Volume 13, Issue 1, Pages (January 2016)

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Date of download: 7/5/2016 Copyright © The American College of Cardiology. All rights reserved. From: Cardiac Magnetic Resonance Imaging for the Interventional.

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Volume 13, Issue 1, Pages 262-273 (January 2016) A swine model of infarct-related reentrant ventricular tachycardia: Electroanatomic, magnetic resonance, and histopathological characterization Cory M. Tschabrunn, CEPS, Sébastien Roujol, PhD, Reza Nezafat, PhD, Beverly Faulkner-Jones, MD, PhD, Alfred E. Buxton, MD, Mark E. Josephson, MD, Elad Anter, MD Heart Rhythm Volume 13, Issue 1, Pages 262-273 (January 2016) DOI: 10.1016/j.hrthm.2015.07.030 Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 1 Induction of myocardial infarction via percutaneous balloon occlusion of the left anterior descending (LAD) coronary artery. A: Coronary angiography performed in the anterior-posterior view before and after balloon inflation with confirmation of distal occlusion immediately after the second diagonal branch of the mid-LAD (white arrow). B: Twelve-lead electrocardiogram shortly after balloon inflation, exhibiting significant ST-segment elevation in leads V1–V3 with reciprocal ST-segment depressions in leads I and aVL. Heart Rhythm 2016 13, 262-273DOI: (10.1016/j.hrthm.2015.07.030) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 2 In vivo high-resolution late gadolinium enhancement (LGE) magnetic resonance imaging performed 6 weeks after myocardial infarction. LGE images were acquired in the axial view with isotropic spatial resolution of 1 mm3. A and B: Reformatted short-axis views extending from the apex (panel A) to the base (panel B) are shown with anterior-septal LGE (yellow arrows). Variable LGE signal intensities were observed within the scar area including regions of dark signal representative of survived myocardial tissue (red arrow). These regions of viable tissue were predominantly preserved to the subendocardial rather than subepicardial tissue. Regions of confluent LGE signal intensity indicative of transmural scar were also observed (black arrow). C: Short-axis view further toward the base without evidence of LGE. D: Reformatted 4-chamber view with anterior, septal, and lateral scar with variable LGE intensities (yellow arrows). Viable septal and lateral subendocardial tissue is present (red arrow) and surrounds a segment of transmural anterior scar (black arrow). LV = left ventricle; RV = right ventricle. Heart Rhythm 2016 13, 262-273DOI: (10.1016/j.hrthm.2015.07.030) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 3 A: Overdrive pacing at incremental cycle lengths from the right ventricular outflow tract (RVOT) showed evidence of progressive fusion. B: Overdrive pacing from a multielectrode catheter positioned within the reentrant circuit at the anteroseptal endocardium. Pacing at 30 ms faster than the tachycardia cycle length (the paced electrode is not shown because of significant artifact) resulted in entrainment of the tachycardia with minimal fusion on the 12-lead electrocardiogram and similar wavefront propagation on the multielectrode catheter, consistent with orthodromic capture. VT = ventricular tachycardia. Heart Rhythm 2016 13, 262-273DOI: (10.1016/j.hrthm.2015.07.030) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 4 Endocardial recordings using a multielectrode catheter during ventricular tachycardia. The catheter was positioned in the anteroseptum and recorded continuous electrical activity consistent with “reentrant excitation.” LV = left ventricular. Heart Rhythm 2016 13, 262-273DOI: (10.1016/j.hrthm.2015.07.030) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 5 A: Endocardial left ventricular (LV) bipolar voltage map (voltage range displayed 0.5–1.5 mV) in the right anterior oblique (RAO) projection 6 weeks after myocardial infarction with anterior low-voltage regions extending to the septum and lateral LV. A region of preserved endocardial bipolar voltage (>1.5 mV) is observed transecting vertically through the anterior scar. The adjacent low-voltage electrograms often displayed fractioned and/or late potentials (black arrow). B: RAO view of in vivo late gadolinium enhancement (LGE) magnetic resonance imaging (MRI) reconstruction of the same animal acquired before the mapping procedure. The reconstruction depicts variable LGE intensities in the 1-mm subendocardial layer across the LV. The LGE MRI map shows scar distribution corresponding to the voltage map (panel A). In particular, a region within the scar area where LGE was not present (white arrows) corresponded to the area of preserved endocardial bipolar voltage. CMR = cardiac magnetic resonance; EAM = electroanatomic mapping; EGM = electrogram. Heart Rhythm 2016 13, 262-273DOI: (10.1016/j.hrthm.2015.07.030) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 6 A: Endocardial right ventricular (RV) and left ventricular (LV) bipolar voltage map (voltage range 0.5–1.5 mV) in the anterior-posterior projection after myocardial infarction. B: Epicardial bipolar voltage map (voltage range 0.5–1.0 mV) in the anterior-posterior projection in the same animal with epicardial anterior low voltage with abnormal electrograms (EGMs) consistent with scar as opposed to epicardial fat. Heart Rhythm 2016 13, 262-273DOI: (10.1016/j.hrthm.2015.07.030) Copyright © 2016 Heart Rhythm Society Terms and Conditions

Figure 7 A: Mason’s trichrome stained histology section of the anterior wall including the septal and lateral borders (magnification 2.25×). The blue stained tissue indicates the extent of fibrosis. The yellow box encloses the anterior wall with transmural endocardial to epicardial fibrosis. The red subendocardial tissue indicated by the yellow arrows is red blood cell accumulation from tissue sectioning. The survived layer of myocardial fibers in disarray was commonly observed at the septal and lateral borders of the scar (black arrows). B: Magnified image (magnification 10×) of the subendocardial region demonstrating predominant fibrotic tissue with red blood cell distribution. C: Magnified image (magnification 10×) of the lateral border of the transmural scar with survived subendocardial tissue. The viable tissue demonstrates loss of the parallel bundle orientation with myocardial fiber disarray and varying degrees of fibrosis. Heart Rhythm 2016 13, 262-273DOI: (10.1016/j.hrthm.2015.07.030) Copyright © 2016 Heart Rhythm Society Terms and Conditions