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Detailed endocardial mapping accurately predicts the transmural extent of myocardial infarction

Tamir Wolf, PhD^*, Lior Gepstein, MD, PhD^*, Uzi Dror, BSc^*, Gal Hayam, BSc^*, Rona Shofti, DVM^*, Asaph Zaretzky, DVM^*, Gideon Uretzky, MD, Uri Oron, PhD and Shlomo A. Ben-Haim, MD, DSc^*

^* Cardiovascular System Laboratory, The Bruce Rappaport Faculty of Medicine, Carmel Medical Center, Technion-Israel Institute of Technology, Haifa, Israel
Department of Cardiothoracic Surgery, Carmel Medical Center, Technion-Israel Institute of Technology, Haifa, Israel
Department of Zoology, Tel Aviv University, Tel Aviv, Israel

View larger version (184K): [in a new window]   Figure 1 Morphometric analysis of the extent of infarct transmurality. After scanning the section, two radii (black) were drawn from the center of mass (LV chamber) to the maximal circumferential extent of the infarct. The total transmural and infarct areas are shown enveloped by the blue and green lines, respectively. Mean transmurality extent (% transmurality) was defined as (infarct area/total transmurality area) x 100.

View larger version (69K): [in a new window]   Figure 2 Typical electromechanical maps of infarcted myocardium. Red indicates regions of abnormal electromechanical activity, whereas a region in which function remains unhindered is color-coded blue/purple. (A) Local shortening (red: abnormally contracting regions with values <4%; purple: normal contractile function >12%). (B) Unipolar electrogram amplitude (red: amplitude <8 mV; purple: >12 mV). (C) Slew rate (red: <0.8 mV/ms; purple: >2 mV/ms). (D) Endocardial impedance (red: <120 ; purple: >160 ). The two red tags indicate ablation points, which were used for correct alignment of the map and the left ventricle prior to the transmurality analysis. Reconstructed maps are shown in a left anterior oblique projection, and the white head indicates the left ventricular base).

View larger version (66K): [in a new window]   Figure 3 Pathological sections of infarcted hearts of various transmural extensions and their respective reconstructions (viewed from a left anterior oblique projection). The superimposed colors in the reconstruction depict bipolar electrogram amplitude (BEA) (purple indicating values >6.1 mV; red indicating values <2.1 mV). Beneath the reconstructed sections are typical recordings of unipolar electrogram and derivatives, unipolar electrogram amplitude (UEA) and slew rate (SR) and bipolar electrogram and amplitude from selected points at the core of the infarcted region (the distance between two white marks on the electrogram time scale denotes a 50-ms period). (A) Section obtained from the apical third of a left ventricle, in which subendocardial infarction (mean transmurality = 23%) is present; (B) Infarction of intermediate transmurality (mean transmurality = 44%). This section was obtained from the basal third of the left ventricle. (C) An example of a section obtained from the midventricle that demonstrates a transmural infarct (mean transmurality = 84%). The corresponding endocardial impedance values are 186.4 (A), 172.8 (B), and 144.3 (C).

View larger version (10K): [in a new window]   Figure 4 Regression plot describing the correlation between average bipolar electrogram amplitude (BEA) values per section and the extent of infarct transmurality. An exponential fit (BEA = 2.811 x e–0.0184 x infarct transmurality extent) demonstrated the highest correlation (R = 0.72). The symbols indicate infarct transmurality subgroups: solid squares = <30%, solid triangles = 31% to 60%, and solid circles = 61% to 100%.