METHODS: Repolarization alternans was simultaneously measured from unipolar electrograms in the right ventricular endocardium, left ventricular (LV) epicardium, and the surface electrocardiogram in patients with cardiomyopathy (n = 14, LV ejection fraction 29 ± 2%) during atrial pacing at cycle length (CL) 800, 600, and 500 ms. Alternans was determined from the entire JT interval as well as the early, mid, and late JT interval with spectral analysis.

RESULTS: Alternans was not uniformly distributed within the heart, with alternating and nonalternating myocardial segments lying adjacent to one another. A greater number of epicardial sites exhibited alternans than endocardial sites at CL 600 ms. Temporal heterogeneity in alternans was present along the JT interval, and apical segments had proportionately less alternans in the late JT interval than mid or basal segments, resulting in apicobasal alternans heterogeneity in late JT interval. Discordant alternans was seen in 5 patients confined to the epicardium. Patients with surface alternans had a greater proportion of intracardiac sites with alternans when compared with those patients without surface alternans.

CONCLUSIONS: Spatiotemporal heterogeneity and discordant alternans are evident in patients with cardiomyopathy. Greater spatial distribution of intracardiac alternans is associated with measurable body surface alternans.

Abbreviations and Acronyms   CL = cycle length   ECG = electrocardiogram   EF = ejection fraction   H = high voltage (intracardiac recording of beat-to-beat fluctuations)   L = low voltage (intracardiac recording of beat-to-beat fluctuations)   LV = left ventricle/ventricular   RV = right ventricle/ventricular   TWA = T-wave alternans

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