Impact of Multidirectional Pacing on Activation and Repolarization Parameters to Localize Ischemic Ventricular Tachycardia Circuits

Background In ventricular tachycardia (VT), optimal substrate mapping strategies identifying arrhythmogenic sites are not established. Objectives This study sought to evaluate multidirectional pacing on the distribution of specific conduction and repolarization metrics to localize re-entrant VT sites in a porcine infarct model. Methods Substrate maps were created in 13 pigs with chronic myocardial infarction using the Advisor HD Grid (Abbott) during right ventricular (RV), left ventricular, biventricular pacing (BIV), and sinus rhythm (SR). Critical VT sites of early-, mid-, and late-diastolic signals were delineated. Vulnerable sites to re-entry were defined as sites of latest activation timing within and post-QRS complex, largest activation and activation-recovery interval gradients. Distances between the 20 most vulnerable sites and diastolic VT points were measured, and identification of VT points was assessed using the area under the receiver-operating characteristic curve. Results A total of 34 VTs were mapped, and 48 sinus and pacing maps were obtained (10 BIV, 13 left ventricular, 13 RV, 12 SR). Late potential mapping in SR was taken as the established clinical standard for comparison. Latest activation time with BIV pacing provided the closest localization for VT isthmus (median 5.5 mm; IQR: 7.15 mm; P < 0.005). The gradient of activation-recovery interval using RV pacing had closest localization for VT exit and entrance (median 10.6 mm; IQR: 5.0 mm; P < 0.005 and 9.4 mm; IQR: 8.0 mm; P < 0.05). Global sensitivity and specificity analysis showed that gradient of activation-recovery interval in SR achieved the highest area under the receiver-operating characteristic curve, with similar results from the gradient of activation timing. Conclusions Multidirectional pacing in combination with conduction and repolarization parameters enables better localization of VT diastolic critical sites vs SR late potentials. (c) 2024 by the American College of Cardiology Foundation.