Document Detail

Layered Activation of Epicardial Scar in Arrhythmogenic Right Ventricular Dysplasia: Possible Substrate for Confined Epicardial Circuits.
MedLine Citation:
PMID:  22634228     Owner:  NLM     Status:  Publisher    
BACKGROUND: -Ventricular tachycardia (VT) ablation in arrhythmogenic right ventricular dysplasia (ARVD) is more successful when including epicardial ablation. Scarring may cause independent, layered epicardial activation and promote epicardially-confined VT circuits. We aimed to characterize transmural right ventricular (RV) activation in ARVD patients and compare this to reference patients without structural heart disease. METHODS AND RESULTS: -Eighteen ARVD patients underwent detailed endocardial and epicardial sinus rhythm electroanatomic mapping. Bipolar activation was annotated at the sharpest intrinsic deflection including late potentials and compared to 6 patients with normal hearts. Total scar area was larger on the epicardium (97±78 cm(2)) than the endocardium (57±44cm(2); p=0.04) with significantly more isolated potentials. Total epicardial activation time was longer than endocardial (172±54 vs 99±27ms, p<0.01) and both were longer than in reference patients. Earliest endocardial site was the RV anteroseptum in 17/18 ARVD patients vs 5/6 controls (p=0.446) and latest endocardial site was in the outflow tract in 13/18 vs 4/6 and tricuspid annulus in 5/18 vs 2/6 (p=1.00). In reference patients epicardial activation directly opposite endocardial sites occurred in 5.2±1.9ms suggesting direct transmural activation. In contrast, ARVD patients had major activation delay to the epicardium with laminar central scar activation from the scar border, not by direct transmural spread from the endocardium. CONCLUSIONS: -Transmural RV activation is modified by ARVD scarring with a delayed epicardial activation sequence suggestive of independent rather than direct transmural activation. This may predispose to VT circuits contained entirely within the epicardium in ARVD and explains observations on the need for direct epicardial ablation to eliminate VT.
Haris M Haqqani; Cory M Tschabrunn; Brian P Betensky; Nimrod Lavi; Wendy S Tzou; Erica S Zado; Francis E Marchlinski
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Publication Detail:
Type:  JOURNAL ARTICLE     Date:  2012-5-25
Journal Detail:
Title:  Circulation. Arrhythmia and electrophysiology     Volume:  -     ISSN:  1941-3084     ISO Abbreviation:  -     Publication Date:  2012 May 
Date Detail:
Created Date:  2012-5-28     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  101474365     Medline TA:  Circ Arrhythm Electrophysiol     Country:  -    
Other Details:
Languages:  ENG     Pagination:  -     Citation Subset:  -    
Hospital of the University of Pennsylvania, Philadelphia, PA.
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