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High Density Intramural Mapping of Post-Infarct Premature Ventricular Contractions.
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  • Eugene Downar,
  • Michiel Janse,
  • Abhishek Bhaskaran,
  • Ahmed Niri,
  • Arulalan Velluppillai,
  • Stéphane Massé,
  • Kumaraswamy Nanthakumar
Eugene Downar
University Health Network
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Michiel Janse
Academic Medical Center
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Abhishek Bhaskaran
University Health Network
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Ahmed Niri
University Health Network
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Arulalan Velluppillai
University Health Network
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Stéphane Massé
University Health Network
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Kumaraswamy Nanthakumar
Toronto General Hospital
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Abstract

Background: Spontaneous ventricular premature contractions (PVCs) in the post infarct milieu is assumed to be due to automaticity. However, the mechanism has not been studied with appropriate mapping tools. Objective: To study the mechanism of spontaneous PVCs with high density intramural mapping in a canine model, to test the hypothesis that post-infarct PVCs are due to re-entry rather than automaticity. Methods: In 15 anesthetized dogs, using 768 intramural unipolar electrograms, simultaneous recordings were made. After 30 mins of stabilization, recordings were made during the first 10 minutes of ischemia, and activation maps were constructed of individual beats. Acute ischemia was produced by clamping the left anterior descending coronary artery proximal to the first diagonal branch. The analysis was limited to the activation pattern of spontaneous ventricular beats. Results: In all experiments ST-T alternans occurred. In 8 of 15 dogs spontaneous ventricular beats occurred. In all 8 of these experiment earliest, ectopic activity occurred in the endocardium, well within the ischemic zone. From there, activity spread rapidly along the subendocardium, with endo-to epicardial spread along the non ischemic myocardium. Epicardial breakthrough always occurred at the border of the ischemic myocardium. In 3 dogs, delayed potentials were observed, which were earliest at the ischemic epicardium and extended transmurally with increasing delay towards the endocardium, where they culminated in a premature beat. Conclusion: Graded responses that occur with each sinus beat intramurally, when able to propagate from epicardium to endocardium is the mechanism by which PVCs are generated in post-infarct myocardium.