Optimal Annotation of Local Activation Time in Ventricular Tachycardia Substrate Mapping.

Background Accurate annotation of electrogram local activation time (LAT) is critical to the functional assessment of ventricular tachycardia (VT) substrate. Contemporary methods of annotation include: 1) earliest bipolar electrogram (LAT(earliest)); 2) peak bipolar electrogram (LAT(peak)); 3) latest bipolar electrogram (LAT(latest)); and 4) steepest unipolar -dV/dt (LAT(-dV/dt)). However, no direct comparison of these methods has been performed in a large dataset, and it is unclear which provides the optimal functional analysis of the VT substrate. Objectives This study sought to investigate the optimal method of LAT annotation during VT substrate mapping. Methods Patients with high-density VT substrate maps and a defined critical site for VT re-entry were included. All electrograms were annotated using 5 different methods: LAT(earliest), LAT(peak), LAT(latest), LAT-dV(/dt), and the novel steepest unipolar -dV/dt using a dynamic window of interest (LAT(DWOI)). Electrograms were also tagged as either late potentials and/or fractionated signals. Maps, utilizing each annotation method, were then compared in their ability to identify critical sites using deceleration zones. Results Fifty cases were identified with 1,.813 +/- 811 points per map. Using LAT(latest), a deceleration zone was present at the critical site in 100% of cases. There was no significant difference with LAT(earliest) (100%) or LAT(peak) (100%). However, this number decreased to 54% using LAT(-dV/dt) and 76% for LAT(DWOI). Using LAT-dV/dt, only 33% of late potentials were correctly annotated, with the larger far field signals often annotated preferentially. Conclusions Annotation with LAT(-dV/dt) and LAT(DWOI) are suboptimal in VT substrate mapping. We propose that LAT(latest) should be the gold standard annotation method, as this allows identification of critical sites and is most suited to automation. (c) 2024 by the American College of Cardiology Foundation.