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Identifying the ventricular tachycardia arrhythmogenic substrate: The quest for the holy grail continues

Published:November 03, 2022DOI:https://doi.org/10.1016/j.hrthm.2022.10.024
      The development of electroanatomic mapping (EAM) technology during the 1990s transformed the field of cardiac electrophysiology.
      • Ben-Haim S.A.
      • Osadchy D.
      • Schuster I.
      • Gepstein L.
      • Hayam G.
      • Josephson M.E.
      Nonfluoroscopic, in vivo navigation and mapping technology.
      Substrate identification facilitated by EAM technologies has been the foundation of catheter ablation procedures for ventricular tachycardia (VT) in patients with structural heart disease. Because reentry typically is the mechanism of scar-related VT, substrate mapping techniques focus on (1) differentiating normal vs abnormal areas of myocardial tissue; and (2) identifying the underlying arrhythmogenic pathophysiological substrate, typically within areas of scar, that contribute to the formation of reentrant circuits. To this end, the development and utilization of multielectrode mapping catheter technologies and implementation of various mapping strategies have provided substantial insight into complex arrhythmia mechanisms and yielded significant clinical benefit for patients.
      • Anter E.
      • Tschabrunn C.M.
      • Josephson M.E.
      High-resolution mapping of scar-related atrial arrhythmias using smaller electrodes with closer interelectrode spacing.
      ,
      • Anter E.
      • Tschabrunn C.M.
      • Buxton A.E.
      • Josephson M.E.
      High-resolution mapping of postinfarction reentrant ventricular tachycardia: electrophysiological characterization of the circuit.
      Nonetheless, postablation VT recurrence in patients with structural heart disease is fairly common and has been reported to occur in 30% of patients during the first year of follow-up.
      • Tung R.
      • Vaseghi M.
      • Frankel D.S.
      • et al.
      Freedom from recurrent ventricular tachycardia after catheter ablation is associated with improved survival in patients with structural heart disease: an International VT Ablation Center Collaborative Group study.
      This has largely been attributed to the inability to identify and/or adequately target arrhythmogenic areas of abnormal ventricular substrate because ablation lesion delivery often is limited in areas of fibrosis and adipose tissue.
      • Barkagan M.
      • Leshem E.
      • Shapira-Daniels A.
      • et al.
      Histopathological characterization of radiofrequency ablation in ventricular scar tissue.
      This is particularly the case in large and complex substrates in both postinfarction and nonischemic VT patients. Strategies and technologies that can bridge this gap further by accurately identifying arrhythmogenic areas of ventricular tissue to facilitate more rapid and efficacious catheter ablation procedures are needed.
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