Noninvasive localization of cardiac arrhythmias using electromechanical wave imaging

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Science Translational Medicine  25 Mar 2020:
Vol. 12, Issue 536, eaax6111
DOI: 10.1126/scitranslmed.aax6111

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Accurately mapping arrhythmias

Identifying the site to ablate in the heart to correct irregular heartbeat (cardiac arrhythmia) can be difficult and often requires invasive electrophysiology studies. Grubb et al. used a form of noninvasive ultrasound called electromechanical wave imaging (EWI) to generate maps of the heart, identifying the sites of arrhythmias in 55 patients with cardiovascular disease in a double-blinded study. EWI outperformed standard 12-lead electrocardiogram in localizing atrial and ventricular arrhythmias, suggesting that the addition of this imaging method to clinical workflows could help improve decision-making and treatment planning.


Cardiac arrhythmias are a major cause of morbidity and mortality worldwide. The 12-lead electrocardiogram (ECG) is the current noninvasive clinical tool used to diagnose and localize cardiac arrhythmias. However, it has limited accuracy and is subject to operator bias. Here, we present electromechanical wave imaging (EWI), a high–frame rate ultrasound technique that can noninvasively map with high accuracy the electromechanical activation of atrial and ventricular arrhythmias in adult patients. This study evaluates the accuracy of EWI for localization of various arrhythmias in all four chambers of the heart before catheter ablation. Fifty-five patients with an accessory pathway (AP) with Wolff-Parkinson-White (WPW) syndrome, premature ventricular complexes (PVCs), atrial tachycardia (AT), or atrial flutter (AFL) underwent transthoracic EWI and 12-lead ECG. Three-dimensional (3D) rendered EWI isochrones and 12-lead ECG predictions by six electrophysiologists were applied to a standardized segmented cardiac model and subsequently compared to the region of successful ablation on 3D electroanatomical maps generated by invasive catheter mapping. There was significant interobserver variability among 12-lead ECG reads by expert electrophysiologists. EWI correctly predicted 96% of arrhythmia locations as compared with 71% for 12-lead ECG analyses [unadjusted for arrhythmia type: odds ratio (OR), 11.8; 95% confidence interval (CI), 2.2 to 63.2; P = 0.004; adjusted for arrhythmia type: OR, 12.1; 95% CI, 2.3 to 63.2; P = 0.003]. This double-blinded clinical study demonstrates that EWI can localize atrial and ventricular arrhythmias including WPW, PVC, AT, and AFL. EWI when used with ECG may allow for improved treatment for patients with arrhythmias.

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