Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.).
Abbott, Abbott Park, IL (M.R., N.A.S.).
Circulation. 2019 Oct 22;140(17):1383-1397. doi: 10.1161/CIRCULATIONAHA.119.042423. Epub 2019 Sep 19.
Accurate and expedited identification of scar regions most prone to reentry is needed to guide ventricular tachycardia (VT) ablation. We aimed to prospectively assess outcomes of VT ablation guided primarily by the targeting of deceleration zones (DZ) identified by propagational analysis of ventricular activation during sinus rhythm.
Patients with scar-related VT were prospectively enrolled in the University of Chicago VT Ablation Registry between 2016 and 2018. Isochronal late activation maps annotated to the latest local electrogram deflection were created with high-density multielectrode mapping catheters. Targeted ablation of DZ (>3 isochrones within 1cm radius) was performed, prioritizing later activated regions with maximal isochronal crowding. When possible, activation mapping of VT was performed, and successful ablation sites were compared with DZ locations for mechanistic correlation. Patients were prospectively followed for VT recurrence and mortality.
One hundred twenty patients (median age 65 years [59-71], 15% female, 50% nonischemic, median ejection fraction 31%) underwent 144 ablation procedures for scar-related VT. 57% of patients had previous ablation and epicardial access was employed in 59% of cases. High-density mapping during baseline rhythm was performed (2518 points [1615-3752] endocardial, 5049±2580 points epicardial) and identified an average of 2±1 DZ, which colocalized to successful termination sites in 95% of cases. The median total radiofrequency application duration was 29 min (21-38 min) to target DZ, representing ablation of 18% of the low-voltage area. At 12±10 months, 70% freedom from VT recurrence (80% in ischemic cardiomyopathy and 63% in nonischemic cardiomyopathy) was achieved. The overall survival rate was 87%.
A novel voltage-independent high-density mapping display can identify the functional substrate for VT during sinus rhythm and guide targeted ablation, obviating the need for extensive radiofrequency delivery. Regions with isochronal crowding during the baseline rhythm were predictive of VT termination sites, providing mechanistic evidence that deceleration zones are highly arrhythmogenic, functioning as niduses for reentry.
为了指导室性心动过速（VT）消融，需要准确快速地识别最容易再进入的疤痕区域。我们旨在前瞻性评估主要通过窦性心律时心室激动传播分析识别的减速区（DZ）靶向指导的 VT 消融的结果。
2016 年至 2018 年期间，前瞻性地将与疤痕相关的 VT 患者纳入芝加哥大学 VT 消融登记处。使用高密度多电极标测导管创建标注最新局部电图偏转的等时晚期激活图。对 DZ（1cm 半径内>3 个等时线）进行靶向消融，优先消融最大等时拥挤的晚期激活区域。如果可能，对 VT 的激动标测，并比较消融部位与 DZ 位置的机制相关性。前瞻性随访患者 VT 复发和死亡率。
120 例患者（中位年龄 65 岁[59-71]，15%为女性，50%非缺血性，中位射血分数 31%）接受了 144 次疤痕相关 VT 消融。57%的患者曾接受过消融治疗，59%的患者进行了心外膜入路。在静息期进行高密度标测（心内膜 2518 个点[1615-3752]，心外膜 5049±2580 个点），平均识别出 2±1 个 DZ，其中 95%的 DZ 与成功终止部位重合。靶向 DZ 的总射频应用时间中位数为 29 分钟（21-38 分钟），消融占低电压区域的 18%。12±10 个月时，70%无 VT 复发（缺血性心肌病为 80%，非缺血性心肌病为 63%）。总的存活率为 87%。
一种新的电压无关的高密度标测显示可以识别窦性心律时 VT 的功能底物，并指导靶向消融，避免了广泛的射频输送。静息期等时拥挤的区域与 VT 终止部位相关，提供了机制证据，表明减速区具有高度致心律失常性，作为折返的核。
