Utility of Substrate Mapping Using Extrasystole to Localise Comprehensive Ventricular Tachycardia Circuits: Results From Intra-operative Mapping Studies.

Abstract

Substrate mapping-based identification of all ventricular tachycardia (VT) circuits (diastolic activation), including partial and complete diastolic circuits in clinical and nonclinical VT, could be beneficial in guiding VT ablation to prevent VT recurrence. The utility of extrasystole induced late potentials has not been compared with late potentials in sinus rhythm (SR) and right ventricular pacing (RVp). Intraoperative simultaneous panoramic endocardial mapping of 21 VTs in 16 ischemic heart disease patients was performed with the use of a 112-bipole endocardial balloon. The decrement of near-field electrogram later than surface QRS during extrasystole (eLP) was studied. Patients had a mean age of 52 ± 9 years and were predominantly (75%) male. The mean sensitivity of eLP (0.75 [95% confidence interval [CI] 0.72-0.78]) to detect VT circuits was better than SR (0.33 [0.30-0.36]; P < 0.001) and RVp (0.36 [0.33-0.39]; P < 0.001) without significant differences in specificity, eLP (0.77 [0.74-0.81], SR (0.82 [0.80-0.84]; P= 0.23), and RVp (0.81 [0.78-0.83]; P= 0.11). Both negative (NPV) and positivie (PPV) predictive values were significantly better for eLP mapping. The mean NPV was 0.77 (95% CI 0.74-0.81), 0.57 (0.55-0.59), and 0.58 (0.55-0.61) for eLP, SR, and RVp, respectively (P < 0.0001). PPV was 0.75 (95% CI 0.72-0.78), 0.63 (0.59-0.67), and 0.63 (0.59-0.67) for eLP, SR, and RVp, respectively (P < 0.001). Overall diagnostic performance (area under the receiver operating characteristic curve) was significantly better for eLP (0.85 [95% CI 0.80-0.90] compared with SR (0.63 [0.56-0.72]; P < 0.001) or RVp (0.61 [0.52-0.74]; P < 0.001). Evoked late potential mapping is a better tool to detect comprehensive diastolic circuits activated during VT, compared with eLP mapping in sinus rhythm or RV pacing.