Optimization of anti-tachycardia pacing efficacy through scar-specific delivery and minimization of re-initiation: a virtual study on a cohort of infarcted porcine hearts. Issue 2 (5th October 2022)

• Record Type: Journal Article
• Authors: Qian, Shuang; Connolly, Adam; Mendonca-Costa, Caroline; Campos, Fernando; Rodero, Cristobal; Whitaker, John; Rinaldi, Christopher A; Bishop, Martin J
• Is Part Of: Europace. Volume 25:Issue 2(2023)
• Page Start: 716
• Page End: 725
• Publication Date: 2022-10-05
• Subjects: ȃAnti-tachycardia pacing -- Cardiac resynchronization therapy -- Implantable cardioverter defibrillator -- Patient-specific modelling -- Ventricular tachycardia; Arrhythmia -- Treatment -- Periodicals; Cardiac pacing -- Periodicals; Catheter ablation -- Periodicals; Heart -- Physiology -- Periodicals; Electrophysiology -- Periodicals; 617.4120645
• DOI: 10.1093/europace/euac165
• Languages: English
• ISSNs: 1099-5129

Abstract

Abstract: Aims: Anti-tachycardia pacing (ATP) is a reliable electrotherapy to painlessly terminate ventricular tachycardia (VT). However, ATP is often ineffective, particularly for fast VTs. The efficacy may be enhanced by optimized delivery closer to the re-entrant circuit driving the VT. This study aims to compare ATP efficacy for different delivery locations with respect to the re-entrant circuit, and further optimize ATP by minimizing failure through re-initiation. Methods and results: Seventy-three sustained VTs were induced in a cohort of seven infarcted porcine ventricular computational models, largely dominated by a single re-entrant pathway. The efficacy of burst ATP delivered from three locations proximal to the re-entrant circuit (septum) and three distal locations (lateral/posterior left ventricle) was compared. Re-initiation episodes were used to develop an algorithm utilizing correlations between successive sensed electrogram morphologies to automatically truncate ATP pulse delivery. Anti-tachycardia pacing was more efficacious at terminating slow compared with fast VTs (65 vs. 46%, P = 0.000039). A separate analysis of slow VTs showed that the efficacy was significantly higher when delivered from distal compared with proximal locations (distal 72%, proximal 59%), being reversed for fast VTs (distal 41%, proximal 51%). Application of our early termination detection algorithm (ETDA) accurately detected VT termination in 79% of re-initiated cases, improving the overall efficacy for proximal delivery with delivery inside the critical isthmus (CI) itself being overall most effective. Conclusion: Anti-tachycardia pacing delivery proximal to the re-entrant circuit is more effective at terminating fast VTs, but less so slow VTs, due to frequent re-initiation. Attenuating re-initiation, through ETDA, increases the efficacy of delivery within the CI for all VTs. Graphical Abstract: Graphical Abstract ATP efficacy with respect to VT rates and delivery locations from the re-entrant circuit and ETDA for attenuating re-initiation and improving efficacy. ATP, anti-tachycardia pacing; ETDA, early termination detection algorithm; VT, ventricular tachycardia.