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Background Pulmonary vein isolation (PVI) has emerged as a safe and effective treatment for patients with paroxysmal and persistent atrial fibrillation. Nevertheless, in some patients, a relapse of atrial fibrillation occurs although pulmonary veins are durably isolated. For those patients, the underlying mechanisms of atrial fibrillation perpetuation are manifold and optimal treatment options are not yet defined. Case summary We describe a case of a 55-year-old man with a history of atrial fibrillation and previous PVI presenting with persistent AF and arrhythmia induced cardiomyopathy. During the redo procedure, electro-anatomical mapping revealed durably isolated PV. Bipolar mapping showed large low-voltage areas at the posterior wall and the septum. As the patient was refractory to electrical cardioversion, it was decided to modify the large low-voltage areas as potential arrhythmic substrate. After performing additional ablation with isolation of the posterior wall and two anterior/septal lines, the patient spontaneously converted to sinus rhythm. Discussion Ablation in patients with persistent AF despite durable PVI remains a challenge for the treating team. Individualized ablation approaches addressing additional arrhythmic substrates or extra-PV triggers can be considered to treat patients with persistent AF and durable PVI. [ABSTRACT FROM AUTHOR]

Aims Successful ventricular arrhythmia (VA) ablation requires identification of functionally critical sites during contact mapping. Estimation of the peak frequency (PF) component of the electrogram (EGM) may improve correct near-field (NF) annotation to identify circuit segments on the mapped surface. In turn, assessment of NF and far-field (FF) EGMs may delineate the three-dimensional path of a ventricular tachycardia (VT) circuit. Methods and results A proprietary NF detection algorithm was applied retrospectively to scar-related re-entry VT maps and compared with manually reviewed maps employing first deflection (FDcorr) for VT activation maps and last deflection (LD) for substrate maps. Ventricular tachycardia isthmus location and characteristics mapped with FDcorr vs. NF were compared. Omnipolar low-voltage areas, late activating areas, and deceleration zones (DZ) in LD vs. NF substrate maps were compared. On substrate maps, PF estimation was compared between isthmus and bystander sites. Activation mapping with entrainment and/or VT termination with radiofrequency (RF) ablation confirmed critical sites. Eighteen patients with high-density VT activation and substrate maps (55.6% ischaemic) were included. Near-field detection correctly located critical parts of the circuit in 77.7% of the cases compared with manually reviewed VT maps as reference. In substrate maps, NF detection identified deceleration zones in 88.8% of cases, which overlapped with FDcorr VT isthmus in 72.2% compared with 83.3% overlap of DZ assessed by LD. Applied to substrate maps, PF as a stand-alone feature did not differentiate VT isthmus sites from low-voltage bystander sites. Omnipolar voltage was significantly higher at isthmus sites with longer EGM durations compared with low-voltage bystander sites. Conclusion The NF algorithm may enable rapid high-density activation mapping of VT circuits in the NF of the mapped surface. Integrated assessment and combined analysis of NF and FF EGM-components could support characterization of three-dimensional VT circuits with intramural segments. For scar-related substrate mapping, PF as a stand-alone EGM feature did not enable the differentiation of functionally critical sites of the dominant VT from low-voltage bystander sites in this cohort. [ABSTRACT FROM AUTHOR]

Abstract Background Dynamic functional substrate mapping of scar-related ventricular tachycardia offers better identification of ablation targets with limited ablation lesions. Several functional substrate mapping approaches have been proposed, including decrement-evoked potential (DEEP) mapping. The aim of our study was to compare the short- and long-term efficacy of a DEEP-guided versus a fixed-substrate-guided strategy for the ablation of scar-related ventricular tachycardia (VT). Results Forty consecutive patients presenting for ablation of scar-related VT were randomized to either DEEP-guided or substrate-guided ablation. Late potentials were tagged and ablated in the non-DEEP group, while those in the DEEP group were subjected to RV extrastimulation after a drive train. Only potentials showing significant delay were ablated. Patients were followed for a median duration of 12 months. Twenty patients were allocated to the DEEP group, while the other 20 were allocated to the non-DEEP group. Twelve patients (60%) in the DEEP group had ischemic cardiomyopathy versus 10 patients (50%) in the non-DEEP group (P-value 0.525). Intraoperatively, the median percentage of points with LPs was 19% in the DEEP group and 20.6% in the non-DEEP group. The procedural time was longer in the DEEP group, approaching but missing statistical significance (P-value 0.059). VT non-inducibility was successfully accomplished in 16 patients (80%) in the DEEP group versus 17 patients (85%) in the non-DEEP group (P value 0.597). After a median follow-up duration of 12 months, the VT recurrence rate was 65% in both groups (P value 0.311), with a dropout rate of 10% in the DEEP group. As for the secondary endpoints, all-cause mortality rates were 20% and 25% in the DEEP and non-DEEP groups, respectively (P-value 0.342). Conclusions DEEP-assisted ablation of scar-related ventricular tachycardia is a feasible strategy with comparable short- and long-term outcomes to a fixed-substrate-based strategy with more specific ablation targets, albeit relatively longer but non-significant procedural times and higher procedural deaths. The imbalance between the study groups in terms of epicardial versus endocardial mapping, although non-significant, warrants the prudent interpretation of our results. Further large-scale randomized trials are recommended. Trial registration: clinicaltrials.gov, registration number: NCT05086510, registered on 28th September 2021, record https://classic.clinicaltrials.gov/ct2/show/NCT05086510

Catheter ablation of ventricular arrhythmias has evolved considerably since it was first described more than 3 decades ago. Advancements in understanding the underlying substrate, utilizing pre-procedural imaging, and evolving ablation techniques have improved the outcomes of catheter ablation. Ensuring safety and efficacy during catheter ablation requires adequate planning, including analysis of the 12 lead ECG and appropriate pre-procedural imaging. Defining the underlying arrhythmogenic substrate and disease eitology allow for the developed of tailored ablation strategies, especially for patients with non-ischemic cardiomyopathies. During ablation, the type of anesthesia can affect VT induction, the quality of the electro-anatomic map, and the stability of the catheter during ablation. For high risk patients, appropriate selection of hemodynamic support can increase the success of VT ablation. For patients in whom VT is hemodynamically unstable or difficult to induce, substrate modification strategies can aid in safe and successful ablation. Recently, there has been an several advancements in substrate mapping strategies that can be used to identify and differentiate local late potentials. The incorporation of high-definition mapping and contact-sense technologies have both had incremental benefits on the success of ablation procedures. It is crucial to harness newer technology and ablation strategies with the highest level of peri-procedural safety to achieve optimal long-term outcomes in patients undergoing VT ablation.

Introduction: Over the past years, mapping and ablation techniques for the treatment of ventricular tachycardia (VT) have evolved rapidly. High Density (HD) substrate mapping is now routine and pre‐procedural imaging is increasingly used. The additional value of these techniques for long‐term VT‐free survival is not clear. Methods: We compared baseline and procedural characteristics, procedural success, safety and outcome of mapping and ablation of ventricular tachycardia in patients with ischemic heart disease between two groups. (1) Low Density (LD) group: VT mapping and ablation with a 4 mm single tip catheter (2) HD group: HD substrate mapping with the Pentaray (Biosense Webster, USA) or HD Grid (Abbott, USA) catheter and ablation with a 4 mm single tip catheter. Results: VT ablation was performed in 133 patients (71 patients in LD group and 62 patients in HD group). The median follow‐up was 5.0 years in LD group and 2.0 years in HD group. One‐, two‐, and five‐year VT recurrence rates were 47%, 56%, and 65% in the LD group versus 39%, 50%, and 55% in the HD group (log‐rank test for VT recurrence p =.70). One‐, two‐, and five‐year ICD shock recurrence rates were 14%, 18%, and 24% in the LD group versus 8%, 15%, and 19% in the HD group (log‐rank test for ICD‐shock p =.79). All‐cause mortality, cardiac (non‐arrhythmic), and arrhythmic death, were similar in both groups. Severe procedural complications (tamponade, stroke, or procedural death) occurred in four patients (5%, 1 vascular, 3 tamponade) in the LD group versus two patients (3%, both tamponade) in the HD group (NS). In univariate and multivariable analysis, only a higher LVEF was significantly associated with VT‐free survival. HD mapping was not significantly associated with VT‐free survival. Anterior infarct location and age were significantly associated with ICD recurrent shock in both univariate and multivariable analyses. Conclusions: In patients with ischemic cardiomyopathy, a HD substrate mapping, and ablation strategy did not lead to higher VT‐free survival and shock‐free survival compared to a single tip mapping and ablation strategy. In this study, only LVF is an independent predictor for VT recurrence. Anterior infarct location and age predict recurrent ICD shocks. [ABSTRACT FROM AUTHOR]

Established electroanatomic mapping techniques for substrate mapping for ventricular tachycardia (VT) ablation includes voltage mapping, isochronal late activation mapping (ILAM), and fractionation mapping. Omnipolar mapping (Abbott Medical, Inc.) is a novel optimized bipolar electrogram creation technique with integrated local conduction velocity annotation. The relative utilities of these mapping techniques are unknown. The purpose of this study was to evaluate the relative utility of various substrate mapping techniques for the identification of critical sites for VT ablation. Electroanatomic substrate maps were created and retrospectively analyzed in 27 patients in whom 33 VT critical sites were identified. Both abnormal bipolar voltage and omnipolar voltage encompassed all critical sites and were observed over a median of 66 cm2 (interquartile range [IQR] 41.3–86 cm2) and 52 cm2 (IQR 37.7–65.5 cm2), respectively. ILAM deceleration zones were observed over a median of 9 cm2 (IQR 5.0–11.1 cm2) and encompassed 22 critical sites (67%), while abnormal omnipolar conduction velocity (CV <1 mm/ms) was observed over 10 cm2 (IQR 5.3–16.6 cm2) and identified 22 critical sites (67%), and fractionation mapping was observed over a median of 4 cm2 (IQR 1.5–7.6 cm2) and encompassed 20 critical sites (61%). The mapping yield was the highest for fractionation + CV (2.1 critical sites/cm2) and least for bipolar voltage mapping (0.5 critical sites/cm2). CV identified 100% of critical sites in areas with a local point density of >50 points/cm2. ILAM, fractionation, and CV mapping each identified distinct critical sites and provided a smaller area of interest than did voltage mapping alone. The sensitivity of novel mapping modalities improved with greater local point density. [ABSTRACT FROM AUTHOR]

Introduction: The assessment of the ventricular myocardial substrate critically depends on the size of mapping electrodes, their orientation with respect to wavefront propagation, and interelectrode distance. We conducted a dual‐center study to evaluate the impact of microelectrode mapping in patients undergoing catheter ablation (CA) of ventricular tachycardia (VT). Methods: We included 21 consecutive patients (median age, 68 [12], 95% male) with structural heart disease undergoing CA for electrical storm (n = 14) or recurrent VT (n = 7) using the QDOT Micro catheter and a multipolar catheter (PentaRay, n = 9). The associations of peak‐to‐peak maximum standard bipolar (BVc) and minibipolar (PentaRay, BVp) with microbipolar (BVμMax) voltages were respectively tested in sinus rhythm with mixed effect models. Furthermore, we compared the features of standard bipolar (BE) and microbipolar (μBE) electrograms in sinus rhythm at sites of termination with radiofrequency energy. Results: BVμMax was moderately associated with both BVc (β =.85, p <.01) and BVp (β =.56, p <.01). BVμMax was 0.98 (95% CI: 0.93−1.04, p <.01) mV larger than corresponding BVc, and 0.27 (95% CI: 0.16−0.37, p <.01) mV larger than matching BVp in sinus rhythm, with higher percentage differences in low voltage regions, leading to smaller endocardial dense scar (2.3 [2.7] vs. 12.1 [17] cm2, p <.01) and border zone (3.2 [7.4] vs. 4.8 [20.1] cm2, p =.03) regions in microbipolar maps compared to standard bipolar maps. Late potentials areas were nonsignificantly greater in microelectrode maps, compared to standard electrode maps. At sites of VT termination (n = 14), μBE were of higher amplitude (0.9 [0.8] vs. 0.4 [0.2] mV, p <.01), longer duration (117 [66] vs. 74 [38] ms, p <.01), and with greater number of peaks (4 [2] vs. 2 [1], p <.01) in sinus rhythm compared to BE. Conclusion: microelectrode mapping is more sensitive than standard bipolar mapping in the identification of viable myocytes in SR, and may facilitate recognition of targets for CA. [ABSTRACT FROM AUTHOR]

The treatment of ventricular tachycardia caused by nonischemic cardiomyopathy (NICM-VT) is challenging in clinical practice, however, the related clinical data of catheter ablation for NICM-VT are limited. This paper reviews the progress of catheter ablation for NICM-VT from three aspects: clinical efficacy, mapping strategy, and future prospect. [ABSTRACT FROM AUTHOR]

The characterization of benthic habitats is essential for aquatic ecosystem science and management, but is frequently limited by waterbody visibility and depth. Recreation‐grade side‐scan sonar systems are increasingly used to aid scientific inquiries in aquatic environments due to their relative low‐cost, ease of operation, low‐weight, and ease of mounting on a variety of vessels. However, existing procedures and software for post‐processing these data are either limited, closed source, or fail on data from new sonar models, limiting the development of reproducible workflows. Here, we present PING‐Mapper, an open‐source and freely available side‐scan sonar post‐processing toolset for processing and mapping sonar recordings from popular Humminbird instruments. The modular software automatically: (a) decodes sonar recordings from any Humminbird system, (b) exports ping attributes from every sonar channel, (c) uses sonar sensor depth for water column removal, and (d) exports sonogram tiles and georectified mosaics. Sonar channels are processed in parallel for quick decoding and metadata extraction. Major processing wokflows, including georectification and image export, are optimized to scale with computing resources. The software has been extensively tested using data from several rivers of varying character and distribution of depths, but could also be used in estuarine and lacustrine environments. Usage of PING‐Mapper is illustrated in three case studies focused on mapping large woody debris, bathymetric mapping, and visual interpretation and mapping of substrates for selected reaches of the Pearl and Pascagoula river systems in Mississippi. Plain Language Summary: Side‐scan sonar instruments provide a way to survey and visualize the bottom of rivers, lakes, or oceans. Since the early 2000s, companies catering predominantly to anglers have manufactured recreation‐grade side‐scan sonar systems to aid fishermen in locating fish and identifying potential hazards. Scientists seeking to understand and manage aquatic habitats used these systems to create grayscale images of water bottoms because they are inexpensive, easy to operate, and require minimal mounting equipment on the boat. Software has been created by companies to process these data, but the underlying processing workflow and computer code are not publicly available, making it difficult to reproduce and compare results across studies. Other publicly available approaches and software are either outdated, not maintained, or not free. That is why we made PING‐Mapper, a freely available software developed in an increasingly popular programming language called Python. We designed the software to work on any computer to export the data sets quickly and efficiently. The scientific use of exported data sets is demonstrated with three case studies focused on locating and mapping targets (specifically large trees and branches), creating depth maps, and visually discerning the distributions of common substrates, such as sand and cobble. Key Points: We developed an open‐source software for exporting benthic data sets and georeferenced imagery from Humminbird side‐scan sonar systemsSoftware provides an automated and reproducible approach to processing sonar data with minimal interaction from the userThree case studies are presented to highlight use cases of processed benthic data sets [ABSTRACT FROM AUTHOR]

Background: Differentiating near-field (NF) and far-field (FF) electrograms (EGMs) is crucial in identifying critical arrhythmogenic substrate during Ventricular Tachycardia (VT) ablation. A novel algorithm annotates NF fractionated signals enabling EGM Peak Frequency (PF) determination using wavelet transformation. This study evaluated the algorithms effectiveness in identifying critical components of the VT circuit during substrate mapping., Methods: A multicentre, international cohort undergoing VT ablation were investigated. VT activation maps were used to demarcate the isthmus zone (IZ). Offline analysis was performed to evaluate the diagnostic performance of low voltage area (LVA) PF substrate mapping., Results: A total of 30 patients encompassing 198,935 EGMs were included. The IZ PF was significantly higher in sinus rhythm (SR) compared to right ventricular paced (RVp) substrate maps (234(195-294)Hz vs 197(166-220)Hz; p=0.010). Compared to LVA PF, the IZ PF was significantly higher in both SR and RVp substrate maps (AUC: 0.74 and 0.70, respectively). A LVA PF threshold of ≥200Hz was optimal in SR maps (sensitivity 69%; specificity 64%) and RVp maps (sensitivity 60%; specificity 64%) in identifying the VT isthmus. In amiodarone-treated patients (n=20), SR substrate map IZ PF was significantly lower (222(186-257)Hz vs 303(244-375)Hz, p=0.009) compared to amiodarone-naïve patients (n=10). The ≥200Hz LVA PF threshold resulted in an 80% freedom from VT with a trend towards reduced ablation lesions and radiofrequency times., Conclusions: LVA PF substrate mapping identifies critical components of the VT circuit with an optimal threshold of ≥200Hz. Isthmus PF is influenced by chronic amiodarone therapy with lower values observed during RV pacing., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Abstract The characterization of benthic habitats is essential for aquatic ecosystem science and management, but is frequently limited by waterbody visibility and depth. Recreation‐grade side‐scan sonar systems are increasingly used to aid scientific inquiries in aquatic environments due to their relative low‐cost, ease of operation, low‐weight, and ease of mounting on a variety of vessels. However, existing procedures and software for post‐processing these data are either limited, closed source, or fail on data from new sonar models, limiting the development of reproducible workflows. Here, we present PING‐Mapper, an open‐source and freely available side‐scan sonar post‐processing toolset for processing and mapping sonar recordings from popular Humminbird instruments. The modular software automatically: (a) decodes sonar recordings from any Humminbird system, (b) exports ping attributes from every sonar channel, (c) uses sonar sensor depth for water column removal, and (d) exports sonogram tiles and georectified mosaics. Sonar channels are processed in parallel for quick decoding and metadata extraction. Major processing wokflows, including georectification and image export, are optimized to scale with computing resources. The software has been extensively tested using data from several rivers of varying character and distribution of depths, but could also be used in estuarine and lacustrine environments. Usage of PING‐Mapper is illustrated in three case studies focused on mapping large woody debris, bathymetric mapping, and visual interpretation and mapping of substrates for selected reaches of the Pearl and Pascagoula river systems in Mississippi.

Losses of river complexity and viable habitat has led to negative effects on Atlantic salmon. With the rapid population decline of Atlantic salmon, there has been an increase in river restoration and salmon reintroduction projects, and an understanding of substrate is a vital component in the restoration of these habitats. However, the isolation and/or inaccessibility of many of these rivers make the collection of this information challenging and expensive based on conventional survey approaches. This study looks at the feasibility and accuracy of conducting substrate analysis using low-cost uncrewed aerial vehicles (UAV) at seven transects through macroscale river habitat (riffles, runs and pools) on the Upper Salmon River located in Fundy National Park near Alma, New Brunswick, Canada. Using ArcGIS, a supervised classification was conducted separating the dry and submerged substrate for higher accuracy. An object-based image analysis was conducted in PCI for delineation of substrate size. Small ideal spawning substrate was found to be concentrated in slower flowing pools while large substrate was concentrated in faster flowing riffles. The substrate analysis was conducted with an accuracy of 79% for dry substrate and 86% for submerged substrate, demonstrating the potential of UAV use in salmon habitat analysis.

Background: The presence of dynamic substrate changes may facilitate functional block and reentry in ventricular tachycardia (VT). Objective: We aimed to study dynamic ventricular repolarization changes in critical regions of the VT circuit during sensed single extrastimulus pacing known as the Sense Protocol (SP). Methods: Twenty patients (aged 67 ± 9 years, 17 male) underwent VT ablation. A bipolar voltage map was obtained during sinus rhythm (SR) and right ventricular SP pacing at 20 ms above ventricular effective refractory period. Ventricular repolarization maps were constructed. Ventricular repolarization time (RT) was calculated from unipolar electrogram T waves, using the Wyatt method, as the dV/dtmax of the unipolar T wave. Entrainment or pace mapping confirmed critical sites for ablation. Results: The median global repolarization range (max-min RT per patient) was 166 ms (interquartile range [IQR] 143–181 ms) during SR mapping vs 208 ms (IQR 182–234) during SP mapping (P = .0003 vs intrinsic rhythm). Regions of late potentials (LP) had a longer RT during SP mapping compared to regions without LP (mean 394 ± 40 ms vs 342 ± 25 ms, P < .001). In paired regions of normal myocardium there was no significant spatial dispersion of repolarization (SDR)/10 mm2 during SP mapping vs SR mapping (SDR 11 ± 6 ms vs 10 ± 6 ms, P = .54). SDR/10 mm2 was greater in critical areas of the VT circuit during SP mapping 63 ± 29 ms vs SR mapping 16 ± 9 ms (P < .001). Conclusion: Ventricular repolarization is prolonged in regions of LP and increases dynamically, resulting in dynamic SDR in critical areas of the VT circuit. These dynamic substrate changes may be an important factor that facilitates VT circuits.

The treatment of atrial fibrillation and other cardiac arrhythmias as a major cause of cardiovascular hospitalization has remained a challenge predominantly for patients with severely remodeled substrate. Individualized ablation strategies are extremely important both for pulmonary vein isolation and subsequent ablations. Current approaches to identifying arrhythmogenic regions rely on electrogram-based features such as activation time and voltage. Novel technologies now enable clinical assessment of the local impedance as tissue property. Previous studies demonstrated its use for ablation monitoring and indicated its potential to differentiate healthy substrate, scar, and pathological tissue. This study investigates the potential of local electrical impedance-based substrate mapping of the atria for human in-vivo data. The presented pipeline for impedance mapping particularly contains options for dealing with undesirable effects originating from cardiac motion, catheter motion, or proximity to other intracardiac devices. Bloodpool impedance was automatically determined as a patient-specific reference. Full-chamber, left atrial impedance maps were drawn up from interpolating the measured impedances to the atrial endocardium. Finally, the origin and magnitude of oscillations of the raw impedance recording were probed into. The most dominant reason for exclusion of impedance samples was the loss of endocardial contact. With median elevations above the bloodpool impedance between 29 and 46 Ω, the impedance within the pulmonary veins significantly exceeded the remaining atrial walls presenting median elevations above the bloodpool impedance between 16 and 20 Ω. Previous ablation lesions were distinguished from their surroundings by a significant drop in local impedance while the corresponding regions did not differ for the control group. The raw impedance was found to oscillate with median amplitudes between 6 and 17 Ω depending on the patient. Oscillations were traced back to an interplay of atrial, ventricular, and respiratory motion. In summary, local impedance measurements demonstrated their capability to distinguish pathological atrial tissue from physiological substrate. Methods to limit the influence of confounding factors that still hinder impedance mapping were presented. Measurements at different frequencies or the combination of multiple electrodes could lead to further improvement. The presented examples indicate that electrogram- and impedance-based substrate mapping have the potential to complement each other toward better patient outcomes in future. [ABSTRACT FROM AUTHOR]

Purpose: This study aimed to investigate the spatial relationship between low-voltage areas (LVAs) in bipolar voltage mapping (BVM) and localized complex conduction (LCC)-cores in a global, non-contact, charge-density-based imaging, and mapping system (AcM).Methods: Patients with history of index PVI for PsAF and scheduled for a repeat ablation procedure for recurrence of the same arrhythmia were enrolled between August 2018 and February 2020. All patients underwent both substrate mappings of the left atrium (LA) with the CARTO 3D map-ping system and with AcM.Results: Ten patients where included in our analysis. All presented with persistency of PVI in all veins at the moment of repeat procedure. There was no linear relationship in BVM maps between SR and CSd (correlation coefficient 0.31 ± 0.15), SR and CSp (0.36 ± 0.12) and CSd and CSp (0.43 ± 0.10). The % overlap of localized irregular activation (LIA), localized rotational activation (LRA) and Focal (F) regions with LVA was lower at 0.2 mV compared to 0.5 mV (4.97 ± 7.39%, 3.27 ± 5.25%, 1.09 ± 1.92% and 12.59 ± 11.81%, 7.8 ± 9.20%, 4.62 ± 5.27%). Sensitivity and specificity are not significantly different when comparing composite maps with different LVA cut-offs. AURC was 0.46, 0.48, and 0.39 for LIA, LRA, and Focal, respectively.Conclusion: Due to wave front direction dependency, LVAs mapped with BVM in sinus rhythm and during coronary sinus pacing only partially overlap in patients with PsAF. LCC-cores mapped during PsAF partially co-localize with LVAs. [ABSTRACT FROM AUTHOR]

Aims: Successful ventricular arrhythmia (VA) ablation requires identification of functionally critical sites during contact mapping. Estimation of the peak frequency (PF) component of the electrogram (EGM) may improve correct near-field (NF) annotation to identify circuit segments on the mapped surface. In turn, assessment of NF and far-field (FF) EGMs may delineate the three-dimensional path of a ventricular tachycardia (VT) circuit., Methods and Results: A proprietary NF detection algorithm was applied retrospectively to scar-related re-entry VT maps and compared with manually reviewed maps employing first deflection (FDcorr) for VT activation maps and last deflection (LD) for substrate maps. Ventricular tachycardia isthmus location and characteristics mapped with FDcorr vs. NF were compared. Omnipolar low-voltage areas, late activating areas, and deceleration zones (DZ) in LD vs. NF substrate maps were compared. On substrate maps, PF estimation was compared between isthmus and bystander sites. Activation mapping with entrainment and/or VT termination with radiofrequency (RF) ablation confirmed critical sites. Eighteen patients with high-density VT activation and substrate maps (55.6% ischaemic) were included. Near-field detection correctly located critical parts of the circuit in 77.7% of the cases compared with manually reviewed VT maps as reference. In substrate maps, NF detection identified deceleration zones in 88.8% of cases, which overlapped with FDcorr VT isthmus in 72.2% compared with 83.3% overlap of DZ assessed by LD. Applied to substrate maps, PF as a stand-alone feature did not differentiate VT isthmus sites from low-voltage bystander sites. Omnipolar voltage was significantly higher at isthmus sites with longer EGM durations compared with low-voltage bystander sites., Conclusion: The NF algorithm may enable rapid high-density activation mapping of VT circuits in the NF of the mapped surface. Integrated assessment and combined analysis of NF and FF EGM-components could support characterization of three-dimensional VT circuits with intramural segments. For scar-related substrate mapping, PF as a stand-alone EGM feature did not enable the differentiation of functionally critical sites of the dominant VT from low-voltage bystander sites in this cohort., Competing Interests: Conflict of interest: P.D.L. is supported by UCL/UCLH NIHR and Barts BRC. J.M. received speaker honoraria from Abbott Laboratories, Biosense Webster (J&J), and Boston Scientific. All remaining authors have declared no conflicts of interest., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Introduction: An important substrate for atrial fibrillation (AF) is fibrotic atrial myopathy. Identifying low voltage, myopathic regions during AF using traditional bipolar voltage mapping is limited by the directional dependency of wave propagation. Our objective was to evaluate directionally independent unipolar voltage mapping, but with far‐field cancellation, to identify low‐voltage regions during AF. Methods: In 12 patients undergoing pulmonary vein isolation for AF, high‐resolution voltage mapping was performed in the left atrium during sinus rhythm and AF using a roving 20‐pole circular catheter. Bipolar electrograms (EGMs) (Bi) < 0.5 mV in sinus rhythm identified low‐voltage regions. During AF, bipolar voltage and unipolar voltage maps were created, the latter with (uni‐res) and without (uni‐orig) far‐field cancellation using a novel, validated least‐squares algorithm. Results: Uni‐res voltage was ~25% lower than uni‐orig for both low voltage and normal atrial regions. Far‐field EGM had a dominant frequency (DF) of 4.5–6.0 Hz, and its removal resulted in a lower DF for uni‐orig compared with uni‐res (5.1 ± 1.5 vs. 4.8 ± 1.5 Hz; p <.001). Compared with Bi, uni‐res had a significantly greater area under the receiver operator curve (0.80 vs. 0.77; p <.05), specificity (86% vs. 76%; p <.001), and positive predictive value (43% vs. 30%; p <.001) for detecting low‐voltage during AF. Similar improvements in specificity and positive predictive value were evident for uni‐res versus uni‐orig. Conclusion: Far‐field EGM can be reliably removed from uni‐orig using our novel, least‐squares algorithm. Compared with Bi and uni‐orig, uni‐res is more accurate in detecting low‐voltage regions during AF. This approach may improve substrate mapping and ablation during AF, and merits further study. [ABSTRACT FROM AUTHOR]

Introduction: Stand‐alone substrate ablation has become a standard ventricular tachycardia (VT) ablation strategy. We sought to evaluate the influence of baseline VT inducibility and activation mapping on ablation outcomes in patients with structural heart disease (SHD) undergoing VT ablation. Methods: Single center, observational and retrospective study including consecutive patients with SHD and documented VT undergoing ablation. Baseline VT induction was attempted before ablation in all patients and VT activation mapping performed when possible. Ablation was guided by activation mapping for mappable VTs plus substrate ablation for all patients. Ablation outcomes and complications were evaluated. Results: One hundred and sixty patients were included and were classified in three groups according to baseline VT inducibility:group 1 (non inducible, n = 18), group 2 (1 VT morphology induced, n = 53), and group 3 (>1 VT morphology induced, n = 89). VT activation mapping was possible in 35%. After a median follow‐up of 38.5 months, baseline inducibility of greater than 1 VT morphology was associated with a significant incidence of VT recurrence (42% for group 3 vs. 15.1% for group 2% and 5.6% for group 1, Log‐rank p <.0001) and activation mapping with a lower rate of VT recurrence (24% vs. 36.3%, Log‐rank p =.035). Baseline inducibility of greater than 1 VT morphology (hazards ratio [HR]: 12.05, 95% confidence interval [CI]: 1.60–90.79, p =.016) was an independent predictor of VT recurrence while left ventricular ejection fraction less than 30% (HR: 1.93, 95% CI: 1.13–3.25, p =.014) and advanced heart failure (HR: 4.69, 95% CI: 2.75–8.01, p <.0001) were predictors of mortality or heart transplantation. Complications occurred in 11.2% (5.6% hemodynamic decompensation). Conclusion: Baseline VT inducibility and activation mapping may add significant prognostic information during VT ablation procedures. [ABSTRACT FROM AUTHOR]

The presented clinical case demonstrates an individual choice of a staged comprehensive approach to interventional treatment of a patient with coronary artery disease and ventricular tachyrhythmias, focused on myocardial revascularization and interventional abolition of ventricular tachyrhythmias.

Aims: The treatment of atrial fibrillation beyond pulmonary vein isolation has remained an unsolved challenge. Targeting regions identified by different substrate mapping approaches for ablation resulted in ambiguous outcomes. With the effective refractory period being a fundamental prerequisite for the maintenance of fibrillatory conduction, this study aims at estimating the effective refractory period with clinically available measurements.Methods and Results: A set of 240 simulations in a spherical model of the left atrium with varying model initialization, combination of cellular refractory properties, and size of a region of lowered effective refractory period was implemented to analyse the capabilities and limitations of cycle length mapping. The minimum observed cycle length and the 25% quantile were compared to the underlying effective refractory period. The density of phase singularities was used as a measure for the complexity of the excitation pattern. Finally, we employed the method in a clinical test of concept including five patients. Areas of lowered effective refractory period could be distinguished from their surroundings in simulated scenarios with successfully induced multi-wavelet re-entry. Larger areas and higher gradients in effective refractory period as well as complex activation patterns favour the method. The 25% quantile of cycle lengths in patients with persistent atrial fibrillation was found to range from 85 to 190 ms.Conclusion: Cycle length mapping is capable of highlighting regions of pathologic refractory properties. In combination with complementary substrate mapping approaches, the method fosters confidence to enhance the treatment of atrial fibrillation beyond pulmonary vein isolation particularly in patients with complex activation patterns. [ABSTRACT FROM AUTHOR]

Background: Right bundle branch block (RBBB) ventricular tachycardia (VT) morphology is a criterion for left ventricular (LV) involvement in arrhythmogenic right ventricular cardiomyopathy (ARVC).Objective: The purpose of this study was to determine the frequency and chamber of origin of RBBB VT in patients with ARVC and VT.Methods: We studied 110 consecutive patients with VT who met the diagnostic International Task Force criteria for ARVC and underwent VT mapping/ablation. Patients with ≥1 RBBB VT were identified. Right ventricular (RV) origin of the RBBB VT was determined based on standard mapping criteria and elimination with ablation.Results: Nineteen patients (17%) had 26 RBBB VTs. Eleven of these 19 patients (58%) had 16 RBBB VTs from the RV, and 9 patients (47%) had 10 RBBB VTs originating from the LV, with 1 patient demonstrating both. RBBB VT from RV most commonly (13/16 RBBB VTs) had an early precordial QRS transition (V2 or V3), with superiorly and typically leftward directed frontal plane axis, consistent with exit from dilated RV adjacent to inferior LV septum, whereas all 10 VTs from LV had RBBB morphology with positive R waves to V5 or V6 and rightward axis in 6 VTs characteristic of basal lateral origin.Conclusion: In patients with ARVC and VT presenting for VT ablation, RBBB VT occurs in 17% of cases, with most RBBB VTs (62%) originating from the RV and not indicative of LV origin. Precordial R-wave transition and frontal plane axis can be used to identify the anticipated chamber of origin of RBBB VT. [ABSTRACT FROM AUTHOR]

BackgroundRe-entrant ventricular tachycardia may be non-inducible or haemodynamically compromising, requiring assessment of the electrophysiological properties of the myocardium during sinus rhythm (i.e., substrate mapping). Areas of heart tissue with slow conduction can act as a critical isthmus for re-entrant electrical excitation and are a potential target for ablation therapy.AimTo develop and validate a novel metric of local conduction delay in the heart, the amplitude-normalized electrogram area (norm_EA).MethodsA computational model of a propagating mouse action potential was used to establish the impact of altering sodium channel conductance, intracellular conductivity, fibrosis density, and electrode size/orientation on bipolar electrogram morphology. Findings were then validated in experimental studies in mouse and guinea pig hearts instrumented for the recording of bipolar electrograms from a multipolar linear mapping catheter. norm_EA was calculated by integrating the absolute area of a bipolar electrogram divided by the electrogram amplitude. Electrogram metrics were correlated with the local conduction delay during sodium channel block, gap junction inhibition, and acute ischemia.ResultsIn computational simulations, reducing sodium channel conductance and intracellular conductivity resulted in a decrease in signal amplitude and increase in norm_EA (reflecting a broadening of electrogram morphology). For larger electrodes (3 mm diameter/7.1 mm2 area), the change in norm_EA was essentially linear with the change in local conduction delay. Experimental studies supported this finding, showing that the magnitude of change in norm_EA induced by flecainide (1–4 μM), carbenoxolone (10–50 μM), and low-flow ischemia (25% of initial flow rate) was linearly correlated with the local conduction delay in each condition (r2 = 0.92). Qualitatively similar effects were observed in guinea pig hearts perfused with flecainide. Increasing fibrosis density in the computational model also resulted in a decrease in signal amplitude and increase in norm_EA. However, this remains to be validated using experimental/clinical data of chronic infarct.Conclusionnorm_EA is a quantitative measure of local conduction delay between the electrode pair that generates a bipolar electrogram, which may have utility in electrophysiological substrate mapping of non-inducible or haemodynamically compromising tachyarrhythmia.

Background: Defining diastolic slow-conduction channels within the borderzone (BZ) of scar-dependent re-entrant ventricular tachycardia (VT) is key for effective mapping and ablation strategies. Understanding wavefront propagation is driving advances in high-density (HD) mapping. The newly developed Advisor™ HD Grid Mapping Catheter (HD GRID) has equidistant spacing of 16, 1 mm electrodes in a 4 × 4 3 mm interspaced arrangement allowing bipolar recordings along and uniquely across the splines (orthogonal vector) to facilitate substrate mapping in a WAVE configuration (WAVE). The purpose of this study was to determine the relative importance of the WAVE configuration compared to the STANDARD linear-only bipolar configuration (STANDARD) in defining VT substrate.Methods: Thirteen patients underwent VT ablation at our institution. In all cases, a substrate map was constructed with the HD GRID in the WAVE configuration (conWAVE) to guide ablation strategy. At the end of the procedure, the voltage map was remapped in the STANDARD configuration (conSTANDARD) using the turbo-map function. Detailed post-hoc analysis of the WAVE and STANDARD maps was performed blinded to the configuration. Quantification of total scar area, BZ and dense scar area with assessment of conduction channels (CC) was performed.Results: The substrate maps conSTANDARD vs conWAVE showed statistically significant differences in the total scar area (56 ± 32 cm2 vs 51 ± 30 cm2; p = 0.035), dense scar area (36 ± 25 cm2 vs 29 ± 22 cm2; p = 0.002) and number of CC (3.3 ± 1.6 vs 4.8 ± 2.5; p = 0.026). conWAVE collected more points than the conSTANDARD settings (p = 0.001); however, it used fewer points in map construction (p = 0.023).Conclusions: The multipolar Advisor™ HD Grid Mapping Catheter in conWAVE provides more efficient point acquisition and greater VT substrate definition of the borderzone particularly at the low-voltage range compared to conSTANDARD. This greater resolution within the low-voltage range facilitated CC definition and quantification within the scar, which is essential in guiding the ablation strategy. [ABSTRACT FROM AUTHOR]

Background: Re-entrant ventricular tachycardia may be non-inducible or haemodynamically compromising, requiring assessment of the electrophysiological properties of the myocardium during sinus rhythm (i.e., substrate mapping). Areas of heart tissue with slow conduction can act as a critical isthmus for re-entrant electrical excitation and are a potential target for ablation therapy. Aim: To develop and validate a novel metric of local conduction delay in the heart, the amplitude-normalized electrogram area (norm_EA). Methods: A computational model of a propagating mouse action potential was used to establish the impact of altering sodium channel conductance, intracellular conductivity, fibrosis density, and electrode size/orientation on bipolar electrogram morphology. Findings were then validated in experimental studies in mouse and guinea pig hearts instrumented for the recording of bipolar electrograms from a multipolar linear mapping catheter. norm_EA was calculated by integrating the absolute area of a bipolar electrogram divided by the electrogram amplitude. Electrogram metrics were correlated with the local conduction delay during sodium channel block, gap junction inhibition, and acute ischemia. Results: In computational simulations, reducing sodium channel conductance and intracellular conductivity resulted in a decrease in signal amplitude and increase in norm_EA (reflecting a broadening of electrogram morphology). For larger electrodes (3 mm diameter/7.1 mm2 area), the change in norm_EA was essentially linear with the change in local conduction delay. Experimental studies supported this finding, showing that the magnitude of change in norm_EA induced by flecainide (1–4 μM), carbenoxolone (10–50 μM), and low-flow ischemia (25% of initial flow rate) was linearly correlated with the local conduction delay in each condition (r 2 = 0.92). Qualitatively similar effects were observed in guinea pig hearts perfused with flecainide. Increasing fibrosis density in the computational model also resulted in a decrease in signal amplitude and increase in norm_EA. However, this remains to be validated using experimental/clinical data of chronic infarct. Conclusion: norm_EA is a quantitative measure of local conduction delay between the electrode pair that generates a bipolar electrogram, which may have utility in electrophysiological substrate mapping of non-inducible or haemodynamically compromising tachyarrhythmia. [ABSTRACT FROM AUTHOR]

Background: The amplitude of bipolar electrograms (EGMs) is directionally sensitive, decreasing when measured from electrode pairs oriented oblique to a propagating wavefront.Objective: The purpose of this study was to use a computational model and clinical data to establish the mechanism and magnitude of directional sensitivity.Methods: Simulated EGMs were created using a computational model with electrode pairs rotated relative to a passing wavefront. A clinical database of 18,740 EGMs with varying electrode separation and orientations was recorded from the left atrium of 10 patients with atrial fibrillation during pacing. For each EGM, the angle of incidence between the electrodes and the wavefront was measured using local conduction velocity (CV) mapping.Results: A theoretical model was derived describing the effect of the changing angle of incidence, electrode spacing, and CV on the local activation time difference between a pair of electrodes. Model predictions were validated using simulated and clinical EGMs. Bipolar amplitude measured by an electrode pair is decreased (directionally sensitive) at angles of incidence resulting in local activation time differences shorter than unipolar downstroke duration. Directional sensitivity increases with closer electrode spacing, faster CV, and longer unipolar EGM duration. For narrowly spaced electrode pairs (<5 mm), it is predicted at all orientations.Conclusion: Directional sensitivity occurs because bipolar amplitude is reduced when the component unipolar EGMs overlap, such that neither electrode is "indifferent." At the electrode spacing of clinical catheters, this is predicted to occur regardless of catheter orientation. This suggests that bipolar directional sensitivity can be lessened but not overcome by recently introduced catheters with additional rotated electrode pairs. [ABSTRACT FROM AUTHOR]

Background: Identifying arrhythmogenic sites to improve ventricular tachycardia (VT) ablation outcomes remains unresolved. The reentry vulnerability index (RVI) combines activation and repolarization timings to identify sites critical for reentrant arrhythmia initiation without inducing VT.Objective: The purpose of this study was to provide the first assessment of RVI's capability to identify VT sites of origin using high-density contact mapping and comparison with other activation-repolarization markers of functional substrate.Methods: Eighteen VT ablation patients (16 male; 72% ischemic) were studied. Unipolar electrograms were recorded during ventricular pacing and analyzed offline. Activation time (AT), activation-recovery interval (ARI), and repolarization time (RT) were measured. Vulnerability to reentry was mapped based on RVI and spatial distribution of AT, ARI, and RT. The distance from sites identified as vulnerable to reentry to the VT site of origin was measured, with distances <10 mm and >20 mm indicating accurate and inaccurate localization, respectively.Results: The origins of 18 VTs (6 entrainment, 12 pace-mapping) were identified. RVI maps included 1012 (408-2098) (median, 1st-3rd quartiles) points per patient. RVI accurately localized 72.2% VT sites of origin, with median distance of 5.1 (3.2-10.1) mm. Inaccurate localization was significantly less frequent for RVI than AT (5.6% vs 33.3%; odds ratio 0.12; P = .035). Compared to RVI, distance to VT sites of origin was significantly larger for sites showing prolonged RT and ARI and were nonsignificantly larger for sites showing highest AT and ARI gradients.Conclusion: RVI identifies vulnerable regions closest to VT sites of origin. Activation-repolarization metrics may improve VT substrate delineation and inform novel ablation strategies. [ABSTRACT FROM AUTHOR]

Aims: Multielectrode mapping catheters can be advantageous for identifying surviving myocardial bundles in scar. This study aimed to evaluate the utility of a new multielectrode catheter with increased number of small and closely spaced electrodes for mapping ventricles with healed infarction.Methods and Results: In 12 swine (four healthy and eight with infarction), the left ventricle was mapped with investigational (OctarayTM) and standard (PentarayTM) multielectrode mapping catheters. The investigational catheter has more electrodes (48 vs. 20), each with a smaller surface area (0.9 vs. 2.0 mm2) and spacing is fixed at 2 mm (vs. 2-6-2 mm). Electrogram (EGM) characteristics, mapping efficiency and scar description were compared between the catheters and late gadolinium enhancement (LGE). Electrogram acquisition rate was faster with the investigational catheter (814 ± 126 vs. 148 ± 58 EGM/min, P = 0.02) resulting in higher density maps (38 ± 10.3 vs. 10.1 ± 10.4 EGM/cm2, P = 0.02). Bipolar voltage amplitude was similar between the catheters in normal and infarcted myocardium (P = 0.265 and P = 0.44) and the infarct surface area was similar between the catheters (P = 0.12) and corresponded to subendocardial LGE. The investigational catheter identified a higher proportion of near-field local abnormal ventricular activities within the low-voltage area (53 ± 16% vs. 34 ± 16%, P = 0.03) that were considered far-field EGMs by the standard catheter. The investigational catheter was also advantageous for mapping haemodymically non-tolerated ventricular tachycardias due to its higher acquisition rate (P < 0.001).Conclusion: A novel multielectrode mapping catheter with higher number of small, and closely spaced electrodes increases the mapping speed, EGM density and the ability to recognize low amplitude near-field EGMs in ventricles with healed infarction. [ABSTRACT FROM AUTHOR]

Introduction: The voltage map during sinus rhythm (SR) is a cornerstone of substrate mapping (SM) in scar‐related ventricular tachycardia (VT) and frequently used with pace mapping (PM). Where to conduct PM is unclear in cases of an extensive or unidentified substrate. Conduction properties are another aspect incorporated by SM, and conduction slowing has gained interest as being related to successful ablation, although its mechanism has not been elucidated. We aimed to investigate the relationship between SR conduction properties and VT isthmuses. Methods: Nineteen patients (mean age, 62 years) who underwent VT ablation with voltage mapping and PM were reviewed. Isochronal late activation maps (ILAMs) with eight zones were reconstructed and sequentially named from one to eight according to the SR propagation. Good PM sites were superimposed on ILAMs, and the isthmus was defined using different pacing latencies. ILAM properties harboring isthmuses were investigated. Results: Twenty‐eight ILAMs (13 epicardium, 1 right ventricular [RV], and 14 left ventricular [LV] endocardium) were reviewed. Eighteen isthmuses of 24 target VTs were identified, in which the proximal ends were in a later zone than the distal ends (zone 6 vs 4; P <.001), suggesting a reverse isthmus vector to the SR. The conduction velocity of the zone involving the distal isthmus was significantly lower than that of the SR preceding zone (0.40 vs 1.30 m/s; P <.001). SR conduction velocity decelerated by 69.5% (range 59.7%‐74.5%) before propagating into the isthmus area. Conclusion: Conduction slowing area during SR were related with the exit portion of the VT isthmuses. [ABSTRACT FROM AUTHOR]

Acquiring adequate mapping data in patients with atrial fibrillation is still one of the main obstacles in the treatment of this atrial arrhythmia. Due to the lack of catheters with both a panoramic field of view and sufficient electrode density for simultaneous mapping, electrophysiologists are forced to fall back on sequential mapping techniques. But, because activation patterns change rapidly during atrial fibrillation, they cannot be mapped sequentially. We propose that mapping tissue properties which are time independent, in contrast, allows a sequential approach. Here, we use the shortest measured electrogram cycle length to estimate the effective refractory period of the underlying tissue in a simulation study. Atrial fibrillation was simulated in a spherical model of the left atrium comprised of regions with varied refractory period. We found that the minimal measured electrogram cycle length correlates with the effective refractory period of the underlying tissue if the regions with distinct refractory properties are large enough and if the absolute difference in effective refractory periods is sufficient. This approach is capable of identifying regions of lowered effective refractory period without the need for cardioversion. Those regions are likely to harbor drivers of atrial fibrillation, which emphasizes the necessity of their localization.

Background Atrial tachycardia (AT) is common in patients with adult congenital heart disease and is challenging to map and ablate. We used ultra‐high‐density mapping to characterize the AT mechanism and investigate whether substrate characteristics are related to ablation outcomes. Methods and Results A total of 50 ATs were mapped with ultra‐high‐density mapping in 23 procedures. Patients were followed up for up to 12 months. Procedures were classified to group A if there was 1 single AT induced (n=12) and group B if there were ≥2 ATs induced (n=11 procedures). AT mechanism per procedure was macro re‐entry (n=10) and localized re‐entry (n=2) in group A and multiple focal (n=6) or multiple macro re‐entry (n=5) in group B. Procedure duration, low voltage area (0.05–0.5 mV), and low voltage area indexed for volume were higher in group B (159 [147–180] versus 412 [352–420] minutes, P

There is no known strategy to differentiate which multicomponent electrograms in sinus rhythm maintain reentrant ventricular tachycardia (VT). Low entropy in the voltage breakdown of a multicomponent electrogram can localize conditions suitable for reentry but has not been validated against the classic VT activation mapping. We examined whether low entropy in a late and diversely activated ventricular scar region characterizes and differentiates the diastolic path of VT and represents protected tissue channels devoid of side branches. Intraoperative bipolar electrogram (BiEGM) activation and entropy maps were obtained during sinus rhythm in 17 patients with ischemic cardiomyopathy and compared with diastolic activation paths of VT (total of 39 VTs). Mathematical modeling of a zigzag main channel with side branches was also used to further validate structural representation of low entropy in the ventricular scar. A median of one region per patient (range: 1-2 regions) was identified in sinus rhythm, in which BiEGM with the latest mean activation time and adjacent minimum entropy were assembled together in a high-activation dispersion region. These regions accurately recognized diastolic paths of 34 VTs, often to multiple inducible VTs within a single individual arrhythmogenic region. In mathematical modeling, side branching from the main channel had a strong influence on the BiEGM composition along the main channel. The BiEGM obtained from a long unbranched channel had the lowest entropy compared with those with multiple side branches. In conclusion, among a population of multicomponent sinus electrograms, those that demonstrate low entropy and are delayed colocalize to critical long-protected channels of VT. This information is pertinent for planning VT ablation in sinus rhythm. [ABSTRACT FROM AUTHOR]

Catheter ablation of ventricular arrhythmias has evolved considerably since it was first described more than 3 decades ago. Advancements in understanding the underlying substrate, utilizing pre-procedural imaging, and evolving ablation techniques have improved the outcomes of catheter ablation. Ensuring safety and efficacy during catheter ablation requires adequate planning, including analysis of the 12 lead ECG and appropriate pre-procedural imaging. Defining the underlying arrhythmogenic substrate and disease eitology allow for the developed of tailored ablation strategies, especially for patients with non-ischemic cardiomyopathies. During ablation, the type of anesthesia can affect VT induction, the quality of the electro-anatomic map, and the stability of the catheter during ablation. For high risk patients, appropriate selection of hemodynamic support can increase the success of VT ablation. For patients in whom VT is hemodynamically unstable or difficult to induce, substrate modification strategies can aid in safe and successful ablation. Recently, there has been an several advancements in substrate mapping strategies that can be used to identify and differentiate local late potentials. The incorporation of high-definition mapping and contact-sense technologies have both had incremental benefits on the success of ablation procedures. It is crucial to harness newer technology and ablation strategies with the highest level of peri-procedural safety to achieve optimal long-term outcomes in patients undergoing VT ablation., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Subramanian, Atreya, Saggu, Yalagudri, and Narasimhan.)

Background Left ventricular aneurysm (LVA) might be an arrhythmogenic substrate. Endocardiectomy and cryoablation for ventricular tachycardia (VT) with LVA can cause extensive myocardial damage. We aimed to evaluate the feasibility of surgical radial linear ablation for VT with LVA guided by electrophysiological mapping. Materials and methods Porcine models of VT with LVA were developed. Endocardial and epicardial substrate mapping during sinus rhythm were performed under thoracotomy. Surgical radial linear ablation was achieved by a bipolar radiofrequency ablation device. Outcomes, including procedural success and acute freedom of VT, were analyzed. Results Fifteen of 20 pigs developed LVA in a 6-wk survival period. A total of 28 sustained monomorphic VTs were initiated in 13 of 15 pigs (86.67%). The number of potential points captured from the endocardium and epicardium were 319 ± 45 and 358 ± 52 per animal, respectively. The ablative targets containing abnormal potentials were located largely on the border zone of LVA. Eight linear lesions from core to border zone of LVA were achieved per animal in a radial and even manner continuously, and ablation was repeated three times to transect border zone. The acute freedom of VT was 84.62%, P < 0.05. Conclusions Surgical linear endo-epicardial ablation seemed to be feasible in a porcine model with VT and LVA. [ABSTRACT FROM AUTHOR]