Intraoperative Electrophysiologic Mapping of the Ventricles During Sinus Rhythm in Patients with a Previous Myocardial Infarction Identification of the Electrophysiologic Substrate of Ventricular Arrhythmias

To determine why only some patients with a previous myocardial infarction develop serious or life-threatening ventricular arrhythmias, we performed electrophysiologic ventricular mapping during sinus rhythm in 38 patients (31 men and seven women, mean age 51 years) during open heart surgery for coronary artery disease. Twenty-nine patients had a left ventricular aneurysm or dyskinetic area, eight had an akinetic area, and one had a severe hypokinetic area. Of 21 patients who had documented ventricular arrhythmias, 16 had recurrent, sustained ventricular tachycardia, two had ventricular tachycardia during exercise testing, and three had frequent premature ventricular complexes only. Seventeen patients were free of ventricular arrhythmias.Epicardial mapping was performed in all 38 patients. The endocardium was also mapped in 10 patients. In 20 patients with ventricular arrhythmias, an area of delayed activation (more than 100 msec after onset of the QRS complex) was found. This type of delay was present in only two of the 17 patients without arrhythmias. The mean latest epicardial activation in patients with arrhythmias was 137 ± 21 msec, whereas in patients without arrhythmias, the mean latest epicardial activation was 74 ± 21 msec (p < 0.001). Twenty of the 21 patients with arrhythmias had fractionated electrograms (three exclusively on the endocardium) and 13 patients had double potentials. Fractionation and double potentials were found in only one of the 17 patients without arrhythmias. The area where abnormal electrograms were recorded (i.e., the number of abnormal recording sites) was significantly larger in patients with recurrent sustained ventricular tachycardia than in patients who had premature ventricular complexes only or had no documented arrhythmias. We conclude that in patients with a previous myocardial infarction associated with serious or life-threatening ventricular arrhythmias, areas of significantly delayed epicardial activation, fractionation and double potentials are characteristic findings of ventricular mapping during sinus rhythm, and presumably constitute the substrate for development of these arrhythmias.

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