- ▪In patients with hemodynamically tolerated ventricular tachycardia, activation and entrainment mapping remain the gold standard for the identification of the critical parts of the circuits.
- ▪The high incidence of non–hemodynamically tolerated ventricular tachycardia has led to the development of substrate mapping techniques during sinus rhythm.
- ▪Multielectrode mapping using small and closely spaced electrodes allows us to delineate late potentials and local abnormal ventricular activities in low-voltage regions related with ventricular tachycardia re-entry.
- ▪Mapping strategies incorporating ventricular extrastimulation have been shown to increase the accuracy of substrate mapping for identifying ventricular tachycardia isthmus sites.
|Model||Manufacturer||Electrodes||Tip electrode size (mm)||Ring electrode size (mm)||Spacing (edge-to edge) (mm)||Spacing recorded (center to center) (mm)||Advantages and disadvantages|
|ThermoCool ST||Biosense Webster||4||3.5||1||1–6–2||3.25||Inability to differentiate near-field from far-field signals in scar and low-voltage regions|
|ThermoCool/SF||Biosense Webster||4||3.5||1||2–5–2||4.25||Inability to differentiate near-field from far-field signals in scar and low-voltage regions|
|FlexAbility||Abbott||4||4||1||1–4–1||3.50||Inability to differentiate near-field from far-field signals in scar and low-voltage regions|
|TactiCath||Abbott||4||3.5||1||2–5–2||4.25||Inability to differentiate near-field from far-field signals in scar and low-voltage regions|
|MiFi||Boston Scientific||4||4.5||1||1.5||2.50||Microelectrode cofiguratiom: radial on the distal tip|
|QDOT||Biosense Webster||4||3.5||0.33||1.5||1.5||Microelectrode cofiguratiom: circumferential on the distal tip|
|PENTARAY||Biosense Webster||20||—||1||2–6–2||(1) Higher mapping density and better substrate definition; (2) higher detection of LAVAs and voltage channels; (3) higher accuracy in identifying and delineating near-field component (LAVAs) and differentiating from far-field signals|
|IntellaMap Orion (RHYTHMIA mapping system)||Boston Scientific||64||—||0.9 × 0.45||1.6||2.50||Lumipoint algorithm signal using information across the whole mapping window, rather than only the peak signal; these features may enhance human interpretation of the electrogram signals during a case, particularly in which the circuit lies in partial scar with low-amplitude near-field signals|
|HD Grid (Abbott, Ensite-X)||Abbott||16||2||1||3||3.00 (along, across), 4.23 (diagonal)||HD-wave solution, omnipolar mapping technology|
Mapping Systems, Tools, and Challenges
Multielectrode Mapping Technology
The Value of EGM Morphology to Identify the Active Circuit
Conventional Methods to Identify Critical Regions
Pace Mapping to Identify the Critical VT Isthmus
- Fernández-Armenta J.
- Andreu D.
- Penela D.
- Trucco E.
- Cipolletta L.
- Arbelo E.
- Berne P.
- María Tolosana J.
- Pedrote A.
- Brugada J.
- Mont L.
- Berruezo A.
Functionally Guided Substrate Modification
Isochronal Late Activation Mapping
Differentiating Functional From Anatomical Block
Functional Extrastimuli Mapping
|Type of mapping||Etiology||Extrastimulus||Location of decremental properties||Ablation target||Acute clinical outcomes||Long-term follow-up|
|70 consecutive patients with ICM and DCM||1 extrastimulus VERP or 250 ms||LAVAs occupied 39 ± 32 cm2 of the 245 ± 174 cm2 of the LV surface (16%)|
Endocardial and epicardial LAVAs in 63 (90%) of 70 patients and 17 (81%) of 21 patients, respectively
|LAVA elimination||Little agreement between noninducibility of VT and LAVA elimination as procedural end points (k statistic 0.038 ± 0.097; P = 0.70)||Median 22 mo: reduction in VT recurrence or death (hazard ratio 0.49; 95% confidence interval 0.26–0.95; P = .035)|
|33 patients with ICM, nonischemic cardiomyopathy, and ARVD, 10 consecutive patients 10 consecutive patients ILAM-guided VT ablation||N/A||N/A||ILAM (10 patients)||Complete noninducibility in 40%, elimination of the clinical VT in 50%||6 ± 1 mo: 80% of the patients free of VT recurrence (50% free of antiarrhythmics|
|20 patients with ICM||1 extrastimulus, VERP +20 ms||In 50% of DEEP areas colocalized with the diastolic isthmus||Only DEEP||High noninducibility (80%)||6 mo: mean VT burden reduced to 0 from 11 preprocedure|
|37 patients with ICM, ARVD, DCM or scar in MRI||2–3 extrastimuli, VERP +60 ms VERP +40–20 ms, and VERP +10–20 ms||Majority (53%) in border zone areas, 18.2% within dense scar regions, 28.8% in normal-voltage tissue surrounding the scar area||Both LPs and HSC, and compared with historical cohort of LP only||Low inducibility (24.3% vs 48.7%)||6 mo: VT-free survival: 13.5% vs 20%|
|RV SP single extra pacing|
|30 patients with ICM||Single sensed extrastimuli +20 ms VERP every fifth beat||LP 9% of the total scar in SR and 38% during SP||Ablation to sites of best entrainment/pace map and all LP and LAVA substrates defined by the Barts SP||29 (97%) of 30 patients noninducibile||12 mo: 90% free from ATP or ICD shocks|
|60 patients with ICM||One extrastimuli, VERP +50 ms||37% of EDPs in areas with normal BV, 91 within the scar and 71% in a region of nontransmural scar based on MRI||Only EDP elimination||67% noninducibility, 23% induced VTs were successfully abolished based on activation, entrainment, or pace mapping, 10% inducibility||16 mo: low recurrence (22%)|
Effect of Activation Wavefront on EGM Characteristics
Clinical Implications of New Technologies: Future Perspectives
- Priori S.G.
- Blomström-Lundqvist C.
- Mazzanti A.
- et al.
- Al-Khatib S.M.
- Stevenson W.G.
- Ackerman M.J.
- et al.
Appendix. Supplementary data
- Limitations and pitfalls of substrate mapping for ventricular tachycardia.J Am Coll Cardiol EP. 2021; 7: 542-560
- Exploring postinfarction reentrant ventricular tachycardia with entrainment mapping.J Am Coll Cardiol. 1997; 29: 1180-1189
- Complete electroanatomic imaging of the diastolic pathway is associated with improved freedom from ventricular tachycardia recurrence.Circ Arrythm Electrophysiol. 2020; 13e008651
- Ablation of stable VTs versus substrate ablation in ischemic cardiomyopathy: the VISTA randomized multicenter trial.J Am Coll Cardiol 29. 2015; 66: 2872-2882
- Linear ablation lesions for control of unmappable ventricular tachycardia in patients with ischemic and nonischemic cardiomyopathy.Circulation. 2000; 101: 1288-1296
- Ablation of electrograms with an isolated, delayed component as treatment of unmappable monomorphic ventricular tachycardias in patients with structural heart disease.J Am Coll Cardiol. 2003; 41: 81-92
- Substrate mapping and ablation for ventricular tachycardia: the LAVA approach.J Cardiovasc Electrophysiol. 2015; 26: 464-471
- Late potentials abolition as an additional technique for reduction of arrhythmia recurrence in scar related ventricular tachycardia ablation.J Cardiovasc Electrophysiol. 2012; 23: 621-627
- The challenge of optimising ablation lesions in catheter ablation of ventricular tachycardia.J Arrhythm. 2021; 37: 140-147
- Substrate-based ablation versus ablation guided by activation and entrainment mapping for ventricular tachycardia: a systematic review and meta-analysis.J Cardiovasc Electrophysiol. 2016; 27: 1437-1447
- Catheter ablation of stable ventricular tachycardia before defibrillator implantation in patients with coronary heart disease (VTACH): a multicentre randomised controlled trial.Lancet. 2010; 375: 31-40
- Ventricular tachycardia ablation versus escalation of antiarrhythmic drugs.N Engl J Med. 2016; 375: 111-121
- Endo-epicardial homogenization of the scar versus limited substrate ablation for the treatment of electrical storms in patients with ischemic cardiomyopathy.J Am Coll Cardiol. 2012; 60: 132-141
- Core isolation of critical arrhythmia elements for treatment of multiple scar-based ventricular tachycardias.Circ Arrythm Electrophysiol. 2015; 8: 353-361
- Prolonged action potential duration and dynamic transmural action potential duration heterogeneity underlie vulnerability to ventricular tachycardia in patients undergoing ventricular tachycardia ablation.Europace. 2019; 21: 616-625
- Elimination of local abnormal ventricular activities: a new end point for substrate modification in patients with scar-related ventricular tachycardia.Circulation. 2012; 125: 2184-2196
- High-resolution mapping of postinfarction reentrant ventricular tachycardia: electrophysiological characterization of the circuit.Circulation. 2016; 134: 314-327
- Multisize electrodes for substrate identification in ischemic cardiomyopathy: validation by integration of whole heart histology.J Am Coll Cardiol EP. 2019; 5: 1130-1140
- Substrate mapping for unstable ventricular tachycardia.Heart Rhythm. 2016; 13: 569-583
- Response to pacing at sites of isolated diastolic potentials during ventricular tachycardia in patients with previous myocardial infarction.J Am Coll Cardiol. 1997; 30: 505-513
- Extended endocardial resection for the treatment of ventricular tachycardia and ventricular fibrillation.Ann Thorac Surg. 1982; 34: 538-552
- Relationship between successful ablation sites and the scar border zone defined by substrate mapping for ventricular tachycardia postmyocardial infarction.J Cardiovasc Electrophysiol. 2005; 16: 465-471
- Characteristics of scar-related ventricular tachycardia circuits using ultra-high-density mapping: a multi-center study.Circ Arrhythm Electrophysiol. 2018; 11e006569
- Effect of activation wavefront on electrogram characteristics during ventricular tachycardia ablation.Circ Arrhythm Electrophysiol. 2019; 12e007293
- Long-term outcome of substrate modification in ablation of post-myocardial infarction ventricular tachycardia.Circ Arrhythm Electrophysiol. 2018; 11e005635
- Impact of electrode type on mapping of scar-related VT.J Cardiovasc Electrophysiol. 2015; 26: 1213-1223
- Use of novel electrogram "Lumipoint" algorithm to detect critical isthmus and abnormal potentials for ablation in ventricular tachycardia.J Am Coll Cardiol EP. 2019; 5: 470-479
- Grid mapping catheter for ventricular tachycardia ablation.Circ Arrhythm Electrophysiol. 2019; 12e007500
- Application of ripple mapping to visualize slow conduction channels within the infarct-related left ventricular scar.Circ Arrhythm Electrophysiol. 2015; 8: 76-86
- Post-infarct ventricular tachycardia substrate: characterisation and ablation of conduction channels using Ripple mapping.Heart Rhythm. 2021; 18: 1682-1690
- Postinfarct ventricular tachycardia substrate: Characterization and ablation of conduction channels using ripple mapping.Heart Rhythm. 2021; 18: 1682-1690
- Electrophysiologic and anatomic basis for fractionated electrograms recorded from healed myocardial infarcts.Circulation. 1985; 72: 596-611
- Disturbed connexin43 gap junction distribution correlates with the location of reentrant circuits in the epicardial border zone of healing canine infarcts that cause ventricular tachycardia.Circulation. 1997; 95: 988-996
- Are wall thickness channels defined by computed tomography predictive of isthmuses of postinfarction ventricular tachycardia?.Heart Rhythm. 2019; 16: 1661-1668
- Structure and function of the ventricular tachycardia isthmus.Heart Rhythm. 2022; 19: 137-153
- Extracellular potentials related to intracellular action potentials during impulse conduction in anisotropic canine cardiac muscle.Circ Res. 1979; 45: 188-204
- Slow conduction in the infarcted human heart. 'Zigzag' course of activation.Circulation. 1993; 88: 915-926
- High-density characterization of the ventricular electrical substrate during sinus rhythm in post-myocardial infarction patients.J Am Coll Cardiol EP. 2020; 6: 799-811
- Identification of the ventricular tachycardia isthmus after infarction by pace mapping.Circulation. 2004; 110: 652-659
- Catheter ablation for ventricular tachycardia.Circulation. 2007; 115: 2750-2760
- Localizing the critical isthmus of postinfarct ventricular tachycardia: the value of pace-mapping during sinus rhythm.Heart Rhythm. 2014; 11: 175-181
- Pace mapping to localize the critical isthmus of ventricular tachycardia.Card Electrophysiol Clin. 2017; 9: 71-80
- Tachycardia-related channel in the scar tissue in patients with sustained monomorphic ventricular tachycardias: influence of the voltage scar definition.Circulation. 2004; 110: 2568-2574
- Combined endocardial and epicardial catheter ablation in arrhythmogenic right ventricular dysplasia incorporating scar dechanneling technique.Circ Arrhythm Electrophysiol. 2012; 5: 111-121
- Sinus rhythm detection of conducting channels and ventricular tachycardia isthmus in arrhythmogenic right ventricular cardiomyopathy.Heart Rhythm. 2014; 11: 747-754
- Scar dechanneling: new method for scar-related left ventricular tachycardia substrate ablation.Circ Arrhythm Electrophysiol. 2015; 8: 326-336
- Relationship between sinus rhythm late activation zones and critical sites for scar-related ventricular tachycardia: systematic analysis of isochronal late activation mapping.Circ Arrhythm Electrophysiol. 2015; 8: 390-399
- Impact of local ablation on interconnected channels within ventricular scar: mechanistic implications for substrate modification.Circ Arrythm Electrophysiol. 2013; 6: 1131-1138
- Ventricular mapping during atrial and ventricular pacing. Relationship of multipotential electrograms to ventricular tachycardia reentry circuits after myocardial infarction.Eur Heart J. 2002; 23: 1131-1138
- Canine ventricular arrhythmias in the late myocardial infarction period. 8. Epicardial mapping of reentrant circuits.Circ Res. 1981; 49: 255-265
- Slow uniform electrical activation during sinus rhythm is an indicator of reentrant VT isthmus location and orientation in an experimental model of myocardial infarction.Comput Methods Programs Biomed. 2020; 196: 105666
- Quantification of spatial inhomogeneity in conduction and initiation of reentrant atrial arrhythmias.Am J Physiol. 1990; 259: H1254-H1263
- Reentrant ventricular arrhythmias in the late myocardial infarction period: mechanism by which a short-long-short cardiac sequence facilitates the induction of reentry.Circulation. 1991; 83: 268-278
- Mechanisms that initiate ventricular tachycardia in the infarcted human heart.Heart Rhythm. 2010; 7: 57-64
- Formation of functional conduction block during the onset of reentrant ventricular tachycardia.Circ Arrythm Electrophysiol. 2016; 9e004462
- Multisite conduction block in the epicardial substrate of Brugada syndrome.Heart Rhythm. 2022; 19: 417-426
- Decrement evoked potential mapping: basis of a mechanistic strategy for ventricular tachycardia ablation.Circ Arrythm Electrophysiol. 2015; 8: 1433-1442
- Targeting the hidden substrate unmasked by right ventricular extrastimulation improves ventricular tachycardia ablation outcome after myocardial infarction.J Am Coll Cardiol EP. 2018; 4: 316-327
- Multicenter study of ischemic ventricular tachycardia ablation with decrement-evoked potential (DEEP) mapping with extra stimulus.J Am Coll Cardiol EP. 2018; 4: 307-315
- Multicenter study of dynamic high-density functional substrate mapping improves identification of substrate targets for ischemic ventricular tachycardia ablation.J Am Coll Cardiol EP. 2020; 6: 1783-1793
- Elucidation of hidden slow conduction by double ventricular extrastimuli: a method for further arrhythmic substrate identification in ventricular tachycardia ablation procedures.Europace. 2018; 20: 337-346
- Directional influences of ventricular activation on myocardial scar characterization: voltage mapping with multiple wavefronts during ventricular tachycardia ablation.Circ Arrythm Electrophysiol. 2016; 9e004155
- High-resolution mapping of ventricular scar: comparison between single and multielectrode catheters.Circ Arrhythm Electrophysiol. 2016; 9e003841
- Impact of changing activation sequence on bipolar electrogram amplitude for voltage mapping of left ventricular infarcts causing ventricular tachycardia.J Interv Card Electrophysiol. 2005; 12: 137-141
- Substrate ablation vs antiarrhythmic drug therapy for symptomatic ventricular tachycardia.J Am Coll Cardiol. 2022; 79: 1441-1453
- 2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: the Task Force for the Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC). Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC).Eur Heart J. 2015; 36: 2793-2867
- 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.Heart Rhythm. 2018; 15: e73-e189
- First-line catheter ablation of monomorphic ventricular tachycardia in cardiomyopathy concurrent with defibrillator implantation: the PAUSE-SCD randomized trial.Circulation. 2022; 145: 1839-1849
- Enhanced ventricular tachycardia substrate resolution with a novel omnipolar high-density mapping catheter: the omnimapping study.J Interv Card Electrophysiol. 2020; 58: 355-362
- Catheter ablation of scar-based ventricular tachycardia: Relationship of procedure duration to outcomes and hospital mortality.Heart Rhythm. 2015; 12: 86-94
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