Heart Digital Twins Predict Features of Invasive Reentrant Circuits and Ablation Lesions in Scar-Dependent Ventricular Tachycardia.

Background: Catheter ablation of scar-dependent ventricular tachycardia (VT) is frequently hampered by hemodynamic instability, long procedure duration, and high recurrence rates. Magnetic resonance imaging-based personalized heart digital twins may overcome these challenges by noninvasively predicting VT circuits and optimum ablation lesion sites. In this combined clinical and digital twin study, we investigated the relationship between digital twin-predicted VTs and optimum ablation lesion sets with their invasively mapped counterparts during clinical VT ablation.

Methods: A total of 18 patients with scar-dependent VT underwent digital twin creation based on preprocedural, contrast-enhanced cardiac magnetic resonance imaging. Using rapid pacing protocols, VT was simulated and ablation targets were derived that would terminate all possible VTs in the models. Patients subsequently underwent invasive VT ablation, including targeting of diastolic activity and optimum entrainment sites. Digital twin-predicted VT circuits and ablation lesions were compared with their invasive clinical counterparts.

Results: Forty-three clinical VTs and 92 digital twin VTs were induced. Diastolic activity was seen in 16 of 43 (37.2%) clinical VTs. Sensitivity, specificity, positive predictive, and negative predictive values for the detection of critical VT sites by digital twins were 81.3%, 83.8%, 21.7%, and 98.8%, respectively. At an American Heart Association-segment level, agreement between clinical VT critical sites and digital twin primary predicted sites was moderate, with a κ coefficient of 0.46 (±0.32; P≤0.001). Termination of VT with ablation was achieved at a digital twin-predicted site in 4 of 5 (80%) cases where attempted. A total of 426 of 709 (60.1%) lesions were within 5 mm of a predicted target site. In total, 54.0% (±28.9%) of the digital twin-predicted area was ablated per patient based on conventional mapping criteria.

Conclusions: Heart digital twin VT circuits and ablation targets accurately predict many features of their respective clinical counterparts but have some limitations in spatial resolution. Our findings demonstrate the significant potential of digital twin technology in guiding catheter ablation for scar-dependent VT.