Electroanatomic Substrate and Ablation Outcome for Suspected Epicardial Ventricular Tachycardia in Left Ventricular Nonischemic Cardiomyopathy
Oscar Cano, MD*, ,
Mathew Hutchinson, MD*,
David Lin, MD*,
Fermin Garcia, MD*,
Erica Zado, PA-C*,
Rupa Bala, MD*,
Michael Riley, MD, PhD*,
Joshua Cooper, MD*,
Sanjay Dixit, MD*,
Edward Gerstenfeld, MD*,
David Callans, MD* and
Francis E. Marchlinski, MD*,*
* Electrophysiology Section, Cardiovascular Division, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
Universitat Autònoma de Barcelona, Barcelona, Spain
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Figure 1 Epicardial Voltage Map of a Patient With a Structurally Normal Heart and Idiopathic Ventricular Tachycardia
Left anterior oblique (left) and right anterior oblique (right) views showing low-voltage areas (<1.0 mV) corresponding to normal distribution of epicardial fat around the left anterior descending coronary artery (LAD), right coronary artery (RCA), and atrioventricular (AV) groove. These areas were excluded to calculate the normal reference values of epicardial bipolar signals by using an imaginary 1.5-cm width line (white arrow line) along the course of the coronary vessels and the AV groove defined by cine-angiography. An electrogram recorded from the AV groove low-voltage area is displayed in the middle of the figure. Note that low voltages in the AV groove are not associated with abnormal electrogram morphologic characteristics.
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Figure 2 Epicardial and Endocardial LV Voltage Maps From 2 Patients With NICM and Epicardial VT
Epicardial (A, C) and endocardial left ventricular (LV) (B, D) voltage maps from 2 patients with nonischemic cardiomyopathy (NICM) and epicardial ventricular tachycardia (VT). Color range represents voltage amplitude. Purple-colored areas represent normal epicardium (>1.0 mV) and endocardium (>1.5 mV), and dense scar is depicted in red (<0.5 mV). (A) Posteroanterior modified view of the epicardial voltage map showing a low-voltage zone in the basal and mid-lateral LV. (B) Endocardial LV voltage map of the same patient showing a smaller low-voltage area in the lateral wall with no dense scar (<0.5 mV). Left lateral modified view of the epicardial (C) and endocardial LV map (D) of another patient showing scar distributed in proximity to the mitral annulus over the basal lateral LV. In both cases abnormal electrograms were recorded in the low-voltage zones (>80 ms, split, and late potentials [LP]).
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Figure 3 Epicardial to Endocardial Distance Measurements
Clipped planes in the left anterior oblique (left) and right anterior oblique views (right). White arrows show the endocardial (ENDO) to epicardial (EPI) distance in the lateral and the anterior wall, respectively, assessed with electroanatomic mapping. LV = left ventricular.
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Figure 4 Epicardial and Endocardial Area of Confluent Low Voltage in the 18 Patients With Epicardial VT
Epicardial (Epi) (red) and endocardial (Endo) (blue) area of confluent low voltage in the 18 patients with epicardial ventricular tachycardia (VT) identified on the basis of entrainment mapping, pacemapping, and successful elimination of VT with epicardial ablation.
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