Body surface projection of action potential duration alternans: A combined clinical–modeling study with implications for improving T-wave alternans detection

BackgroundAction potential duration alternans (APDA) can vary regionally in magnitude and phase. The influence of APDA heterogeneity on T-wave alternans (TWA) has not been defined.ObjectiveOur objectives were: (1) to determine how APDA affects the magnitude and spatial distribution of TWA, and (2) to optimize electrocardiographic (ECG) lead configuration accordingly to improve TWA detection.MethodsGlobal, regional, and discordant APDA were simulated in a 257-node heart model. Using a forward solution, body surface potentials were derived at 300 points on the thorax and TWA was computed at each point. In 22 patients with cardiomyopathy (left ventricular ejection fraction 28% ± 6%), TWA was measured from a 114-electrode body surface map using the spectral method during atrial pacing at 110 beats/min.ResultsAn increase in global APDA from 4 to 12 ms resulted in an increase in maximum TWA from 10 to 30 μV. TWA magnitude varied with the size and location of the alternating myocardium, but was largest with discordant APDA compared with regional or global APDA. Irrespective of the location or phase of APDA, TWA was largest over the precordium and correlated with T-wave amplitude in the simulation (R2 = 0.56 ± 0.24, P <.01) and clinical study (R2 = 0.45 ± 0.23, P <.02). A novel lead configuration (12 precordial leads + limb leads) significantly improved maximum TWA detection compared with the conventional 12-lead ECG+ Frank lead configuration.ConclusionTWA magnitude is dependent on the interaction of concordant and discordant alternating sources within the heart. Maximum TWA consistently localizes to the precordium and a novel lead configuration using 12 precordial leads improves TWA quantification.