Cardiology Research, ISSN 1923-2829 print, 1923-2837 online, Open Access
Article copyright, the authors; Journal compilation copyright, Cardiol Res and Elmer Press Inc
Journal website https://www.cardiologyres.org

Original Article

Volume 8, Number 6, December 2017, pages 293-303


High-Density Mapping in Ventricular Tachycardia Ablation: A PentaRay® Study

Figures

Figure 1.
Figure 1. (a, b) Right anterior oblique (RAO) view showing the steerable sheath (large curve Agilis™, SJM), and the 20-pole steerable catheter PentaRay® with 1 mm electrodes distributed over five soft, radiating spines (2-6-2 mm interelectrode spacing) entering the left ventricle by passing the mitral valve. (c-f) Fluoroscopy images in RAO and left anterior oblique (LAO) view showing the various 180° of unidirectional flexion of the PentaRay® with its soft and very flexible branches allowing reaching any region in the left ventricle.
Figure 2.
Figure 2. Boxplots of the procedure duration, mapping time, ablation time, and fluoroscopy time. We found a tendency to increased competence with the technology (P not significant), comparing phase 1 (the initial 10 cases) representing the learning curve, and phase 2 (the next 10 cases).
Figure 3.
Figure 3. Two electroanatomic map of a patient with non ischemic cardiomyopathy. Left lateral and right anterior oblique views of the epicardium and a part of the left ventricle are depicted. Substratemap of the pericardium obtained with the PentaRay® was set at 45% transparency, so that each recorded bipolar electrogram, its morphology and timing in relation to QRS complex could be related to the underlying tissue.
Figure 4.
Figure 4. Example of the accuracy of the PentaRay® mapping catheter identifying a channel in a patient with a prior anterior wall myocardial infarction. (a) CARTO®3-guided electroanatomic map (EAM) of the left ventricle: activation map left sided, in which the area with the latest activation appears in blue, and the voltage map right sided with identification of a large dense scar in the anterior wall; to the left the bipolar signals of LAVAs at the center showing the latest activities suggesting a channel identified by the PentaRay® (white line in the EAM). This channel yields from inside the dense scar into the border zone and was identified as ablation target. (b) At baseline, VT was successful induced and well tolerated (CL 330 ms). (c) During VT, in the border zone, prasystolic fractionated signals but not mid-diastolic potentials (gray arrow) were recorded with the PentaRay® and annotated on the EAM (white points and gray arrow). Mapping the dense scar, the channel was then found inside dense scar and also annotated on the EAM (EAM, arrow). (d) VT terminates under radiofrequency ablation (blue point in the maps); the first beat is a paced rhythm.

Tables

Table 1. Clinical Characteristics of PentaRay® Patients
 
VariableN = 26
CABG: coronary artery bypass graft; ICD: internal cardioverter defibrillator; NYHA: New York Heart Association; VT: ventricular tachycardia. Values are expressed as mean ± SD or n (%).
Age, years61.8 ± 10.1
Sex, males22 (84.6%)
Device25 (97.2%)
  Single chamber ICD15 (57.7%)
  Dual chamber ICD6 (23.1%)
  Cardiac resynchronization therapy with ICD4 (15.4%)
Ischemic cardiomyopathy18 (69.2%)
  Three-vessel disease and/or CABG12 (46.1%)
  Anterior wall/septal myocardial infarction13 (50.0%)
  Posterior/inferior wall myocardial infarction11 (42.3%)
  Lateral wall myocardial infarction2 (7.7%)
  Sustained VT and/or ICD shock8 (30.8%)
  Electrical storm2 (7.7%)
  Slow VT4 (15.4%)
Non-ischemic cardiomyopathy8 (30.8%)
  Sustained VT and/or ICD shock2 (7.7%)
  Electrical storm3 (11.5%)
Ejection fraction < 35%23 (88.4%)
Ejection fraction in mean, %28.2 ± 11.5
Atrial fibrillation10 (38.5%)
NYHA ≥ 314 (53.9%)
≥ 2 prior VT ablation13 (50%)
≥ 2 scars (patchy pattern and/or dens scar)15 (57.7%)
Hypertension23 (88.5%)
Diabetes11 (42.3%)
Hyperlipidemia22 (84.6%)
Smoking10 (38.5%)
Antiarrhythmic therapy22 (91.7%)
  Beta-blocker25 (96.2%)
  Amiodarone11 (42.3%)
  Sotalol1 (3.8%)

 

Table 2. Procedural Data of the PentaRay® Patients
 
VariableN = 26
ICM: ischemic cardiomyopathy; LV: left ventricle; NICM: non-ischemic cardiomyopathy; VT: ventricular tachycardia. Values are expressed as mean ± SD or n (%).
Total area LV in cm2311.7 ± 100.5
Number of VT ≥ 27 (26.9%)
VT cycle length in ms
  VT 1 cycle length in ms366.2 ± 90.5
  VT 2 cycle length in ms402.8 ± 114.1
≥ 1 scar in voltage map15 (57.6%)
  Ischemic cardiomyopathy9 (34.6%)
  Non-ischemic cardiomyopathy6 (23.1%)
LV approach
  Retrograd6 (23.1%)
  Transseptal24 (92.3%)
  Epicardial4 (15.4%)
Programmed ventricular stimulation pre-ablation24 (92.3%)
  Inducible VT17 (65.4%)
  ICM14 (53.9%)
  NICM3 (11.5%)
  Non-inducibility in programmed ventricular stimulation7 (26.9%)
Programmed ventricular stimulation post-ablation12 (46.2%)
Hemodynamic stability during VT9 (34.6%)
Hemodynamic instability during VT17 (65.4%)
Complication0 (0%)
Procedure success
  Complete12 (46.2%)
  Partial14 (53.9%)
  Failure0 (0%)
Entrainment maneuver3 (11.5%)
Procedure time, min (range 80 - 300 min)175.4 ± 52.0
Mapping time (range 15 - 160 min)55.6 ± 34.4
Ablation time (range 15 - 130 min)50.7 ± 30.1
Mapping points1,085.9 ± 726.1
Fluoroscopy time22.1 ± 13.7

 

Table 3. Follow-Up of the PentaRay® Patients
 
VariableN = 26
ICM: ischemic cardiomyopathy; LV: left ventricle; NICM: non-ischemic cardiomyopathy; VT: ventricular tachycardia. Values are expressed as mean ± SD or n (%).
Follow-up in months (range 1 - 33)14.7 ± 8.5
Lost to follow-up1 (3.8%)
Recurrence of VT
  None17 (65.4%)
  Non-sustained VT with amiodarone3 (11.5%)
  Sustained VT5 (19.2%)
Further ablation due to recurrences of VT5 (19.2%)
  Non-sustained VT with amiodarone after 3 months1 (3.8%)
  Sustained VT with amiodarone after 6 months4 (15.4%)
Death4 (15.4%)