Electrocardiographic Imaging for Cardiac Arrhythmias and Resynchronization Therapy

Helder Pereira; Steven Niederer; Christopher A. Rinaldi


Europace. 2020;22(10):1447-1462. 

In This Article

Abstract and Introduction


Use of the 12-lead electrocardiogram (ECG) is fundamental for the assessment of heart disease, including arrhythmias, but cannot always reveal the underlying mechanism or the location of the arrhythmia origin. Electrocardiographic imaging (ECGi) is a non-invasive multi-lead ECG-type imaging tool that enhances conventional 12-lead ECG. Although it is an established technology, its continuous development has been shown to assist in arrhythmic activation mapping and provide insights into the mechanism of cardiac resynchronization therapy (CRT). This review addresses the validity, reliability, and overall feasibility of ECGi for use in a diverse range of arrhythmias. A systematic search limited to full-text human studies published in peer-reviewed journals was performed through Medline via PubMed, using various combinations of three key concepts: ECGi, arrhythmia, and CRT. A total of 456 studies were screened through titles and abstracts. Ultimately, 42 studies were included for literature review. Evidence to date suggests that ECGi can be used to provide diagnostic insights regarding the mechanistic basis of arrhythmias and the location of arrhythmia origin. Furthermore, ECGi can yield valuable information to guide therapeutic decision-making, including during CRT. Several studies have used ECGi as a diagnostic tool for atrial and ventricular arrhythmias. More recently, studies have tested the value of this technique in predicting outcomes of CRT. As a non-invasive method for assessing cardiovascular disease, particularly arrhythmias, ECGi represents a significant advancement over standard procedures in contemporary cardiology. Its full potential has yet to be fully explored.


Cardiovascular disease (CVD) is the leading cause of death in Western countries,[1] and imposes a severe burden on society. While many advanced non-invasive measurement technologies have been developed, the 12-lead electrocardiogram (ECG) has been in use for over 100years and has become established as the 'de facto standard' for the non-invasive assessment of a wide range of heart diseases. The ability to obtain numerical readings of electrical measurements of the heart has long helped healthcare professionals provide both prevention and treatment.

Despite being a powerful diagnostic tool, 12-lead ECG has some limitations when used to support management procedures in modern cardiology. The current pool of research has established that 12-lead ECG is limited in detecting the precise location of arrhythmias, or detailed electrical activation pattern when cardiac resynchronization therapy (CRT) is involved.[2,3] Further drawbacks include its limited value in precisely identifying atrial and ventricular activation during arrhythmias, including accessory atrioventricular conduction activation,[4] and in providing a detailed assessment of electrical ventricular activation abnormalities,[5] inadequate pinpointing of the location of ventricular tachycardia (VT),[6] and poor spatial resolution.[7] These limitations may necessitate invasive electrophysiological studies to understand the patient's underlying conditions.

Electrocardiographic imaging (ECGi) is a non-invasive, multi-lead ECG-type imaging tool (50 to approximately 300 electrodes depending on the manufacturer) that allows 3D visualization of the cardiac geometry with onset activation maps providing further diagnostic data compared to a conventional 12-lead ECG.[2,4,8] It has been shown to be accurate for detecting a broad spectrum of specific arrhythmic characteristics.[3] This novel method may be able to address the limitations of 12-lead ECG. This review addresses the validity, reliability, and overall feasibility of ECGi for use in a diverse range of arrhythmias.