Endocardial and epicardial repolarization alternans in human cardiomyopathy: evidence for spatiotemporal heterogeneity and correlation with body surface T-wave alternans.

OBJECTIVES The aim of this study was to define the spatiotemporal distribution of intracardiac alternans and its relationship to body surface alternans in humans. BACKGROUND Spatial heterogeneity of alternans exists in the animal heart owing to nonuniform calcium cycling and restitution kinetics. Patients with cardiomyopathy manifest similar myocardial substrate, which might influence the distribution of intracardiac alternans and its projection onto the body surface. METHODS Repolarization alternans was simultaneously measured from unipolar electrograms in the right ventricular endocardium, left ventricular (LV) epicardium, and the surface electrocardiogram in patients with cardiomyopathy (n = 14, LV ejection fraction 29 +/- 2%) during atrial pacing at cycle length (CL) 800, 600, and 500 ms. Alternans was determined from the entire JT interval as well as the early, mid, and late JT interval with spectral analysis. RESULTS Alternans was not uniformly distributed within the heart, with alternating and nonalternating myocardial segments lying adjacent to one another. A greater number of epicardial sites exhibited alternans than endocardial sites at CL 600 ms. Temporal heterogeneity in alternans was present along the JT interval, and apical segments had proportionately less alternans in the late JT interval than mid or basal segments, resulting in apicobasal alternans heterogeneity in late JT interval. Discordant alternans was seen in 5 patients confined to the epicardium. Patients with surface alternans had a greater proportion of intracardiac sites with alternans when compared with those patients without surface alternans. CONCLUSIONS Spatiotemporal heterogeneity and discordant alternans are evident in patients with cardiomyopathy. Greater spatial distribution of intracardiac alternans is associated with measurable body surface alternans.