Ventricular tachycardia (VT) is common in patients after myocardial infarction (MI) and can lead to sudden cardiac death (SCD); treatment options include catheter-based radiofrequency VT ablation, but important limitations, such as the difficulty of localizing ablation targets in infarcted tissues, lower the success rate of the procedure. In a new, proof-of-concept study, Natalia Trayanova and colleagues report the use of 3D personalized heart models for noninvasive guidance of VT ablation in patients with ischaemic cardiomyopathy.

Credit: Activation maps of induced arrhythmia in patient model and VAAT-predicted ablation targets. Reprinted from Prakosa, A. et al. Personalized virtual-heart technology for guiding the ablation of infarct-related ventricular tachycardia. Nat. Biomed. Eng. https://doi.org/10.1038/s41551-018-0282-2 (2018)

The virtual-heart arrhythmia ablation targeting (VAAT) technology uses computational modelling to reconstruct geometric models of the hearts of patients with MI from clinical MRI data and incorporates cell and tissue properties into these models; simulations of electrical activity are then executed to evaluate patient-specific VT and identify ablation targets.

The investigators had previously demonstrated the feasibility of using 3D cardiac models to predict the risk of SCD in patients with ischaemic cardiomyopathy; the new study was designed to explore the clinical applications of the ‘virtual heart’ beyond diagnostic purposes.

“The study represents the first attempt to incorporate personalized simulation predictions as part of antiarrhythmia treatment,” explains Trayanova. First, a retrospective study including 21 patients that had undergone MRI and successful infarct-related VT ablation confirmed the capacity of VAAT to predict the clinical procedure targets. VAAT was then used in a prospective study including five patients to guide VT ablation without previous electrical mapping. The approach successfully terminated VT in the patients with inducible VT after MI.

The results demonstrate the feasibility of integrating the computer-simulated prediction of ablation targets into the clinical routine

“The results demonstrate the feasibility of integrating the computer-simulated prediction of ablation targets into the clinical routine,” says Trayanova, adding that a larger prospective study has just been approved. “We expect that implementing the VAAT approach in the clinics will decrease the lengthy and invasive cardiac mapping process and reduce procedure complications,” she concludes.