Characteristics of Scar-Related Ventricular Tachycardia Circuits Using Ultra-High-Density Mapping

BACKGROUND: Ventricular tachycardia (VT) with structural heart disease is dependent on reentry within scar regions. We set out to assess the VT circuit in greater detail than has hitherto been possible, using ultra-high-density mapping. METHODS: All ultra-high-density mapping guided VT ablation cases from 6 high-volume European centers were assessed. Maps were analyzed offline to generate activation maps of tachycardia circuits. Topography, conduction velocity, and voltage of the VT circuit were analyzed in complete maps. RESULTS: Thirty-six tachycardias in 31 patients were identified, 29 male and 27 ischemic. VT circuits and isthmuses were complex, 11 were single loop and 25 double loop; 3 had 2 entrances, 5 had 2 exits, and 15 had dead ends of activation. Isthmuses were defined by barriers, which included anatomic obstacles, lines of complete block, and slow conduction (in 27/36 isthmuses). Median conduction velocity was 0.08 m/s in entrance zones, 0.29 m/s in isthmus regions ( P<0.001), and 0.11 m/s in exit regions ( P=0.002). Median local voltage in the isthmus was 0.12 mV during tachycardia and 0.06 mV in paced/sinus rhythm. Two circuits were identifiable in 5 patients. The median timing of activation was 16% of diastole in entrances, 47% in the mid isthmus, and 77% in exits. CONCLUSIONS: VT circuits identified were complex, some of them having multiple entrances, exits, and dead ends. The barriers to conduction in the isthmus seem to be partly functional in 75% of circuits. Conduction velocity in the VT isthmus slowed at isthmus entrances and exits when compared with the mid isthmus. Isthmus voltage is often higher in VT than in sinus or paced rhythms.