Body Surface Distribution of T Wave Alternans is Modulated by Heart Rate and Ventricular Activation Sequence in Patients with Cardiomyopathy

Overview

Journal PLoS One

Specialties General Medicine
Science

Date 2019 Apr 11

PMID 30969986

Authors

Behnaz Ghoraani

Adrian M Suszko

Raja J Selvaraj

Anandaraja Subramanian

Sridhar Krishnan

Vijay S Chauhan

Affiliations

Soon will be listed here.

Abstract

Background: T wave alternans (TWA) is an electrocardiographic marker of heightened sudden death risk from ventricular tachyarrhythmias in patients with cardiomyopathy. TWA is evaluated from the 12-lead electrocardiogram, Frank lead, or Holter lead recordings, however these clinical lead configurations will not record TWA from adjacent regions of the body torso.

Objective: We tested the hypothesis that changing heart rate or ventricular activation may alter the body surface distribution of TWA such that the clinical ECG leads fail to detect TWA in some patients; thereby producing a false-negative test.

Methods: In 28 cardiomyopathy patients (left ventricular ejection fraction 28±6%), 114 unipolar electrograms were recorded across the body torso during incremental atrial pacing, followed by atrioventricular pacing at 100, 110 and 120bpm. TWA was measured from each unipolar electrogram using the spectral method. A clinically positive TWA test was defined as TWA magnitude (Valt) ≥1.9 uV with k ≥3 at ≤110bpm.

Results: Maximum Valt (TWAmax) was greater from the body torso than clinical leads during atrial (p<0.005) and atrioventricular pacing (p<0.005). TWAmax was most prevalent in the right lower chest with atrial pacing 100 bpm and shifted to the left lower chest at 120 bpm. TWAmax was most prevalent in left lower chest with atrioventricular pacing at 100 bpm and shifted to the left upper chest at 120 bpm. Using the body torso as a gold standard, the false-negative rate for clinically positive TWA with clinical leads was 21% during atrial and 11% during atrioventricular pacing. Due to TWA signal migration outside the clinical leads, clinically positive TWA became false-negative when pacing mode was switched (atrial→atrioventricular pacing) in 21% of patients.

Conclusions: The body surface distribution of TWA is modulated by heart rate and the sequence of ventricular activation in patients with cardiomyopathy, which can give rise to modest false-negative TWA signal detection using standard clinical leads.

References

Shusterman V, Goldberg A, London B . Upsurge in T-wave alternans and nonalternating repolarization instability precedes spontaneous initiation of ventricular tachyarrhythmias in humans. Circulation. 2006; 113(25):2880-7. DOI: 10.1161/CIRCULATIONAHA.105.607895. View

Jackson C, Myles R, Tsorlalis I, Dalzell J, Spooner R, Rodgers J . Profile of microvolt T-wave alternans testing in 1003 patients hospitalized with heart failure. Eur J Heart Fail. 2012; 14(4):377-86. DOI: 10.1093/eurjhf/hfs010. View

Hohnloser S, Ikeda T, Cohen R . Evidence regarding clinical use of microvolt T-wave alternans. Heart Rhythm. 2009; 6(3 Suppl):S36-44. DOI: 10.1016/j.hrthm.2008.10.011. View

Ehrlich J, Wegener F, Anneken L, Duray G, Israel C, Hohnloser S . Biventricular pacing does not affect microvolt T-wave alternans in heart failure patients. Heart Rhythm. 2008; 5(3):348-52. DOI: 10.1016/j.hrthm.2007.10.032. View

Verrier R, Nearing B, Kwaku K . Noninvasive sudden death risk stratification by ambulatory ECG-based T-wave alternans analysis: evidence and methodological guidelines. Ann Noninvasive Electrocardiol. 2005; 10(1):110-20. PMC: 6931922. DOI: 10.1111/j.1542-474X.2005.10103.x. View

Gold M, Ip J, Costantini O, Poole J, McNulty S, Mark D . Role of microvolt T-wave alternans in assessment of arrhythmia vulnerability among patients with heart failure and systolic dysfunction: primary results from the T-wave alternans sudden cardiac death in heart failure trial substudy. Circulation. 2008; 118(20):2022-8. PMC: 2777708. DOI: 10.1161/CIRCULATIONAHA.107.748962. View

Selvaraj R, Suszko A, Subramanian A, Sivananthan D, Hill A, Nanthakumar K . Body surface projection of action potential duration alternans: a combined clinical-modeling study with implications for improving T-wave alternans detection. Heart Rhythm. 2009; 6(8):1211-9. DOI: 10.1016/j.hrthm.2009.04.002. View

Narayan S, Lindsay B, Smith J . Demonstration of the proarrhythmic preconditioning of single premature extrastimuli by use of the magnitude, phase, and distribution of repolarization alternans. Circulation. 1999; 100(18):1887-93. DOI: 10.1161/01.cir.100.18.1887. View

Choi B, Jang W, Salama G . Spatially discordant voltage alternans cause wavebreaks in ventricular fibrillation. Heart Rhythm. 2007; 4(8):1057-68. PMC: 2137164. DOI: 10.1016/j.hrthm.2007.03.037. View

10.

Mironov S, Jalife J, Tolkacheva E . Role of conduction velocity restitution and short-term memory in the development of action potential duration alternans in isolated rabbit hearts. Circulation. 2008; 118(1):17-25. PMC: 2574713. DOI: 10.1161/CIRCULATIONAHA.107.737254. View

11.

Raatikainen M, Jokinen V, Virtanen V, Hartikainen J, Hedman A, Huikuri H . Microvolt T-wave alternans during exercise and pacing in patients with acute myocardial infarction. Pacing Clin Electrophysiol. 2005; 28 Suppl 1:S193-7. DOI: 10.1111/j.1540-8159.2005.00110.x. View

12.

Klingenheben T, Ptaszynski P, Hohnloser S . Quantitative assessment of microvolt T-wave alternans in patients with congestive heart failure. J Cardiovasc Electrophysiol. 2005; 16(6):620-4. DOI: 10.1111/j.1540-8167.2005.40708.x. View

13.

Frank E . An accurate, clinically practical system for spatial vectorcardiography. Circulation. 1956; 13(5):737-49. DOI: 10.1161/01.cir.13.5.737. View

14.

Kraaier K, Verhorst P, van der Palen J, van Dessel P, Wilde A, Scholten M . Microvolt T-wave alternans during exercise and pacing are not comparable. Europace. 2009; 11(10):1375-80. DOI: 10.1093/europace/eup253. View

15.

Cantillon D, Stein K, Markowitz S, Mittal S, Shah B, Morin D . Predictive value of microvolt T-wave alternans in patients with left ventricular dysfunction. J Am Coll Cardiol. 2007; 50(2):166-73. DOI: 10.1016/j.jacc.2007.02.069. View

16.

Chow T, Kereiakes D, Onufer J, Woelfel A, Gursoy S, Peterson B . Does microvolt T-wave alternans testing predict ventricular tachyarrhythmias in patients with ischemic cardiomyopathy and prophylactic defibrillators? The MASTER (Microvolt T Wave Alternans Testing for Risk Stratification of Post-Myocardial.... J Am Coll Cardiol. 2008; 52(20):1607-15. DOI: 10.1016/j.jacc.2008.08.018. View

17.

Shalaby A, Voigt A, El-Saed A, Mains M, Shusterman V . Microvolt T-wave alternans during atrial and ventricular pacing. Pacing Clin Electrophysiol. 2007; 30 Suppl 1:S178-82. DOI: 10.1111/j.1540-8159.2007.00633.x. View

18.

Anh D, Srivatsa U, Bui H, Vasconcellos S, Narayan S . Biventricular pacing attenuates T-wave alternans and T-wave amplitude compared to other pacing modes. Pacing Clin Electrophysiol. 2008; 31(6):714-21. DOI: 10.1111/j.1540-8159.2008.01074.x. View

19.

Hohnloser S, Klingenheben T, Zabel M, Li Y, Albrecht P, Cohen R . T wave alternans during exercise and atrial pacing in humans. J Cardiovasc Electrophysiol. 1997; 8(9):987-93. DOI: 10.1111/j.1540-8167.1997.tb00621.x. View

20.

Verrier R, Klingenheben T, Malik M, El-Sherif N, Exner D, Hohnloser S . Microvolt T-wave alternans physiological basis, methods of measurement, and clinical utility--consensus guideline by International Society for Holter and Noninvasive Electrocardiology. J Am Coll Cardiol. 2011; 58(13):1309-24. PMC: 4111570. DOI: 10.1016/j.jacc.2011.06.029. View