June 7, 2005Circulation263 citationsOpen Access
View Full PaperThree-Dimensional Electroanatomic Voltage Mapping Increases Accuracy of Diagnosing Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia
Key Result
Three-dimensional electroanatomic voltage mapping enhanced ARVC/D diagnostic accuracy by identifying low-voltage areas associated with fibrofatty myocardial replacement (P<0.0001).
Key Points
- The aim is to evaluate the effectiveness of three-dimensional electroanatomic voltage mapping in diagnosing arrhythmogenic right ventricular cardiomyopathy/dysplasia.
- Thirty-one patients underwent electroanatomic voltage mapping and endomyocardial biopsy for diagnosis validation.
- Electrogram samples from the right ventricle were collected during sinus rhythm.
- Comparison of low-voltage electrogram findings with echocardiographic and histopathological data.
- 20 patients (65%) had low-voltage areas indicating significant myocardial loss; associated with worse arrhythmic outcomes (P=0.02).
- Low-voltage areas correlated with fibrofatty replacement at biopsy (P<0.0001).
- 11 patients (35%) had preserved voltages and related inflammatory cardiomyopathy, suggesting alternative diagnoses.
Study Design
Type
Observational (n=31)
Structured PICO
Does three-dimensional electroanatomic voltage mapping increase the accuracy of diagnosing Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia in patients fulfilling noninvasive diagnostic criteria?
P
Population
31 consecutive patients (22 men and 9 women; mean age, 30.8+/-7 years) who fulfilled the criteria of the Task Force of the European Society of Cardiology and International Society and Federation of Cardiology (ESC/ISFC) for ARVC/D diagnosis after noninvasive clinical evaluation
I
Intervention
Invasive study including right ventricular (RV) three-dimensional electroanatomic voltage mapping and endomyocardial biopsy (EMB)
O
Outcome
Association of low-voltage areas with myocyte loss and fibrofatty replacement at endomyocardial biopsysurrogate
Three-dimensional electroanatomic voltage mapping enhances the diagnostic accuracy of ARVC/D by identifying low-voltage areas corresponding to fibrofatty replacement and differentiating true ARVC/D from inflammatory cardiomyopathy mimics.
Main Result
p-value: p=<0.0001
Abstract
BACKGROUND: Three-dimensional electroanatomic voltage mapping offers the potential to identify low-voltage areas that correspond to regions of right ventricular (RV) myocardial loss and fibrofatty replacement in patients with arrhythmogenic RV cardiomyopathy/dysplasia (ARVC/D). METHODS AND RESULTS: Thirty-one consecutive patients (22 men and 9 women; mean age, 30.8+/-7 years) who fulfilled the criteria of the Task Force of the European Society of Cardiology and International Society and Federation of Cardiology (ESC/ISFC) for ARVC/D diagnosis after noninvasive clinical evaluation underwent further invasive study including RV electroanatomic voltage mapping and endomyocardial biopsy (EMB) to validate the diagnosis. Multiple RV endocardial, bipolar electrograms (175+/-23) were sampled during sinus rhythm. Twenty patients (group A; 65%) had an abnormal RV electroanatomic voltage mapping showing > or =1 area (mean 2.25+/-0.7) with low-voltage values (bipolar electrogram amplitude 1.5 mV). Low-voltage electrograms appeared fractionated with significantly prolonged duration and delayed activation. In 11 patients (group B; 35%), electroanatomic voltage mapping was normal, with preserved electrogram voltage (4.4+/-0.7 mV) and duration (37.2+/-0.9 ms) throughout the RV. Low-voltage areas in patients from group A corresponded to echocardiographic/angiographic RV wall motion abnormalities and were significantly associated with myocyte loss and fibrofatty replacement at EMB (P<0.0001) and familial ARVC/D (P<0.0001). Patients from group B had sporadic disease and histopathological evidence of inflammatory cardiomyopathy (P<0.0001). During the time interval from onset of symptoms to the invasive study, 11 patients (55%) with electroanatomic low-voltage regions received an implantable cardioverter/defibrillator because of life-threatening ventricular arrhythmias, whereas all but 1 patient with a normal voltage map remained stable on antiarrhythmic drug therapy (P=0.02). CONCLUSIONS: Three-dimensional electroanatomic voltage mapping enhanced accuracy for diagnosing ARVC/D (1) by demonstrating low-voltage areas that were associated with fibrofatty myocardial replacement and (2) by identifying a subset of patients who fulfilled ESC/ISFC Task Force diagnostic criteria but showed a preserved electrogram voltage, an inflammatory cardiomyopathy mimicking ARVC/D, and a better arrhythmic outcome.