VALIDATION OF NONINVASIVE EPI-ENDOCARDIAL ELECTROCARDIOGRAPHIC IMAGING ACCURACY USING LEFT VENTRICULAR EPICARDIAL PACING

Topical diagnosis of focal arrhythmias using different invasive electroanatomic mapping systems is based on the registration of electrical potentials on the endo- or epicardial surface. At the same time, simultaneous registration of early activation zones on both epi- and endocardium remains a challenging task, especially in complex and unstable atrial and ventricular arrhythmias. Noninvasive ElectroCardioGraphic Imaging (ECGI) is a method that allows to electrically map endocardial and epicardial surfaces. The aim of this single-center cross-sectional single-blind study was to evaluate the accuracy of noninvasive ECGI epi-endocardial mapping based on the left ventricular (LV) epicardial pacings in patients with implanted CRT devices.
Methods. 30 patients with previously implanted pacemakers underwent epi-endocardial ECGI mapping using “Amycard 01C EP Lab” system (Amycard LLC, Russia - EP Solutions SA, Switzerland). Multichannel ECG were recorded during left epicardial ventricular pacings followed by torso and ECG-gated cardiac computed tomography. The data obtained from CT was imported into “Amycard 01C EP lab” software in DICOM-format to reconstruct 3D polygonal models of the torso and heart. In this study we consider both epicardial and epi-endocardial 3D models of the heart. Early activation zone was determined from the isopotential maps with 1 ms step followed by geodesic distance measurement between noninvasively reconstructed and the reference pacing site.
Results. The mean (SD) geodesic distance between noninvasively reconstructed and the reference pacing sites was 9 (6) mm for the LV epicardial and 12 (5) for the LV epi-endocardial models, median (25-75% IQR) - 7 (5-11) mm и 11 (9-16) mm respectively. There was a signifi cant difference in accuracy for LV epicardial and epi-endocardial models (p=0,007). At the same time, there were no signifi cant interrelations between cardiac CT, pacing, clinical characteristics and accuracy values.
Conclusions. This is the fi rst clinical study that specifi cally demonstrates noninvasive epi-endocardial ECGI accuracy considering also the quality of polygon models as well as possible infl uence of different factors on the utilized inverse ECG problem algorithm. The main fi nding of this study was that the median accuracy of noninvasive ECGI mapping was 12 mm for the epicardial LV pacing on epi- and endocardial surfaces. Therefore, this study showed suffi cient accuracy to use this technology in routine clinical practice for identifi cation of focal arrhythmia sources. 

1. MacLeod R., Brooks D. Recent progress in inverse problems in electrocardiology // IEEE Engineering in Medicine and Biology Magazine. 1998. 17. № 1. С. 73-83.

2. Ramanathan C., Ghanem R.N., Jia P. et al. Noninvasive electrocardiographic imaging for cardiac electrophysiology and arrhythmia // Nature medicine. 2004. 10. № 4. С. 422-428.

3. Berger T., Hintringer F., Fischer G. Noninvasive Imaging of Cardiac Electrophysiology // Indian Pacing and Electrophysiology Journal. 2007. 7. № 3. С. 160-165.

4. Seger M., Tilg B., Modre-Osprian R. et al. ECG mapping and imaging of cardiac electrical function // Studies in health technology and informatics. 2003. 95. С. 56-61.

5. Бокерия Л.А., Ревишвили А.Ш., Калинин В.В. и др. Неинвазивное эндокардиальное картирование желудочков сердца на основе решения обратной задачи электрокардиографии // Вестник аритмологии. 2009. № 57. С. 24-28.

6. Bokeriya L.A., Revishvili A.S., Kalinin A.et al. Hardware-Software System for Noninvasive Electrocardiographic Heart Examination Based on Inverse Problem of Electrocardiography // Biomedical Engineering, Translated from Meditsinskaya Tekhnika. 2008. 42. № 6. С. 273-279.

7. Чмелевский М.П., Зубарев С.В., Буданова М.А. Неинвазивное электрофизиологическое картирование в диагностике желудочковых аритмий: от научных исследований к клинической практике // Трансляционная медицина. 2015. 5. № 2. С. 91-103.

8. Ревишвили А.Ш., Калинин В.В., Ляджина О.С., Фетисова Е.А. Верификация новой методики неинвазивного электрофизиологического исследования сердца, основанной на решении обратной задачи электрокардиографии // Вестник аритмологии. 2008. № 51. С. 7-13.

9. Revishvili A., Wissner E., Lebedev D. et al Validation of the mapping accuracy of a novel non-invasive epicardial and endocardial electrophysiology system // Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 2015. 17. № 8. С. 1282-1288.

10. Зубарев С.В., Чмелевский М.П., Буданова М.А. и др. Совершенствование методики поверхностного неинвазивного эпи- и эндокардиального картирования при нарушениях внутрижелудочковой проводимости // Вестник аритмологии. 2015. № 80. С. 42-48.

11. KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease // Kidney international supplements. 2013. 3. № 1. С. 163.

12. Denisov A.M., Zakharov E.V., Kalinin A.V., Kalinin V.V. Numerical solution of the inverse electrocardiography problem with the use of the Tikhonov regularization method // Moscow University Computational Mathematics and Cybernetics. 2008. 32. № 2. С. 61-68.

13. International Committee of Medical Journal Editors. Recommendations for the Conduct, Reporting, Editing, and Publication of Scholarly Work in Medical Journals, 2017. URL: http://www.icmje.org/icmje-recommendations.pdf. 19 c.

14. Lang T.A., Secic M. How to report statistics in medicine: Annotated guidelines for authors, editors, and reviewers / Thomas A. Lang, Michelle Secic. 2-e изд. New York: American College of Physicians, 2006.

15. Elm E. von, Altman D.G., Egger M. et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies // Epidemiology (Cambridge, Mass.). 2007. 18. № 6. С. 800-804.

16. Vandenbroucke J.P., Elm E. von, Altman D.G. et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration // Epidemiology (Cambridge, Mass.). 2007. 18. № 6. С. 805-835.

17. Cerqueira M.D., Weissman N.J., Dilsizian V. et al. Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the Cardiac Imaging Committee of the Council on Clinical Cardiology of the American Heart Association // Circulation. 2002. 105. № 4. С. 539-542.

18. Аритмии сердца. Механизмы, диагностика, лечение. Том 1 / Cост. Мандел В.Дж. Москва: Медицина, 1996.

19. Benezet-Mazuecos J., Iglesias J.A., Rubio J.M., Farré J. Anodal Stimulation in Biventricular Pacing: Unrecognized and Misinterpreted Phenomenon // Pacing and clinical electrophysiology : PACE. 2015. 38. № 12. С. 1485-1488.

20. Wikswo J.P., Lin S.F., Abbas R.A. Virtual electrodes in cardiac tissue: a common mechanism for anodal and cathodal stimulation // Biophysical journal. 1995. 69. № 6. С. 2195-2210.

21. Nash M.P., Pullan A.J. Challenges facing validation of noninvasive electrical imaging of the heart // Annals of noninvasive electrocardiology : the offi cial journal of the International Society for Holter and Noninvasive Electrocardiology, Inc. 2005. 10. № 1. С. 73-82.

22. Barr R.C., Spach M.S. Inverse calculation of QRS-T epicardial potentials from body surface potential distributions for normal and ectopic beats in the intact dog // Circulation research. 1978. 42. № 5. С. 661-675.

23. Bear L.R., LeGrice I.J., Sands G.B. et al. How Accurate Is Inverse Electrocardiographic Mapping? // Circulation: Arrhythmia and Electrophysiology. 2018. 11. № 5. e006108.

24. Cluitmans M., Bonizzi P., Karel J. et al. In Vivo Validation of Electrocardiographic Imaging // JACC: Clinical Electrophysiology. 2017. 3. № 3. С. 232-242.

25. Sapp J.L., Dawoud F., Clements J.C., Horácek B.M. Inverse solution mapping of epicardial potentials: quantitative comparison with epicardial contact mapping // Circulation. Arrhythmia and electrophysiology. 2012. 5. № 5. С. 1001-1009.

26. Oosterhoff P., Meijborg V.M.F., van Dam P.M. et al. Experimental Validation of Noninvasive Epicardial and Endocardial Activation Imaging // Circulation. Arrhythmia and electrophysiology. 2016. 9. № 8. e004104.