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Recognition of far-field electrograms during entrainment mapping of ventricular tachycardia

^a Cardiovascular Division, Department of Internal Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA

View larger version (32K): [in a new window]   Figure 1 Distinguishing far-field (FFP) and local potentials (LP) from analysis of entrainment (A) or the effect of radiofrequency ablation (B) are shown. In both panels ventricular tachycardia with a cycle length of 550 ms is present. From the top are surface electrocardiogram leads (I, aVF, V1, V6) and bipolar intracardiac electrograms recorded from the distal (Abl D) and proximal (Abl P) electrode pairs of the ablation catheter. Potentials are labeled 1, 2, and 3. Entrainment indicates potential 1 is an FFP. Radiofrequency ablation reduces the amplitude of potential 3 (B) indicating it is an LP, but does not affect potentials 1 and 2. See text for discussion. Time lines are 20 ms.

View larger version (38K): [in a new window]   Figure 2 Entrainment of ventricular tachycardia (VT) at a site with a double potential is shown. From the top are surface electrocardiogram leads (I, II, III), and bipolar intracardiac electrograms recorded from the distal (Abl D) and proximal (Abl P) electrode pairs of the ablation catheter; VT with a cycle length of 410 ms is present. Pacing at a cycle length of 390 ms entrains tachycardia without altering the QRS morphology (concealed fusion). Recordings at the pacing site show two potentials marked with an asterisk and arrowhead, respectively. During entrainment, the potential marked with the asterisk is present and accelerated to the pacing cycle length. The tissue generating this potential is not directly depolarized by the pacing stimulus and is, therefore, designated as far-field (FFP). The local potential (indicated by an arrowhead) is not discernable during pacing, consistent with direct capture, but reappears after the last stimulus. The true post-pacing interval (PPI) (TPPI), which is measured from the last stimulus to the local potential, is 425 ms. The false PPI (FPPI), which is measured from the last stimulus to the FFP, is 210 ms, or, if measured to the next FFP electrogram one cycle later, would be 620 ms. Radiofrequency ablation at this site abolished tachycardia. Time lines are 20 ms.

View larger version (33K): [in a new window]   Figure 3 The relation between false post-pacing interval (FPPI) determined from the far-field potential (FFP), and the true post-pacing interval (TPPI) for classifying circuit sites are shown. A circuit site is defined as having a TPPI-ventricular tachycardia cycle length difference of 30 ms (14). At 12% of the sites where a TPPI >30 ms indicated a bystander site, measurement to the FFP yielded a false PPI-tachycardia cycle length difference 30 ms that falsely classified the site as in the reentry circuit. At 44% of sites where the TPPI-tachycardia cycle length difference 30 ms classified the site as in the circuit, the FPPI was >30 ms, classifying the site as remote from the circuit. At 44% of the sites, both FPPI and TPPI classified the site as a bystander.