Figure 4.

Local Activation Map, Correlation With Myocardial Fibrosis on CMR and Associated AHR at Different Locations in 1 Patient

(Top) Electroanatomic (EAM) contact map showing local activation in the same subject as in Figure 2. White signifies earliest activation and blue latest activation, demonstrating the basal lateral region as the site of latest electrical delay. In this case, the optimal AHR (star) matched the site of latest electrical delay, which was distant from ischemic scar. (Bottom) Cardiac MR (CMR), late gadolinium enhancement sequences in the short axis, mid ventricular (left), 2-chamber (middle), and 4 chamber (right) views. The white arrows demonstrate areas of thin walled myocardium with associated subendocardial myocardial fibrosis, corresponding to an left anterior descending (LAD) territory myocardial infarction. There is a close correlation between the scar demonstrated on the EAM and that displayed with CMR. (Right) AHA bulls-eye plot diagram with scar (derived from CMR and EAM) spray painted in grey (anterior, LAD infarct). All different positions for the LV lead are demonstrated (both epicardial and endocardial) with the legend detailing whether the associated AHR with biventricular pacing was <10% or >10% improvement from baseline. Pacing around the anterior regions of scar corresponded to a poor AHR, compared with much better AHRs in sites out of scar. Abbreviations as in Figures 1 and 3.