Standard Ablation Versus Magnetic Resonance Imaging–Guided Ablation in the Treatment of Ventricular Tachycardia

Name: Standard Ablation Versus Magnetic Resonance Imaging–Guided Ablation in the Treatment of Ventricular Tachycardia
Uploaded: 2018-01-01

Tarek Zghaib; Esra Gücük İpek; Rozann Hansford; Hiroshi Ashikaga; Ronald D. Berger; Joseph E. Marine; David Spragg; Harikrishna Tandri; Stefan L. Zimmerman; Henry R. Halperin; Scott C. Brancato; Hugh Calkins; Charles A. Henrikson; Saman Nazarian

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ID: W2784190520
Title: Standard Ablation Versus Magnetic Resonance Imaging–Guided Ablation in the Treatment of Ventricular Tachycardia
Abstract: HomeCirculation: Arrhythmia and ElectrophysiologyVol. 11, No. 1Standard Ablation Versus Magnetic Resonance Imaging–Guided Ablation in the Treatment of Ventricular Tachycardia Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessLetterPDF/EPUBStandard Ablation Versus Magnetic Resonance Imaging–Guided Ablation in the Treatment of Ventricular Tachycardia Tarek Zghaib, MD, Esra G. Ipek, MD, Rozann Hansford, RN, Hiroshi Ashikaga, MD, PhD, Ronald D. Berger, MD, PhD, Joseph E. Marine, MD, David D. Spragg, MD, Harikrishna Tandri, MD, Stefan L. Zimmerman, MD, Henry Halperin, MD, MA, Scott Brancato, MD, Hugh Calkins, MD, Charles Henrikson, MD, MPH and Saman Nazarian, MD, PhD Tarek ZghaibTarek Zghaib From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.). , Esra G. IpekEsra G. Ipek From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.). , Rozann HansfordRozann Hansford From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.). , Hiroshi AshikagaHiroshi Ashikaga From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.). , Ronald D. BergerRonald D. Berger From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.). , Joseph E. MarineJoseph E. Marine From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.). , David D. SpraggDavid D. Spragg From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.). , Harikrishna TandriHarikrishna Tandri From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.). , Stefan L. ZimmermanStefan L. Zimmerman From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.). , Henry HalperinHenry Halperin From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.). , Scott BrancatoScott Brancato From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.). , Hugh CalkinsHugh Calkins From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.). , Charles HenriksonCharles Henrikson From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.). and Saman NazarianSaman Nazarian From the Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD (T.Z., E.G.I., R.H., H.A., R.D.B., J.E.M., D.D.S., H.T., H.H., H.C., C.H.); Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD (S.L.Z., H.H.); Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD (H.H.); Department of Cardiology, Providence St. Vincent Medical Center, Portland, OR (S.B.); Division of Cardiology, Oregon Health Sciences University, Portland (C.H.); and Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia (S.N.). Originally published12 Jan 2018https://doi.org/10.1161/CIRCEP.117.005973Circulation: Arrhythmia and Electrophysiology. 2018;11:e005973Radiofrequency ablation is an effective treatment strategy for ischemic and nonischemic cardiomyopathy-related ventricular tachycardia (VT). The role of substrate-guided ablation, performed using electrogram characteristics (low amplitude, fractionated or isolated potentials) as scar surrogates, is expanding because of frequent hemodynamic instability during entrainment mapping of scar-related VT. Late gadolinium-enhancement on cardiac magnetic resonance imaging (LGE-MRI) can accurately characterize the transmural extent, location, and configuration of ventricular scar.1 Integration of LGE-MRI into electroanatomical mapping during VT ablation was shown, in preliminary studies, to be feasible and to provide accurate localization of VT substrate and reentry circuits.2–4 However, studies to date examining the impact of MRI scar integration on procedural outcomes have lacked control groups, precluding any comparisons with standard practice. We performed a study to (1) demonstrate the feasibility in clinical practice of integrating MRI-derived scar for guidance of VT ablation; (2) report on the periprocedural performance of LGE-MRI in identifying the arrhythmogenic substrate; and (3) examine the impact of MRI-guided ablation on procedural length and acute and long-term outcomes.Study DesignIn this prospective multicenter study, we enrolled 24 consecutive patients with ischemic (n=9) and nonischemic cardiomyopathy (n=15), referred for catheter ablation of scar-related monomorphic VT. Patients were assigned, at the discretion of the treating physician (not randomized), to undergo either MRI-derived scar–guided ablation or traditional ablation. Clinical characteristics of patients in both groups were statistically comparable with a higher tendency to use scar integration for patients with prior failed ablation, lower left ventricular ejection fraction, and epicardial circuits (Table I in the Data Supplement).MRI acquisition and analysis, as well as standard ablation strategy, are fully described in the supplement. Briefly, an electrophysiology study, using programmed stimulation, was performed at the procedure onset to induce the clinical VT(s) and to enable the identification and ablation of VT critical sites by pace mapping or entrainment mapping. Additional ablation targets included areas with fractionated, isolated, and low-voltage potentials. In MRI scar–guided ablation, registration of LGE map and electroanatomical mapping was accomplished, and regions exhibiting LGE were carefully interrogated to identify low-voltage or abnormal electrograms. Entrainment mapping or pace mapping maneuvers were then performed in regions with LGE to ascertain their involvement in clinical VT. LGE areas were ablated if found to be implicated in VT, and areas with LGE and abnormal electrograms were ablated in a substrate modification strategy if VT could not be induced/mapped. The Figure displays examples of VT ablation performed with and without MRI scar integration.Download figureDownload PowerPointFigure. A, Representative example of ventricular tachycardia (VT) ablation performed without magnetic resonance imaging (MRI)–derived scar integration. Endocardial electroanatomical mapping (EAM) identified scar at the basal infero-lateral region of the left ventricle (LV), the ablation of which terminated clinical VT. B, Representative example of VT ablation performed with MRI-derived scar integration. Voltage map of the right ventricle (RV) was constructed and merged with the previously acquired MRI (both segmented anatomic shell in blue as well as scar in gray). A basal septal and inferior RV scar noted on late gadolinium-enhancement (LGE)-MRI (marked by *) closely matched the areas of low voltage, fractionated and isolated potentials found on EAM. Substrate modification was performed within the scar. No sustained VT was inducible subsequently. Ao indicates aorta; and PA, pulmonary artery.Patients were followed post-procedure with regular implantable cardioverter defibrillator interrogations, Holter monitoring, or ECG recordings. The primary end point was long-term freedom from target VT recurrence.ResultsTable I and Figure II in the Data Supplement exhibit procedural and MRI scar data, respectively. In the scar integration group, all patients with inducible VTs had evidence of LGE on MRI, and ablation within or at the border of LGE sites terminated the arrhythmia in all these patients (100% match between clinical VT critical sites and LGE). In patients without LGE on MRI, sustained VT could not be induced. In 1 patient with nonischemic cardiomyopathy, MRI revealed LGE in the midinferior wall, correlating with low-voltage and abnormal potentials on electroanatomical mapping. In this patient, VT could not be elicited on various maneuvers, and substrate modification was done using radiofrequency energy in that area. Data on interrogation of LGE areas for abnormal electrograms were available in 9 of 13 patients in scar merge group. Abnormal electrograms were colocalized with LGE in all patients and were targeted by ablation in patients in whom a substrate modification approach was adopted. Procedural, fluoroscopy, and ablation times, as well as ablation burden, were similar in both study arms (P>0.05). Acute procedural success (clinical VT termination or noninducibility) was achieved in all patients.During a median follow-up of 38.5 interquartile range (26–53) months, 16 (73%) patients had VT recurrence (7 in the study group versus 9 controls; Table II in the Data Supplement). After adjusting for age, sex, cardiac substrate, epicardial ablation, and left ventricular ejection fraction, MRI-guided ablation was associated with reduced VT recurrence during follow-up (hazard ratio, 0.12; 95% confidence interval, 0.02–0.75; P=0.023). Follow-up echocardiographic studies were performed in a subset of patients and described in the Data Supplement.DiscussionThe current study is the first to evaluate the impact of integration of LGE-MRI scar into electroanatomical mapping during VT ablation on long-term procedural outcome using a control group for comparison. The main findings of this study are as follows: (1) integration of MRI-derived scar during VT ablation is feasible; (2) MRI-defined scar accurately identifies VT substrate without differences on procedural or fluoroscopy time; (3) acute ablation success rates were similar in procedures performed with and without scar merging; and (4) after adjusting for clinical parameters, MRI-guided ablation was associated with decreased risk of long-term VT recurrence.Incorporation of the LGE-derived scar facilitates VT ablation in the setting of hemodynamic instability that precludes conventional electrophysiological mapping and dense point-by-point voltage mapping and may shorten procedure time devoted to substrate identification. LGE-MRI can also complement VT substrate mapping by focusing substrate mapping on scar regions. Indeed, regional necrosis/fibrosis is accompanied by hypertrophy of adjacent viable tissue (as a result of remodeling),5 exhibit normal voltage, and be glossed over after identification of sparse neighboring healthy points. Mid-wall scar may also contain critical parts of VT reentry circuits and, while missed on bipolar voltage mapping, can be displayed on integration of MRI scar. We think that scar integration enhances the operator's ability to target substrate that would otherwise have been missed, potentially improving patient outcomes. In addition, MRI scar integration may impact safety by avoiding unnecessary ablation of healthy myocardium in procedures guided solely by voltage mapping. In fact, false-positive low-voltage may be because of poor contact, thinner walls, or epicardial fat, leading to overestimation of arrhythmogenic substrate. Study limitations are listed in the Data Supplement.Sources of FundingThe study was funded by the National Institutes of Health (grant nos. K23HL089333 and R01HL116280) as well as by a Biosense Webster grant to Drs Nazarian and Henrikson; the Roz and Marvin H. Weiner and Family Foundation; the Dr Francis P. Chiaramonte Foundation; Marilyn and Christian Poindexter; and the Norbert and Louise Grunwald Cardiac Arrhythmia Research Fund.DisclosuresDr Nazarian is a scientific advisor to Medtronic, CardioSolv, and Biosense Webster. The other authors report no conflicts.FootnotesThe Data Supplement is available at http://circep.ahajournals.org/lookup/suppl/doi:10.1161/CIRCEP.117.005973/-/DC1.Circ Arrhythm Electrophysiol is available at http://circep.ahajournals.org.Correspondence to: Saman Nazarian, MD, PhD, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Founders 9124, Philadelphia, PA 19104. E-mail [email protected]References1. Kim RJ, Fieno DS, Parrish TB, Harris K, Chen EL, Simonetti O, Bundy J, Finn JP, Klocke FJ, Judd RM. 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Okada D, Xie E, Assis F, Smith J, Derakhshan A, Gowani Z, Ambale‐Venkatesh B, Gilotra N, Zimmerman S, Berger R, Calkins H, Lima J, Tandri H and Chrispin J (2019) Regional abnormalities on cardiac magnetic resonance imaging and arrhythmic events in patients with cardiac sarcoidosis, Journal of Cardiovascular Electrophysiology, 10.1111/jce.14082, 30:10, (1967-1976), Online publication date: 1-Oct-2019. Runge M, Ibrahim E, Bogun F, Attili A, Mahani M, Pang Y, Horwood L, Chenevert T and Stojanovska J (2019) Metal Artifact Reduction in Cardiovascular MRI for Accurate Myocardial Scar Assessment in Patients With Cardiac Implantable Electronic Devices, American Journal of Roentgenology, 10.2214/AJR.19.21187, 213:3, (555-561), Online publication date: 1-Sep-2019. Markman T and Nazarian S (2019) Treatment of ventricular arrhythmias: What's New?, Trends in Cardiovascular Medicine, 10.1016/j.tcm.2018.09.014, 29:5, (249-261), Online publication date: 1-Jul-2019. Okada D, Smith J, Derakhshan A, Gowani Z, Zimmerman S, Misra S, Berger R, Calkins H, Tandri H and Chrispin J (2019) Electrophysiology study for risk stratification in patients with cardiac sarcoidosis and abnormal cardiac imaging, IJC Heart & Vasculature, 10.1016/j.ijcha.2019.03.002, 23, (100342), Online publication date: 1-Jun-2019. Jang J, Tschabrunn C, Barkagan M, Anter E, Menze B, Nezafat R and Bauer W (2018) Three-dimensional holographic visualization of high-resolution myocardial scar on HoloLens, PLOS ONE, 10.1371/journal.pone.0205188, 13:10, (e0205188) Bourier F and Sacher F (2018) Moderne Mapping-TechnologienModern mapping technologies, Herzschrittmachertherapie + Elektrophysiologie, 10.1007/s00399-018-0576-9, 29:3, (271-277), Online publication date: 1-Sep-2018. Zghaib T, Ipek E, Hansford R, Ashikaga H, Berger R, Marine J, Spragg D, Tandri H, Zimmerman S, Halperin H, Brancato S, Calkins H, Henrikson C and Nazarian S (2018) Response by Zghaib et al to Letter Regarding Article, "Standard Ablation Versus Magnetic Resonance Imaging–Guided Ablation in the Treatment of Ventricular Tachycardia", Circulation: Arrhythmia and Electrophysiology, 11:4, Online publication date: 1-Apr-2018.Penela D, Andreu D and Berruezo A (2018) Letter by Penela et al Regarding Article, "Standard Ablation Versus Magnetic Resonance Imaging–Guided Ablation in the Treatment of Ventricular Tachycardia", Circulation: Arrhythmia and Electrophysiology, 11:4, Online publication date: 1-Apr-2018. January 2018Vol 11, Issue 1 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.117.005973PMID: 29330333 Manuscript receivedJune 27, 2017Manuscript acceptedNovember 30, 2017Originally publishedJanuary 12, 2018 Keywordstachycardia, ventricularmagnetic resonance imagingelectrophysiologycatheter ablationcardiomyopathiesPDF download Advertisement SubjectsArrhythmiasElectrophysiologyImagingMagnetic Resonance Imaging (MRI)Ventricular Fibrillation
Publication Year: 2018
Publication Date: 2018-01-01
Language: en
Type: letter
Indexed In: ['crossref', 'pubmed']

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1179, 1263], 'OR': [162, 248, 332, 416, 502, 588, 674, 758, 844, 928, 1012, 1096, 1180, 1264], '(S.B.);': [163, 249, 333, 417, 503, 589, 675, 759, 845, 929, 1013, 1097, 1181, 1265], 'Oregon': [167, 253, 337, 421, 507, 593, 679, 763, 849, 933, 1017, 1101, 1185, 1269], 'Health': [168, 254, 338, 422, 508, 594, 680, 764, 850, 934, 1018, 1102, 1186, 1270, 2398], 'Sciences': [169, 255, 339, 423, 509, 595, 681, 765, 851, 935, 1019, 1103, 1187, 1271], 'Portland': [171, 257, 341, 425, 511, 597, 683, 767, 853, 937, 1021, 1105, 1189, 1273], '(C.H.);': [172, 258, 342, 426, 512, 598, 684, 768, 854, 938, 1022, 1106, 1190, 1274], 'Pennsylvania': [179, 265, 349, 433, 519, 605, 691, 775, 861, 945, 1029, 1113, 1197, 1281], 'Perelman': [180, 266, 350, 434, 520, 606, 692, 776, 862, 946, 1030, 1114, 1198, 1282, 2483], 'Philadelphia': [184, 270, 354, 438, 524, 610, 696, 780, 866, 950, 1034, 1118, 1202, 1286], '(S.N.).': [185, 271, 355, 439, 525, 611, 697, 781, 867, 951, 1035, 1119, 1203, 1287], ',': [186, 272, 356, 440, 526, 612, 698, 782, 868, 952, 1036, 1120], 'IpekEsra': [189], 'Ipek': [191, 3582], 'HansfordRozann': [274], 'Hansford': [275, 2692, 3584], 'AshikagaHiroshi': [358], 'Ashikaga': [359, 3586], 'BergerRonald': [443], 'Berger': [445, 2720, 3373, 3495, 3588], 'MarineJoseph': [529], 'Marine': [531, 2702, 3590], 'SpraggDavid': [615], 'Spragg': [617, 2704, 3592], 'TandriHarikrishna': [700], 'Tandri': [701, 2708, 3379, 3499, 3594], 'ZimmermanStefan': [785], 'Zimmerman': [787, 2714, 3371, 3491, 3596], 'HalperinHenry': [870], 'Halperin': [871, 2724, 3598], 'BrancatoScott': [954], 'Brancato': [955, 3600], 'CalkinsHugh': [1038], 'Calkins': [1039, 2722, 3375, 3497, 3602], 'HenriksonCharles': [1122], 'Henrikson': [1123, 2700, 3604], 'NazarianSaman': [1206], 'Nazarian': [1207, 2414, 2446, 2726, 3126, 3463, 3607], 'Originally': [1288], 'published12': [1289], 'Jan': [1290], '2018https://doi.org/10.1161/CIRCEP.117.005973Circulation:': [1291], 'Electrophysiology.': [1294], '2018;11:e005973Radiofrequency': [1295], 'ablation': [1296, 1369, 1454, 1483, 1505, 1554, 1586, 1598, 1691, 1708, 1734, 1745, 1885, 1999, 2013, 2018, 2084, 2136, 2163, 2182, 2203, 2219, 2348, 2797, 3103, 3297], 'is': [1297, 1328, 2119, 2164, 2262, 2447, 2465, 2471], 'an': [1298, 1563], 'effective': [1299], 'treatment': [1300, 2938, 3288], 'strategy': [1301, 1678], 'for': [1302, 1429, 1481, 1527, 1972, 2071, 2145, 2199, 2568, 2900, 3164, 3191, 3225, 3335, 3437, 3507], 'ischemic': [1303, 1474], 'nonischemic': [1305, 1477, 1926, 2565], 'cardiomyopathy-related': [1306], 'ventricular': [1307, 1359, 1535, 1705, 2080, 2571, 2624, 2678, 2738, 2903, 2940, 3105, 3295, 3468], 'tachycardia': [1308, 1706, 2679, 2739, 2796, 2941, 3296], '(VT).': [1309], 'The': [1310, 1685, 1842, 2147, 2457, 3097], 'role': [1311, 3098], 'substrate-guided': [1313], 'ablation,': [1314, 1532, 1611, 2077], 'performed': [1315, 1414, 1570, 1642, 1692, 1709, 1746, 1811, 2105, 2189], 'using': [1316, 1566, 1960, 2141, 2856], 'electrogram': [1317], 'characteristics': [1318, 1510, 2620], '(low': [1319], 'amplitude,': [1320], 'fractionated': [1321, 1801], 'or': [1322, 1506, 1594, 1631, 1636, 1839, 1887, 2033, 2177, 2371, 2799], 'isolated': [1323, 1803], 'potentials)': [1324], 'as': [1325, 1550, 1552, 1773, 1775, 2015, 2017, 2154, 2404, 2406], 'scar': [1326, 1398, 1428, 1525, 1697, 1715, 1722, 1749, 1776, 1785, 1865, 1870, 1983, 2130, 2160, 2168, 2193, 2216, 2257, 2290, 2318, 2340, 2619, 2670, 2802, 3552], 'surrogates,': [1327], 'expanding': [1329], 'because': [1330, 2365], 'frequent': [1332], 'hemodynamic': [1333, 2224], 'instability': [1334, 2225], 'during': [1335, 1367, 2091, 2134, 2161], 'entrainment': [1336, 1595], 'mapping': [1337, 1366, 1593, 1618, 1635, 1638, 1719, 2133, 2230, 2235, 2251, 2255, 2615, 2935, 3568], 'scar-related': [1339, 1485], 'VT.': [1340, 1487, 1653, 1739], 'Late': [1341], 'gadolinium-enhancement': [1342, 1789], 'on': [1343, 1400, 1436, 1455, 1787, 1806, 1882, 1914, 1941, 1952, 1967, 2137, 2175, 2256, 2303, 2310, 3294, 3387, 3553], 'cardiac': [1344, 2074, 2805, 2908, 3075, 3261, 3388, 3398, 3513, 3517], 'magnetic': [1345, 1711, 2561, 2609, 2668, 2742, 2806, 3253, 3389], 'resonance': [1346, 1712, 2562, 2610, 2669, 3254, 3390, 3704], 'imaging': [1347, 1713, 2563, 2611, 3100, 3391], '(LGE-MRI)': [1348], 'can': [1349, 2246, 2307, 3286], 'accurately': [1350, 2169], 'characterize': [1351], 'transmural': [1353], 'extent,': [1354], 'location,': [1355], 'configuration': [1357], 'scar.1': [1360], 'Integration': [1361, 2662], 'LGE-MRI': [1363, 1441, 2129, 2245], 'into': [1364, 2131, 2672], 'electroanatomical': [1365, 1617, 1718, 1942, 2132, 2613], 'VT': [1368, 1384, 1432, 1588, 1680, 1690, 1744, 1817, 1851, 1905, 1917, 1947, 2031, 2053, 2089, 2135, 2162, 2171, 2211, 2218, 2249, 2297], 'was': [1370, 1569, 1619, 1758, 1810, 1818, 1846, 1958, 2008, 2035, 2085, 2204, 2391], 'shown,': [1371], 'preliminary': [1373], 'studies,': [1374], 'be': [1376, 1661, 1683, 1920, 1950, 2279, 2308, 2364], 'feasible': [1377], 'provide': [1380], 'accurate': [1381], 'localization': [1382], 'substrate': [1385, 1676, 1956, 2005, 2172, 2243, 2250, 2254, 2326], 'reentry': [1387, 2298], 'circuits.2–4': [1388], 'However,': [1389], 'studies': [1390, 2103], 'date': [1392], 'examining': [1393], 'impact': [1395, 1451, 2125, 2343], 'MRI': [1397, 1609, 1696, 1766, 1864, 1928, 2313, 2339, 2523, 3224, 3436], 'integration': [1399, 1526, 1871, 2127, 2157, 2311, 2319, 2341, 2628], 'procedural': [1401, 1456, 1862, 2028, 2139, 2176], 'outcomes': [1402], 'have': [1403, 2330], 'lacked': [1404], 'control': [1405, 2143], 'groups,': [1406], 'precluding': [1407], 'any': [1408], 'comparisons': [1409], 'with': [1410, 1473, 1519, 1529, 1602, 1645, 1667, 1693, 1747, 1762, 1831, 1875, 1925, 1936, 1990, 2087, 2190, 2206, 2623, 2731, 2804, 2907, 2945, 3397, 3512], 'standard': [1411, 1553], 'practice.': [1412], 'We': [1413, 2315], 'a': [1415, 1520, 1675, 2004, 2040, 2107, 2142, 2271, 2408, 2448, 2734, 2943, 2948], 'study': [1416, 2024, 2058, 2118, 2152, 2390, 2735, 3506], '(1)': [1418, 2156], 'demonstrate': [1419], 'feasibility': [1421], 'clinical': [1423, 1578, 1652, 1738, 1904, 2200], 'practice': [1424], 'integrating': [1426], 'MRI-derived': [1427, 1503, 1748, 2159], 'guidance': [1430], 'ablation;': [1433], '(2)': [1434, 2166], 'report': [1435, 2460], 'periprocedural': [1438], 'performance': [1439], 'identifying': [1443, 2569], 'arrhythmogenic': [1445, 2378], 'substrate;': [1446], '(3)': [1448, 2180], 'examine': [1449], 'MRI-guided': [1453, 2083, 2202], 'length': [1457], 'acute': [1459, 2181], 'long-term': [1461, 1847, 2138, 2210], 'outcomes.Study': [1462], 'DesignIn': [1463], 'this': [1464, 1945, 2151], 'prospective': [1465], 'multicenter': [1466], 'study,': [1467, 1565, 2813], 'we': [1468], 'enrolled': [1469], '24': [1470], 'consecutive': [1471], 'patients': [1472, 1512, 1528, 1874, 1900, 1911, 1981, 1994, 2001, 2051, 2110, 2622, 2906, 3396, 3511], '(n=9)': [1475], 'cardiomyopathy': [1478], '(n=15),': [1479], 'referred': [1480], 'catheter': [1482, 3102], 'monomorphic': [1486], 'Patients': [1488, 3136, 3226, 3342, 3443], 'were': [1489, 1516, 1625, 1640, 1656, 1672, 1828, 1975, 1988, 1996, 2020, 2104, 2185], 'assigned,': [1490], 'at': [1491, 1571, 1723, 1888, 2467, 2473], 'discretion': [1493], 'treating': [1496], 'physician': [1497], '(not': [1498], 'randomized),': [1499], 'undergo': [1501], 'either': [1502], 'scar–guided': [1504, 1610], 'traditional': [1507], 'ablation.': [1508], 'Clinical': [1509, 2912, 3078, 3109], 'both': [1514, 2023], 'groups': [1515], 'statistically': [1517], 'comparable': [1518], 'higher': [1521], 'tendency': [1522], 'use': [1524], 'prior': [1530], 'failed': [1531], 'lower': [1533], 'left': [1534, 1730, 2079], 'ejection': [1536, 2081], 'fraction,': [1537, 2082], 'epicardial': [1539, 2076, 2372], 'circuits': [1540, 2299], '(Table': [1541], 'I': [1542, 1853], 'Data': [1545, 1859, 1966, 2067, 2115, 2386, 2463], 'Supplement).MRI': [1546], 'acquisition': [1547], 'analysis,': [1549], 'well': [1551, 1774, 2016, 2405], 'strategy,': [1555], 'are': [1556, 2153, 2382], 'fully': [1557], 'described': [1558, 2112], 'supplement.': [1561], 'Briefly,': [1562], 'electrophysiology': [1564], 'programmed': [1567], 'stimulation,': [1568], 'procedure': [1573, 2239], 'onset': [1574], 'induce': [1576], 'VT(s)': [1579], 'enable': [1582], 'identification': [1584, 2283], 'critical': [1589, 1906, 2294], 'sites': [1590, 1893, 1907], 'by': [1591, 1792, 1998, 2252, 2264, 2345, 2356, 2393, 2407, 2801, 3611, 3649], 'pace': [1592, 1637], 'mapping.': [1596, 1943, 2358], 'Additional': [1597], 'targets': [1599], 'included': [1600], 'areas': [1601, 1655, 1666, 1797, 1971], 'fractionated,': [1603], 'isolated,': [1604], 'low-voltage': [1606, 1630, 1937, 2362], 'potentials.': [1607], 'In': [1608, 1868, 1910, 1922, 1944, 2337, 2359], 'registration': [1612], 'LGE': [1614, 1624, 1646, 1654, 1668, 1881, 1892, 1913, 1930, 1970, 1991], 'map': [1615, 1752], 'accomplished,': [1620], 'regions': [1622, 1644], 'exhibiting': [1623], 'carefully': [1626], 'interrogated': [1627], 'identify': [1629], 'abnormal': [1632, 1670, 1939, 1973, 3516], 'electrograms.': [1633], 'Entrainment': [1634], 'maneuvers': [1639], 'then': [1641], 'ascertain': [1648], 'their': [1649], 'involvement': [1650], 'ablated': [1657, 1673], 'if': [1658, 1679], 'found': [1659, 1805], 'implicated': [1662], 'VT,': [1664], 'electrograms': [1671, 1974, 1987], 'modification': [1677, 1809, 1957, 2006], 'could': [1681, 1918, 1948], 'not': [1682, 1919, 1949], 'induced/mapped.': [1684], 'Figure': [1686, 1855], 'displays': [1687], 'examples': [1688], 'without': [1695, 1710, 1912, 2173, 2192], 'integration.Download': [1698], 'figureDownload': [1699], 'PowerPointFigure.': [1700], 'A,': [1701, 2555, 2642, 2707, 2713, 2761, 2770, 2774, 2778, 2840, 2884, 2961, 3019, 3042, 3046, 3088, 3155, 3320, 3364, 3418, 3488], 'Representative': [1702, 1741], 'example': [1703, 1742], '(VT)': [1707], '(MRI)–derived': [1714], 'integration.': [1716, 1750], 'Endocardial': [1717], '(EAM)': [1720], 'identified': [1721], 'basal': [1725, 1780], 'infero-lateral': [1726], 'region': [1727], 'ventricle': [1731, 1756], '(LV),': [1732], 'which': [1736], 'terminated': [1737, 1894], 'B,': [1740, 2541, 3368, 3539], 'Voltage': [1751], 'right': [1755], '(RV)': [1757], 'constructed': [1759], 'merged': [1761], 'previously': [1764], 'acquired': [1765], '(both': [1767], 'segmented': [1768], 'anatomic': [1769], 'shell': [1770], 'blue': [1772], 'gray).': [1778], 'A': [1779, 2790, 2929, 3277, 3280, 3292, 3646], 'septal': [1781], 'inferior': [1783], 'RV': [1784], 'noted': [1786], 'late': [1788], '(LGE)-MRI': [1790], '(marked': [1791], '*)': [1793], 'closely': [1794], 'matched': [1795], 'low': [1799], 'voltage,': [1800, 2277], 'potentials': [1804, 1940], 'EAM.': [1807], 'Substrate': [1808, 3331], 'within': [1812, 1886], 'scar.': [1814, 2314], 'No': [1815], 'sustained': [1816, 1916], 'inducible': [1819, 1876], 'subsequently.': [1820], 'Ao': [1821], 'indicates': [1822], 'aorta;': [1823], 'PA,': [1825], 'pulmonary': [1826], 'artery.Patients': [1827], 'followed': [1829], 'post-procedure': [1830], 'regular': [1832], 'implantable': [1833], 'cardioverter': [1834], 'defibrillator': [1835], 'interrogations,': [1836], 'Holter': [1837], 'monitoring,': [1838], 'ECG': [1840], 'recordings.': [1841], 'primary': [1843], 'end': [1844], 'point': [1845], 'freedom': [1848], 'from': [1849], 'target': [1850, 2325], 'recurrence.ResultsTable': [1852], 'II': [1856, 2064], 'Supplement': [1860, 2464], 'exhibit': [1861, 2275], 'data,': [1866], 'respectively.': [1867], 'group,': [1872], 'all': [1873, 1898, 1993, 2038], 'VTs': [1877], 'had': [1878, 2052], 'evidence': [1879], 'MRI,': [1883, 1915], 'border': [1890], 'arrhythmia': [1896, 2572], 'these': [1899], '(100%': [1901], 'match': [1902], 'between': [1903], 'LGE).': [1909], 'induced.': [1921], '1': [1923, 3681], 'patient': [1924, 2335, 2944], 'cardiomyopathy,': [1927], 'revealed': [1929], 'midinferior': [1933], 'wall,': [1934], 'correlating': [1935], 'patient,': [1946], 'elicited': [1951], 'various': [1953], 'maneuvers,': [1954], 'done': [1959], 'radiofrequency': [1961], 'energy': [1962], 'that': [1964, 2226, 2317, 2327], 'area.': [1965], 'interrogation': [1968], 'available': [1976, 2466, 2472], '9': [1978, 2061], '13': [1980], 'merge': [1984], 'group.': [1985], 'Abnormal': [1986], 'colocalized': [1989], 'targeted': [1997], 'whom': [2003], 'approach': [2007], 'adopted.': [2009], 'Procedural,': [2010], 'fluoroscopy,': [2011], 'times,': [2014], 'burden,': [2019], 'similar': [2021, 2186], 'arms': [2025], '(P>0.05).': [2026], 'Acute': [2027], 'success': [2029, 2183], '(clinical': [2030], 'termination': [2032], 'noninducibility)': [2034], 'achieved': [2036], 'patients.During': [2039], 'median': [2041], 'follow-up': [2042, 2092], '38.5': [2044], 'interquartile': [2045], 'range': [2046], '(26–53)': [2047], 'months,': [2048], '16': [2049], '(73%)': [2050], 'recurrence': [2054, 2090], '(7': [2055], 'group': [2059, 2144], 'versus': [2060], 'controls;': [2062], 'Table': [2063], 'Supplement).': [2068], 'After': [2069], 'adjusting': [2070, 2198], 'age,': [2072, 2531], 'sex,': [2073], 'substrate,': [2075], 'associated': [2086, 2205], 'reduced': [2088], '(hazard': [2093], 'ratio,': [2094], '0.12;': [2095], '95%': [2096], 'confidence': [2097], 'interval,': [2098], '0.02–0.75;': [2099], 'P=0.023).': [2100], 'Follow-up': [2101], 'echocardiographic': [2102], 'subset': [2108], 'Supplement.DiscussionThe': [2116], 'current': [2117], 'first': [2121], 'evaluate': [2123], 'outcome': [2140], 'comparison.': [2146], 'main': [2148], 'findings': [2149], 'follows:': [2155], 'feasible;': [2165], 'MRI-defined': [2167], 'identifies': [2170], 'differences': [2174], 'fluoroscopy': [2178], 'time;': [2179], 'rates': [2184], 'procedures': [2188, 2353], 'merging;': [2194], '(4)': [2196], 'after': [2197, 2282], 'parameters,': [2201], 'decreased': [2207], 'risk': [2208, 3508], 'recurrence.Incorporation': [2212], 'LGE-derived': [2215], 'facilitates': [2217], 'setting': [2222], 'precludes': [2227], 'conventional': [2228], 'electrophysiological': [2229], 'dense': [2232], 'point-by-point': [2233], 'voltage': [2234, 2305, 2357, 2614], 'may': [2237, 2291, 2342, 2363], 'shorten': [2238], 'time': [2240], 'devoted': [2241], 'identification.': [2244], 'also': [2247, 2292], 'complement': [2248], 'focusing': [2253], 'regions.': [2258], 'Indeed,': [2259], 'regional': [2260], 'necrosis/fibrosis': [2261], 'accompanied': [2263], 'hypertrophy': [2265], 'adjacent': [2267], 'viable': [2268], 'tissue': [2269], '(as': [2270], 'result': [2272], 'remodeling),5': [2274], 'normal': [2276], 'glossed': [2280], 'over': [2281], 'sparse': [2285], 'neighboring': [2286], 'healthy': [2287, 2350], 'points.': [2288], 'Mid-wall': [2289], 'contain': [2293], 'parts': [2295], 'and,': [2300], 'while': [2301], 'missed': [2302], 'bipolar': [2304], 'mapping,': [2306], 'displayed': [2309], 'think': [2316], 'enhances': [2320], "operator's": [2322], 'ability': [2323], 'would': [2328], 'otherwise': [2329], 'been': [2331], 'missed,': [2332], 'potentially': [2333], 'improving': [2334], 'outcomes.': [2336], 'addition,': [2338], 'safety': [2344], 'avoiding': [2346], 'unnecessary': [2347], 'myocardium': [2351], 'guided': [2354, 2798], 'solely': [2355], 'fact,': [2360], 'false-positive': [2361], 'poor': [2367], 'contact,': [2368], 'thinner': [2369], 'walls,': [2370], 'fat,': [2373], 'leading': [2374], 'overestimation': [2376], 'substrate.': [2379], 'Study': [2380], 'limitations': [2381], 'listed': [2383], 'Supplement.Sources': [2387], 'FundingThe': [2389], 'funded': [2392], 'National': [2395], 'Institutes': [2396], '(grant': [2399], 'nos.': [2400], 'K23HL089333': [2401], 'R01HL116280)': [2403], 'Biosense': [2409, 2455], 'Webster': [2410], 'grant': [2411], 'Drs': [2413], 'Henrikson;': [2416], 'Roz': [2418], 'Marvin': [2420], 'H.': [2421], 'Weiner': [2422], 'Family': [2424], 'Foundation;': [2425, 2431], 'Dr': [2427], 'Francis': [2428], 'P.': [2429], 'Chiaramonte': [2430], 'Marilyn': [2432], 'Christian': [2434], 'Poindexter;': [2435], 'Norbert': [2438], 'Louise': [2440], 'Grunwald': [2441], 'Cardiac': [2442, 3138, 3223, 3228, 3445], 'Research': [2444], 'Fund.DisclosuresDr': [2445], 'scientific': [2449], 'advisor': [2450], 'Medtronic,': [2452], 'CardioSolv,': [2453], 'Webster.': [2456], 'other': [2458], 'authors': [2459], 'no': [2461], 'conflicts.FootnotesThe': [2462], 'http://circep.ahajournals.org/lookup/suppl/doi:10.1161/CIRCEP.117.005973/-/DC1.Circ': [2468], 'Arrhythm': [2469, 2681, 2746], 'Electrophysiol': [2470], 'http://circep.ahajournals.org.Correspondence': [2474], 'to:': [2475], 'Pennsylvania,': [2489], '3400': [2490], 'Spruce': [2491], 'St,': [2492], 'Founders': [2493], '9124,': [2494], 'Philadelphia,': [2495], 'PA': [2496], '19104.': [2497], 'E-mail': [2498], '[email': [2499], 'protected]References1.': [2500], 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[3544], '(2018)': [3545, 3565, 3609, 3647], 'Three-dimensional': [3546], 'holographic': [3547], 'visualization': [3548], 'high-resolution': [3550], 'myocardial': [3551], 'HoloLens,': [3554], 'PLOS': [3555], 'ONE,': [3556], '10.1371/journal.pone.0205188,': [3557], '13:10,': [3558], '(e0205188)': [3559], 'Bourier': [3560], 'Sacher': [3563], 'Moderne': [3566], 'Mapping-TechnologienModern': [3567], 'technologies,': [3569], 'Herzschrittmachertherapie': [3570], 'Elektrophysiologie,': [3572], '10.1007/s00399-018-0576-9,': [3573], '29:3,': [3574], '(271-277),': [3575], '1-Sep-2018.': [3579], 'C': [3605], 'Response': [3610], 'et': [3613, 3651], 'al': [3614, 3652], 'Letter': [3616, 3648], 'Regarding': [3617, 3653], 'Article,': [3618, 3654], '"Standard': [3619, 3655], 'Tachycardia",': [3631, 3667], '11:4,': [3636, 3672], '1-Apr-2018.Penela': [3640], '1-Apr-2018.': [3676], 'January': [3677], '2018Vol': [3678], 'Issue': [3680], 'Advertisement': [3682, 3708], 'Article': [3683], 'InformationMetrics': 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'updated_date': '2024-09-26T05:40:54.885932', 'created_date': '2018-01-26'}

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