Heart rhythm · 2026
Revisiting the link between substrate and ventricular tachycardia rate: The critical role of conduction-isthmus structure and function.
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Guichard Jean-Baptiste, Castrillo-Golvano Leticia, Molero-Pereira Sílvia, Regany-Closa Mariona, Lopez Elvihots Ayauja, Vázquez-Calvo Sara, Tonko Johanna, Ventosa-Blázquez Oriol, Rosseel Thomas, Graterol Freddy R, Valenzuela Frida Eulogio, Falzone Pasquale V, Garre Paz, Borràs Roger, Althoff Till F, Arbelo Elena, Brugada Josep, Guasch Eduard, Mont Lluís, Ortiz José Tomás, Tolosana Jose María, Sitges Marta, Porta-Sánchez Andreu, Roca-Luque Ivo
Аннотация
BACKGROUND: Ventricular tachycardia (VT) rate determines hemodynamic tolerance and informs risk stratification and ablation strategy. Although global-substrate metrics have been associated with VT dynamics, the relative contribution of local conduction-isthmus properties remains incompletely defined.
OBJECTIVE: We compared the predictive value of global with isthmus-specific substrate features on VT rate.
METHODS: In a prospective cohort, 62 patients undergoing ablation for scar-related VT underwent high-density electroanatomic mapping and late gadolinium enhancement cardiac magnetic resonance. Functional metrics included total activation time, deceleration zone (DZ) duration/area, and late potential (LP) area; structural metrics included scar/border-zone mass and conduction channel (CC) length, protected volume, and 2-dimensional architecture. The primary outcome was fast VT defined as >180 beats/min.
RESULTS: We analyzed 107 VT episodes, and 39% (n = 42) were classified as fast. Only isthmus-specific features independently predicted fast VT: a DZ duration of <110 ms (adjusted odds ratio 21.16; P < .001) and a CC length of <3 cm (adjusted odds ratio 10.18; P = .02). These thresholds showed strong discrimination (area under the curve of 0.88 for a DZ duration of <110 ms and 0.89 for a CC length of <30 mm); an LP area of <20 cm2 yielded an area under the curve of 0.79-each with ≥80% global accuracy. Structural-functional coupling was observed: CC length correlated with DZ duration (ρ = 0.54), DZ area (ρ = 0.35), and LP area (ρ = 0.55) (all P ≤ .01). Compared with ischemic cardiomyopathy, nonischemic cardiomyopathy had faster VT and a more compact isthmus; however, etiology was not an independent predictor and did not modify isthmus-VT rate associations.
CONCLUSION: Conduction-isthmus properties predominate as determinants of VT rate. Quantitative characterization of VT-related conducting segments may support procedural planning in structural heart disease.
OBJECTIVE: We compared the predictive value of global with isthmus-specific substrate features on VT rate.
METHODS: In a prospective cohort, 62 patients undergoing ablation for scar-related VT underwent high-density electroanatomic mapping and late gadolinium enhancement cardiac magnetic resonance. Functional metrics included total activation time, deceleration zone (DZ) duration/area, and late potential (LP) area; structural metrics included scar/border-zone mass and conduction channel (CC) length, protected volume, and 2-dimensional architecture. The primary outcome was fast VT defined as >180 beats/min.
RESULTS: We analyzed 107 VT episodes, and 39% (n = 42) were classified as fast. Only isthmus-specific features independently predicted fast VT: a DZ duration of <110 ms (adjusted odds ratio 21.16; P < .001) and a CC length of <3 cm (adjusted odds ratio 10.18; P = .02). These thresholds showed strong discrimination (area under the curve of 0.88 for a DZ duration of <110 ms and 0.89 for a CC length of <30 mm); an LP area of <20 cm2 yielded an area under the curve of 0.79-each with ≥80% global accuracy. Structural-functional coupling was observed: CC length correlated with DZ duration (ρ = 0.54), DZ area (ρ = 0.35), and LP area (ρ = 0.55) (all P ≤ .01). Compared with ischemic cardiomyopathy, nonischemic cardiomyopathy had faster VT and a more compact isthmus; however, etiology was not an independent predictor and did not modify isthmus-VT rate associations.
CONCLUSION: Conduction-isthmus properties predominate as determinants of VT rate. Quantitative characterization of VT-related conducting segments may support procedural planning in structural heart disease.