Abstract
This study presents a novel non-invasive equivalent dipole layer (EDL) based inverse electrocardiography (iECG) technique which estimates both endocardial and epicardial ventricular activation sequences. We aimed to quantitatively compare our iECG approach with invasive electro-anatomical mapping (EAM) during sinus rhythm with the objective of enabling functional substrate imaging and sudden cardiac death risk stratification in patients with cardiomyopathy. Thirteen patients (77% males, 48 ± 20 years old) referred for endocardial and epicardial EAM underwent 67-electrode body surface potential mapping and CT imaging. The EDL-based iECG approach was improved by mimicking the effects of the His-Purkinje system on ventricular activation. EAM local activation timing (LAT) maps were compared with iECG-LAT maps using absolute differences and Pearson’s correlation coefficient, reported as mean ± standard deviation [95% confidence interval]. The correlation coefficient between iECG-LAT maps and EAM was 0.54 ± 0.19 [0.49–0.59] for epicardial activation, 0.50 ± 0.27 [0.41–0.58] for right ventricular endocardial activation and 0.44 ± 0.29 [0.32–0.56] for left ventricular endocardial activation. The absolute difference in timing between iECG maps and EAM was 17.4 ± 7.2 ms for epicardial maps, 19.5 ± 7.7 ms for right ventricular endocardial maps, 27.9 ± 8.7 ms for left ventricular endocardial maps. The absolute distance between right ventricular endocardial breakthrough sites was 30 ± 16 mm and 31 ± 17 mm for the left ventricle. The absolute distance for latest epicardial activation was median 12.8 [IQR: 2.9–29.3] mm. This first in-human quantitative comparison of iECG and invasive LAT-maps on both the endocardial and epicardial surface during sinus rhythm showed improved agreement, although with considerable absolute difference and moderate correlation coefficient. Non-invasive iECG requires further refinements to facilitate clinical implementation and risk stratification.
Highlights
Non-invasive imaging of cardiac depolarization and repolarization sequences, known as electrocardiographic imaging, is based on body surface potentials maps and cardiovascular imaging (Huiskamp and Van Oosterom, 1988; Ramanathan et al, 2004; van Dam et al, 2009; Rudy, 2013)
Two major methods have been introduced: (1) the potential based Equivalent Potential Distribution (EPD) method (Ramanathan et al, 2004; Sapp et al, 2012; Rudy, 2013; Cluitmans et al, 2017; Duchateau et al, 2019; Graham et al, 2019; Hohmann et al, 2019), which estimates electrograms on the epicardium in a linear relation whereof activation and recovery timings are determined on the epicardium, and (2) the wave-front formulation based on the equivalent dipole layer (EDL) (Huiskamp and Van Oosterom, 1988; van Dam et al, 2009; van Oosterom, 2014; Oosterhoff et al, 2016)
The QRS complex morphology of the recorded body surface potential maps correlated with the QRS complex morphology of the simulated body surface potential maps in the inverse electrocardiography (iECG) procedure
Summary
Non-invasive imaging of cardiac depolarization and repolarization sequences, known as electrocardiographic imaging, is based on body surface potentials maps and cardiovascular imaging (Huiskamp and Van Oosterom, 1988; Ramanathan et al, 2004; van Dam et al, 2009; Rudy, 2013). Two major methods have been introduced: (1) the potential based Equivalent Potential Distribution (EPD) method (Ramanathan et al, 2004; Sapp et al, 2012; Rudy, 2013; Cluitmans et al, 2017; Duchateau et al, 2019; Graham et al, 2019; Hohmann et al, 2019), which estimates electrograms on the epicardium in a linear relation whereof activation and recovery timings are determined on the epicardium, and (2) the wave-front formulation based on the equivalent dipole layer (EDL) (Huiskamp and Van Oosterom, 1988; van Dam et al, 2009; van Oosterom, 2014; Oosterhoff et al, 2016). Quantitative comparison studies during sinus rhythm are limited and have shown poor performance, represented by low correlation coefficients between non-invasive estimations and invasive mapping (Duchateau et al, 2019)
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