Noninvasive epi-endocardial electrocardiographic imaging of ventricular septal pacing

Noninvasive epi-endocardial ElectroCardioGraphic Imaging (ECGI) allows reconstruction of electrograms and high-resolution visualization of various isoparametric maps based on multichannel ECG recordings and tomography. We aimed to verify the ECGI accuracy during septal ventricular pacing in patients with pre-implanted pacemakers using the new ECGI algorithm. Methods. Ten patients underwent epi-endocardial ECGI mapping (Amycard 01C EP Lab, Amycard LLC, Russia - EP Solutions SA, Switzerland). The iterative Equal Single Layer algorithm (ESL-iterative) and a new Fast Route algorithm in combination with the vector approach (FRA-V) were used to reconstruct isopotential and correlation similarity maps. Geodesic distance between noninvasively reconstructed early activation zone and RV reference pacing sites were measured to evaluate the ECGI accuracy. Results. The mean (SD) geodesic distance between noninvasively identified sites and reference pacing sites was 22 (15) mm for the ESL-iterative and 12 (7) for FRA-V algorithms, median (25-75% IQR) - 23 (8-29) mm and 10 (8-14) mm, respectively. The accuracy of ECGI mapping based on the FRA-V algorithm was significantly better than ESL-iterative algorithm (p=0,01). A detailed visual analysis of correlation similarity and isopotential maps showed significantly more accurate localization of early activation zones using the new FRA-V algorithm. Conclusions. Our study showed the feasibility and accuracy of a novel epi-endocardial ECGI mapping approach to identify early activation zones during septal ventricular pacing using the new FRA-V algorithm. The FRA-V algorithm is significantly better for epi-endocardial ECGI mapping and shows a significant advantage of this technique compared to other non-invasive methods of topical diagnostics. Moreover, simultaneous beat-to-beat mapping of entire ventricular septum allows using this technique for pre-ablation evaluation of unstable and polymorphic ventricular arrhythmia exit sites.