151
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Rayatzadeh H, Tan A, Chan RH, Patel SJ, Hauser TH, Ngo L, Shaw JL, Hong SN, Zimetbaum P, Buxton AE, Josephson ME, Manning WJ, Nezafat R. Scar heterogeneity on cardiovascular magnetic resonance as a predictor of appropriate implantable cardioverter defibrillator therapy. J Cardiovasc Magn Reson 2013; 15:31. [PMID: 23574733 PMCID: PMC3750752 DOI: 10.1186/1532-429x-15-31] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Accepted: 03/08/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite the survival benefit of implantable-cardioverter-defibrillators (ICDs), the vast majority of patients receiving an ICD for primary prevention do not receive ICD therapy. We sought to assess the role of heterogeneous scar area (HSA) identified by late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) in predicting appropriate ICD therapy for primary prevention of sudden cardiac death (SCD). METHODS From September 2003 to March 2011, all patients who underwent primary prevention ICD implantation and had a pre-implantation LGE-CMR were identified. Scar size was determined using thresholds of 4 and 6 standard deviations (SD) above remote normal myocardium; HSA was defined using 3 different criteria; as the region between 2 SD and 4 SD (HSA2-4SD), between 2SD and 6SD (HSA2-6SD), and between 4SD and 6SD (HSA4-6SD). The end-point was appropriate ICD therapy. RESULTS Out of 40 total patients followed for 25 ± 24 months, 7 had appropriate ICD therapy. Scar size measured by different thresholds was similar in ICD therapy and non-ICD therapy groups (P = NS for all). However, HSA2-4SD and HSA4-6SD were significantly larger in the ICD therapy group (P = 0.001 and P = 0.03, respectively). In multivariable model HSA2-4SD was the only significant independent predictor of ICD therapy (HR = 1.08, 95%CI: 1.00-1.16, P = 0.04). Kaplan-Meier analysis showed that patients with greater HSA2-4SD had a lower survival free of appropriate ICD therapy (P = 0.026). CONCLUSIONS In primary prevention ICD implantation, LGE-CMR HSA identifies patients with appropriate ICD therapy. If confirmed in larger series, HSA can be used for risk stratification in primary prevention of SCD.
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MESH Headings
- Aged
- Arrhythmias, Cardiac/etiology
- Arrhythmias, Cardiac/mortality
- Arrhythmias, Cardiac/physiopathology
- Arrhythmias, Cardiac/therapy
- Cicatrix/complications
- Cicatrix/pathology
- Cicatrix/physiopathology
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable
- Disease-Free Survival
- Electric Countershock/instrumentation
- Female
- Humans
- Kaplan-Meier Estimate
- Magnetic Resonance Imaging
- Male
- Middle Aged
- Myocardium/pathology
- Patient Selection
- Predictive Value of Tests
- Primary Prevention/instrumentation
- Primary Prevention/methods
- Proportional Hazards Models
- Prosthesis Design
- Prosthesis Failure
- Retrospective Studies
- Risk Factors
- Stroke Volume
- Time Factors
- Treatment Outcome
- Ventricular Function, Left
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Affiliation(s)
| | - Alex Tan
- Department of Medicine, Boston, MA, USA
| | | | | | | | - Long Ngo
- Department of Medicine, Boston, MA, USA
| | | | | | | | | | | | - Warren J Manning
- Department of Medicine, Boston, MA, USA
- Radiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Reza Nezafat
- Department of Medicine, Boston, MA, USA
- Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, USA
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152
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Pauriah M, Cismaru G, Magnin-Poull I, Andronache M, Sellal JM, Schwartz J, Brembilla-Perrot B, Sadoul N, Aliot E, de Chillou C. A Stepwise Approach to the Management of Postinfarct Ventricular Tachycardia Using Catheter Ablation as the First-Line Treatment. Circ Arrhythm Electrophysiol 2013; 6:351-6. [PMID: 23512203 DOI: 10.1161/circep.113.000261] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Maheshwar Pauriah
- From the Department of Cardiology, CHU de Nancy, University Hospital Nancy, Nancy, France (M.P., G.C., I.M.-P., M.A., J.-M.S., J.S., B.B.-P., N.S., E.A., C.d.C.); and IADI—INSERM, U947, Nancy, France (I.M.-P., M.A., C.d.C.)
| | - Gabriel Cismaru
- From the Department of Cardiology, CHU de Nancy, University Hospital Nancy, Nancy, France (M.P., G.C., I.M.-P., M.A., J.-M.S., J.S., B.B.-P., N.S., E.A., C.d.C.); and IADI—INSERM, U947, Nancy, France (I.M.-P., M.A., C.d.C.)
| | - Isabelle Magnin-Poull
- From the Department of Cardiology, CHU de Nancy, University Hospital Nancy, Nancy, France (M.P., G.C., I.M.-P., M.A., J.-M.S., J.S., B.B.-P., N.S., E.A., C.d.C.); and IADI—INSERM, U947, Nancy, France (I.M.-P., M.A., C.d.C.)
| | - Marius Andronache
- From the Department of Cardiology, CHU de Nancy, University Hospital Nancy, Nancy, France (M.P., G.C., I.M.-P., M.A., J.-M.S., J.S., B.B.-P., N.S., E.A., C.d.C.); and IADI—INSERM, U947, Nancy, France (I.M.-P., M.A., C.d.C.)
| | - Jean-Marc Sellal
- From the Department of Cardiology, CHU de Nancy, University Hospital Nancy, Nancy, France (M.P., G.C., I.M.-P., M.A., J.-M.S., J.S., B.B.-P., N.S., E.A., C.d.C.); and IADI—INSERM, U947, Nancy, France (I.M.-P., M.A., C.d.C.)
| | - Jérôme Schwartz
- From the Department of Cardiology, CHU de Nancy, University Hospital Nancy, Nancy, France (M.P., G.C., I.M.-P., M.A., J.-M.S., J.S., B.B.-P., N.S., E.A., C.d.C.); and IADI—INSERM, U947, Nancy, France (I.M.-P., M.A., C.d.C.)
| | - Béatrice Brembilla-Perrot
- From the Department of Cardiology, CHU de Nancy, University Hospital Nancy, Nancy, France (M.P., G.C., I.M.-P., M.A., J.-M.S., J.S., B.B.-P., N.S., E.A., C.d.C.); and IADI—INSERM, U947, Nancy, France (I.M.-P., M.A., C.d.C.)
| | - Nicolas Sadoul
- From the Department of Cardiology, CHU de Nancy, University Hospital Nancy, Nancy, France (M.P., G.C., I.M.-P., M.A., J.-M.S., J.S., B.B.-P., N.S., E.A., C.d.C.); and IADI—INSERM, U947, Nancy, France (I.M.-P., M.A., C.d.C.)
| | - Etienne Aliot
- From the Department of Cardiology, CHU de Nancy, University Hospital Nancy, Nancy, France (M.P., G.C., I.M.-P., M.A., J.-M.S., J.S., B.B.-P., N.S., E.A., C.d.C.); and IADI—INSERM, U947, Nancy, France (I.M.-P., M.A., C.d.C.)
| | - Christian de Chillou
- From the Department of Cardiology, CHU de Nancy, University Hospital Nancy, Nancy, France (M.P., G.C., I.M.-P., M.A., J.-M.S., J.S., B.B.-P., N.S., E.A., C.d.C.); and IADI—INSERM, U947, Nancy, France (I.M.-P., M.A., C.d.C.)
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153
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ALMENDRAL JESÚS. Resetting and Entrainment of Reentrant Arrhythmias: Part II: Informative Content and Practical Use of These Responses. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2013; 36:641-61. [DOI: 10.1111/pace.12075] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Accepted: 11/24/2012] [Indexed: 11/27/2022]
Affiliation(s)
- JESÚS ALMENDRAL
- From the Cardiac Arrhythmia Unit; Grupo Hospital de Madrid; Universidad CEU-San Pablo; Madrid; Spain
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154
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Tereshchenko LG, McNitt S, Han L, Berger RD, Zareba W. ECG marker of adverse electrical remodeling post-myocardial infarction predicts outcomes in MADIT II study. PLoS One 2012; 7:e51812. [PMID: 23251630 PMCID: PMC3522579 DOI: 10.1371/journal.pone.0051812] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 11/06/2012] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Post-myocardial infarction (MI) structural remodeling is characterized by left ventricular dilatation, fibrosis, and hypertrophy of the non-infarcted myocardium. OBJECTIVE The goal of our study was to quantify post-MI electrical remodeling by measuring the sum absolute QRST integral (SAI QRST). We hypothesized that adverse electrical remodeling predicts outcomes in MADIT II study participants. METHODS Baseline orthogonal ECGs of 750 MADIT II study participants (448 [59.7%] ICD arm) were analyzed. SAI QRST was measured as the arithmetic sum of absolute QRST integrals over all three orthogonal ECG leads. The primary endpoint was defined as sudden cardiac death (SCD) or sustained ventricular tachycardia (VT)/ventricular fibrillation (VF) with appropriate ICD therapies. All-cause mortality served as a secondary endpoint. RESULTS Adverse electrical remodeling in post-MI patients was characterized by wide QRS, increased magnitudes of spatial QRS and T vectors, J-point deviation, and QTc prolongation. In multivariable Cox regression analysis after adjustment for age, QRS duration, atrial fibrillation, New York Heart Association heart failure class and blood urea nitrogen, SAI QRST predicted SCD/VT/VF (HR 1.33 per 100 mV*ms (95%CI 1.11-1.59); P = 0.002), and all-cause death (HR 1.27 per 100 mV*ms (95%CI 1.03-1.55), P = 0.022) in both arms. No interaction with therapy arm and bundle branch block (BBB) status was found. CONCLUSIONS In MADIT II patients, increased SAI QRST is associated with increased risk of sustained VT/VF with appropriate ICD therapies and all-cause death in both ICD and in conventional medical therapy arms, and in patients with and without BBB. Further studies of SAI QRST are warranted.
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Affiliation(s)
- Larisa G Tereshchenko
- The Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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155
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156
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Kim J, Han D, Sohn C, Kim JS, Park YH. Catheter Ablation of Ventricular Arrhythmias via the Radial Artery in a Patient With Prior Myocardial Infarction and Peripheral Vascular Disease. Korean Circ J 2012; 42:632-7. [PMID: 23091510 PMCID: PMC3467449 DOI: 10.4070/kcj.2012.42.9.632] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 02/08/2012] [Accepted: 02/13/2012] [Indexed: 11/22/2022] Open
Abstract
Herein, we present a case of a successful catheter ablation of ventricular tachycardia (VT) using a radial artery approach in a post-myocardial infarction patient, who had an implantable cardioverter-defibrillator and peripheral artery disease. Although the patient did not use antiarrhythmic drugs, the patient experienced no recurrence of VT during the following 3-year period.
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Affiliation(s)
- Jun Kim
- Division of Cardiology, Pusan National University Yangsan Hospital, Yangsan, Korea
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157
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Benito B, Josephson ME. Ventricular tachycardia in coronary artery disease. Rev Esp Cardiol 2012; 65:939-55. [PMID: 22951088 DOI: 10.1016/j.recesp.2012.03.027] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 03/09/2012] [Indexed: 10/27/2022]
Abstract
Ventricular arrhythmias are important contributors to morbidity and mortality in patients with coronary artery disease. Ventricular fibrillation accounts for the majority of deaths occurring in the acute phase of ischemia, whereas sustained, monomorphic ventricular tachycardia due to reentry generated in the scar tissue develops most often in the setting of healed myocardial infarction, especially in patients with lower left ventricular ejection fraction. Despite determinant advances in population education and myocardial infarction management, the ventricular tachycardia risk in the overall population with coronary artery disease continues to be a major problem in clinical practice. The initial evaluation of a patient presenting with ventricular tachycardia requires a 12-lead electrocardiogram, which can be helpful to confirm the diagnosis, suggest the presence of potential underlying heart disease, and identify the location of the ventricular tachycardia circuit. An invasive electrophysiologic study is usually crucial to determine the mechanism of the arrhythmia once induced and to provide guidance for ablation. The approach for ventricular tachycardia ablation depends on several factors, including inducibility, sustainability, and clinical tolerance of ventricular tachycardia. The paper also reviews other therapeutic options for patients with ventricular tachycardia associated with coronary artery disease, including antiarrhythmic drug therapy, surgical ablation, and current implantable cardioverter-defibrillator indications.
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Affiliation(s)
- Begoña Benito
- Sección de Arritmias, Servicio de Cardiología, Hospital del Mar, Barcelona, España
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158
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Nogami A. Successful catheter ablation of ventricular tachycardia at a site with manifest entrainment and a long postpacing interval: What is the mechanism? J Arrhythm 2012. [DOI: 10.1016/j.joa.2012.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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159
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Houmsse M, Daoud EG. Biophysics and clinical utility of irrigated-tip radiofrequency catheter ablation. Expert Rev Med Devices 2012; 9:59-70. [PMID: 22145841 DOI: 10.1586/erd.11.42] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Catheter ablation by radiofrequency (RF) energy has successfully eliminated cardiac tachyarrhythmias. RF ablation lesions are created by thermal energy. Electrode catheters with 4-mm-tips have been adequate to ablate arrhythmias located near the endocardium; however, the 4-mm-tip electrode does not readily ablate deeper tachyarrhythmia substrate. With 8- and 10-mm-tip RF electrodes, ablation lesions were larger; yet, these catheters are associated with increased risk for coagulum, char and thrombus formation, as well as myocardial steam rupture. Cooled-tip catheter technology was designed to cool the electrode tip, prevent excessive temperatures at the electrode tip-tissue interface, and thus allow continued delivery of RF current into the surrounding tissue. This ablation system creates larger and deeper ablation lesions and minimizes steam pops and thrombus formation. The purpose of this article is to review cooled-tip RF ablation biophysics and outcomes of clinical studies as well as to discuss future technological improvements.
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Affiliation(s)
- Mahmoud Houmsse
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University, Columbus, USA.
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160
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Peyrol M, Sbragia P, Orabona M, Casalta AC, Laine M, Decourt A, Quatre A, Jacquier A, Siddo ND, Paganelli F. Ventricular allorhythmia during infarct-related ventricular tachycardia. J Electrocardiol 2012; 45:394-397. [DOI: 10.1016/j.jelectrocard.2012.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2011] [Indexed: 11/16/2022]
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161
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162
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Gao P, Yee R, Gula L, Krahn AD, Skanes A, Leong-Sit P, Klein GJ, Stirrat J, Fine N, Pallaveshi L, Wisenberg G, Thompson TR, Prato F, Drangova M, White JA. Prediction of arrhythmic events in ischemic and dilated cardiomyopathy patients referred for implantable cardiac defibrillator: evaluation of multiple scar quantification measures for late gadolinium enhancement magnetic resonance imaging. Circ Cardiovasc Imaging 2012; 5:448-56. [PMID: 22572740 DOI: 10.1161/circimaging.111.971549] [Citation(s) in RCA: 164] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Scar signal quantification using late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) identifies patients at higher risk of future events, both in ischemic cardiomyopathy (ICM) and nonischemic dilated cardiomyopathy (DCM). However, the ability of scar signal burden to predict events in such patient groups at the time of referral for implantable cardioverter-defibrillator (ICD) has not been well explored. This study evaluates the predictive use of multiple scar quantification measures in ICM and DCM patients being referred for ICD. METHODS AND RESULTS One hundred twenty-four consecutive patients referred for ICD therapy (59 with ICM and 65 with DCM) underwent a standardized LGE-CMR protocol with blinded, multithreshold scar signal quantification and, for those with ICM, peri-infarct signal quantification. Patients were followed prospectively for the primary combined outcome of appropriate ICD therapy, survived cardiac arrest, or sudden cardiac death. At a mean follow-up of 632 ± 262 days, 18 patients (15%) had suffered the primary outcome. Total scar was significantly higher among those suffering a primary outcome, a relationship maintained within each cardiomyopathy cohort (P<0.01 for all comparisons). Total scar was the strongest independent predictor of the primary outcome and demonstrated a negative predictive value of 86%. In the ICM subcohort, peri-infarct signal showed only a nonsignificant trend toward elevation among those having a primary end point. CONCLUSIONS Myocardial scar quantification by LGE-CMR predicts arrhythmic events in patients being evaluated for ICD eligibility irrespective of cardiomyopathy etiology.
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Affiliation(s)
- Peng Gao
- Division of Cardiology, Department of Medicine, University of Western Ontario, London, Ontario, Canada
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163
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Tung R, Mathuria N, Michowitz Y, Yu R, Buch E, Bradfield J, Mandapati R, Wiener I, Boyle N, Shivkumar K. Functional pace-mapping responses for identification of targets for catheter ablation of scar-mediated ventricular tachycardia. Circ Arrhythm Electrophysiol 2012; 5:264-72. [PMID: 22333344 DOI: 10.1161/circep.111.967976] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Myocardial scars harbor areas of slow conduction and display abnormal electrograms. Pace-mapping at these sites can generate a 12-lead ECG morphological match to a targeted ventricular tachycardia (VT), and in some instances, multiple exit morphologies can result. At times, this can also result in the initiation of VT, termed pace-mapped induction (PMI). We hypothesized that in patients undergoing catheter ablation of VT, scar substrates with multiple exit sites (MES) identified during pace-mapping have improved freedom from recurrent VT, and PMI of VT predicts successful sites of termination during ablation. METHODS AND RESULTS High-density mapping was performed in all subjects to delineate scar (0.5-1.5 mV). Sites with abnormal electrograms were tagged, stimulated (bipolar 10 mA at 2 ms), and targeted for ablation. MES was defined as >1 QRS morphology from a single pacing site. PMI was defined as initiation of VT during pace-mapping (400-600 ms). In a 2-year period, 44 consecutive patients with scar-mediated VT underwent mapping and ablation. MES were observed during pace-mapping in 25 patients (57%). At 9 months, 74% of patients who exhibited MES during pace-mapping had no recurrence of VT compared with 42% of those without MES observed (P=0.024), with an overall freedom from VT of 61%. Thirteen patients (30%) demonstrated PMI, and termination of VT was seen in 95% (18/19) of sites where ablation was performed. CONCLUSIONS During pace-mapping, electrograms that exhibit MES and PMI may be specific for sites critical to reentry. These functional responses hold promise for identifying important sites for catheter ablation of VT.
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Affiliation(s)
- Roderick Tung
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1679, USA.
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164
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Reithmann C, Fiek M, Hahnefeld A, Ulbrich M, Steinbeck G. Recording of low-amplitude diastolic electrograms through the coronary veins: a guide for epicardial ventricular tachycardia ablation. Europace 2011; 14:865-71. [DOI: 10.1093/europace/eur383] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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165
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Bunch TJ, Darby A, May HT, Ragosta M, Lim DS, Taylor AM, DiMarco JP, Ailawadi G, Revenaugh JR, Weiss JP, Mahapatra S. Efficacy and safety of ventricular tachycardia ablation with mechanical circulatory support compared with substrate-based ablation techniques. Europace 2011; 14:709-14. [PMID: 22080473 DOI: 10.1093/europace/eur347] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Catheter ablation of ventricular tachycardia (VT) can be limited by haemodynamic instability. In these cases, substrate-based ablation is typically performed. An alternative is to perform activation and entrainment mapping during VT supported by a percutaneous left ventricular assist device (pVAD). We sought to compare the complication and success rates of pVAD-assisted VT ablation with scar-based techniques. METHODS AND RESULTS Thirteen consecutive patients with haemodynamically unstable VT underwent pVAD-assisted ablation (pVAD group) and were retrospectively compared with 18-matched patients undergoing a substrate-based VT ablation (non-pVAD group). There was no significant difference in age or ejection fraction between the groups although pVAD patients tended to have more shocks in the preceding months. Procedure times were longer for the pVAD group. The number of monomorphic VTs induced was greater in the pVAD group (3.2 vs. 1.6, P= 0.04); however, after ablation, there was no difference in inducibility between the pVAD and non-pVAD group (10 of 13 vs. 12 of 18; 77 vs. 67%, P = 0.69). There was no difference in acute complications including stroke or death. At 9 ± 3 months, 1-year freedom from implantable cardioverter-defibrillator (ICD) shocks/therapies for sustained VT were similar (P= 0.96). In multivariable analysis, the absence of atrial fibrillation (hazard ratio=0.15, P= 0.04) was associated with a lower incidence of ICD shocks. CONCLUSIONS In high-risk patients, pVAD-assisted VT ablation guided by activation and entrainment mapping is a feasible alternative to substrate mapping and allows outcomes comparable to substrate mapping.
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Affiliation(s)
- T Jared Bunch
- Intermountain Medical Center, Salt Lake City, UT, USA
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166
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NAKANO EMI, HARADA TOMOO, AONUMA KAZUTAKA, SOEJIMA KYOKO, WAKIMOTO HIROFUMI, MATSUMOTO NAOKI, MIYAKE FUMIHIKO. Identification of Unusual Reentry Circuit Sites of Nonischemic Ventricular Outflow Tract Tachycardia. J Cardiovasc Electrophysiol 2011; 23:179-87. [DOI: 10.1111/j.1540-8167.2011.02149.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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167
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Affiliation(s)
- Roderick Tung
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095-1679 USA.
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168
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Link MS, Exner DV, Anderson M, Ackerman M, Al-Ahmad A, Knight BP, Markowitz SM, Kaufman ES, Haines D, Asirvatham SJ, Callans DJ, Mounsey JP, Bogun F, Narayan SM, Krahn AD, Mittal S, Singh J, Fisher JD, Chugh SS. HRS policy statement: clinical cardiac electrophysiology fellowship curriculum: update 2011. Heart Rhythm 2011; 8:1340-56. [PMID: 21699868 DOI: 10.1016/j.hrthm.2011.06.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Indexed: 01/29/2023]
Affiliation(s)
- Mark S Link
- Tufts Medical Center, Boston, Massachusetts, USA
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169
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Woie L, Eftestol T, Engan K, Kvaloy JT, Nilsen DWT, Orn S. The heart rate of ventricular tachycardia following an old myocardial infarction is inversely related to the size of scarring. Europace 2011; 13:864-8. [DOI: 10.1093/europace/euq466] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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170
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Michowitz Y, Mathuria N, Tung R, Esmailian F, Kwon M, Nakahara S, Bourke T, Boyle NG, Mahajan A, Shivkumar K. Hybrid procedures for epicardial catheter ablation of ventricular tachycardia: Value of surgical access. Heart Rhythm 2010; 7:1635-43. [DOI: 10.1016/j.hrthm.2010.07.009] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Accepted: 07/10/2010] [Indexed: 11/16/2022]
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171
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Bernhardt P, Stiller S, Kottmair E, Binner L, Spieß J, Großmann G, Rasche V, Walcher D, Hombach V. Myocardial scar extent evaluated by cardiac magnetic resonance imaging in ICD patients: relationship to spontaneous VT during long-term follow-up. Int J Cardiovasc Imaging 2010; 27:893-900. [DOI: 10.1007/s10554-010-9726-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 10/02/2010] [Indexed: 11/30/2022]
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172
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Akhtar M. Ventricular Tachycardia. Card Electrophysiol Clin 2010; 2:245-265. [PMID: 28770759 DOI: 10.1016/j.ccep.2010.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Understanding of ventricular tachycardia has improved greatly in recent years. Still diagnosis has remained challenging. This article presents four cases to illustrate different presentations of this disorder.
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Affiliation(s)
- Masood Akhtar
- University of Wisconsin School of Medicine and Public Health, Aurora Sinai, St Luke's Medical Center, 960 North 12th Street, Milwaukee, WI, USA
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173
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Tsai CF, Ueng KC, Wu DJ, Tsai TP, Lin CS. Remodeled left ventricular myocardium remote to infarction sites is the arrhythmogenic substrate for sudden cardiac death. Med Hypotheses 2010; 75:368-71. [PMID: 20399566 DOI: 10.1016/j.mehy.2010.03.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2010] [Accepted: 03/24/2010] [Indexed: 11/26/2022]
Abstract
Ventricular tachyarrhythmias are life threatening cardiac arrhythmias and are the most common causes of sudden cardiac death. Greater post-infarction left ventricular remodeling has been shown to have a greater preponderance of ventricular arrhythmias. The hypothesis herein is that adverse structural and electrophysiological remodeling at non-infarcted regions after myocardial infarction constitutes the arrhythmogenic substrate responsible for clinically occurring ventricular arrhythmias leading to sudden cardiac death. Post-infarction patients with more severe left ventricular remodeling (regional hypertrophy) at sites remote to infarction scar might have the highest risk for sudden cardiac death due to lethal ventricular arrhythmias. In the hypertrophic non-infarcted zone, larger action potential duration and repolarization heterogeneity is not in self arrhythmogenic, but can predispose towards arrhythmia development under certain condition, such as transient myocardial ischemia. We should draw more attention to apparently "normal" non-infarction region for further understanding the mechanism of sudden cardiac death.
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Affiliation(s)
- Chin-Feng Tsai
- School of Medicine, Chung Shan Medical University, Taichung, Taiwan, ROC.
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174
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Arruda M, Fahmy T, Armaganijan L, Di Biase L, Patel D, Natale A. Endocardial and epicardial mapping and catheter ablation of post myocardial infarction ventricular tachycardia: A substrate modification approach. J Interv Card Electrophysiol 2010; 28:137-45. [PMID: 20396939 DOI: 10.1007/s10840-010-9469-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2008] [Accepted: 01/03/2010] [Indexed: 11/28/2022]
Abstract
Ventricular tachycardia associated with prior myocardial infarction account for significant morbidity, mortality, and health care costs despite the favorable outcomes shown by ICD clinical trials. Catheter ablation has been increasingly used as an adjunctive therapy in the management of scar-related ventricular tachycardia. Novel technologies have facilitated the outcomes of current ablation strategies. Three-dimensional mapping systems have allowed identification of the scar substrate, its critical sites in the tachycardia circuit, and selection of ablation sites based on fairly precise electroanatomic substrate.
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Affiliation(s)
- Mauricio Arruda
- University Hospitals, Harrington-McLaughlin Heart and Vascular Institute, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Lakeside 5038, Cleveland, OH 44106, USA.
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175
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KANNANKERIL PRINCEJ, BONNEY WILLIAMJ, DZURIK MATTHEWV, FISH FRANKA. Entrainment to Distinguish Orthodromic Reciprocating Tachycardia from Atrioventricular Nodal Reentry Tachycardia in Children. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 33:469-74. [DOI: 10.1111/j.1540-8159.2009.02639.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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176
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ABOUEZZEDDINE OMAR, SULEIMAN MAHMOUD, BUESCHER TRACI, KAPA SURAJ, FRIEDMAN PAULA, JAHANGIR ARSHAD, MEARS JENNIFERA, LADEWIG DOROTHYJ, MUNGER THOMASM, HAMMILL STEPHENC, PACKER DOUGLASL, ASIRVATHAM SAMUELJ. Relevance of Endocavitary Structures in Ablation Procedures for Ventricular Tachycardia. J Cardiovasc Electrophysiol 2010; 21:245-54. [DOI: 10.1111/j.1540-8167.2009.01621.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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177
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Natale A, Raviele A, Al-Ahmad A, Alfieri O, Aliot E, Almendral J, Breithardt G, Brugada J, Calkins H, Callans D, Cappato R, Camm JA, Della Bella P, Guiraudon GM, Haïssaguerre M, Hindricks G, Ho SY, Kuck KH, Marchlinski F, Packer DL, Prystowsky EN, Reddy VY, Ruskin JN, Scanavacca M, Shivkumar K, Soejima K, Stevenson WJ, Themistoclakis S, Verma A, Wilber D. Venice Chart International Consensus document on ventricular tachycardia/ventricular fibrillation ablation. J Cardiovasc Electrophysiol 2010; 21:339-79. [PMID: 20082650 DOI: 10.1111/j.1540-8167.2009.01686.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
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178
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Steven D, Roberts-Thomson KC, Seiler J, Inada K, Tedrow UB, Mitchell RN, Sobieszczyk PS, Eisenhauer AC, Couper GS, Stevenson WG. Ventricular Tachycardia Arising From the Aortomitral Continuity in Structural Heart Disease. Circ Arrhythm Electrophysiol 2009; 2:660-6. [DOI: 10.1161/circep.109.853531] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
The aortomitral continuity (AMC) has been described as a site of origin for ventricular tachycardias (VT) in structurally normal hearts. There is a paucity of data on the contribution of this region to VTs in patients with structural heart disease.
Methods and Results—
Data from 550 consecutive patients undergoing catheter ablation for VT associated with structural heart disease were reviewed. Twenty-one (3.8%) had a VT involving the peri-AMC region (age, 62.7�11 years; median left ventricular ejection fraction, 43.6�17%). Structural heart disease was ischemic in 7 (33%), dilated cardiomyopathy in 10 (47.6%), and valvular cardiomyopathy in 4 (19%) patients, respectively. After 1.9�0.8 catheter ablation procedures (including 3 transcoronary ethanol ablations) the peri-AMC VT was not inducible in 19 patients. The remaining 2 patients underwent cryosurgical ablation. Our first catheter ablation procedure was less often successful (66.7%) for peri-AMC VTs compared with that for 246 VTs originating from the LV free wall (81.4%,
P
=0.03). During a mean follow-up of 1.9�2.1 years, 12 (57.1%) patients remained free of VT, peri-AMC VT recurred in 7 patients, and 1 patient had recurrent VT from a remote location. Three patients died. Analysis of 50 normal coronary angiograms demonstrated an early septal branch supplying the peri-AMC area in 58% of cases that is a potential target for ethanol ablation.
Conclusions—
VTs involving the peri-AMC region occur in patients with structural heart disease and appear to be more difficult to ablate compared with VTs originating from the free LV wall. This region provides unique challenges for radiofrequency ablation, but cryosurgery and transcoronary alcohol ablation appear feasible in some cases.
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Affiliation(s)
- Daniel Steven
- From the Cardiovascular Division, Department of Medicine (D.S., K.C.R.-T., J.S., K.I., U.B.T., P.S.S., A.C.E., G.S.C., W.G.S.) and Department of Pathology (R.N.M.), Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - Kurt C. Roberts-Thomson
- From the Cardiovascular Division, Department of Medicine (D.S., K.C.R.-T., J.S., K.I., U.B.T., P.S.S., A.C.E., G.S.C., W.G.S.) and Department of Pathology (R.N.M.), Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - Jens Seiler
- From the Cardiovascular Division, Department of Medicine (D.S., K.C.R.-T., J.S., K.I., U.B.T., P.S.S., A.C.E., G.S.C., W.G.S.) and Department of Pathology (R.N.M.), Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - Keiichi Inada
- From the Cardiovascular Division, Department of Medicine (D.S., K.C.R.-T., J.S., K.I., U.B.T., P.S.S., A.C.E., G.S.C., W.G.S.) and Department of Pathology (R.N.M.), Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - Usha B. Tedrow
- From the Cardiovascular Division, Department of Medicine (D.S., K.C.R.-T., J.S., K.I., U.B.T., P.S.S., A.C.E., G.S.C., W.G.S.) and Department of Pathology (R.N.M.), Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - Richard N. Mitchell
- From the Cardiovascular Division, Department of Medicine (D.S., K.C.R.-T., J.S., K.I., U.B.T., P.S.S., A.C.E., G.S.C., W.G.S.) and Department of Pathology (R.N.M.), Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - Piotr S. Sobieszczyk
- From the Cardiovascular Division, Department of Medicine (D.S., K.C.R.-T., J.S., K.I., U.B.T., P.S.S., A.C.E., G.S.C., W.G.S.) and Department of Pathology (R.N.M.), Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - Andrew C. Eisenhauer
- From the Cardiovascular Division, Department of Medicine (D.S., K.C.R.-T., J.S., K.I., U.B.T., P.S.S., A.C.E., G.S.C., W.G.S.) and Department of Pathology (R.N.M.), Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - Gregory S. Couper
- From the Cardiovascular Division, Department of Medicine (D.S., K.C.R.-T., J.S., K.I., U.B.T., P.S.S., A.C.E., G.S.C., W.G.S.) and Department of Pathology (R.N.M.), Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
| | - William G. Stevenson
- From the Cardiovascular Division, Department of Medicine (D.S., K.C.R.-T., J.S., K.I., U.B.T., P.S.S., A.C.E., G.S.C., W.G.S.) and Department of Pathology (R.N.M.), Brigham and Women’s Hospital, Harvard Medical School, Boston, Mass
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179
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Affiliation(s)
- Hein J Wellens
- Cardiovascular Research Center Maastricht, Maastricht, the Netherlands.
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180
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Timmermans C, Manusama R, Alzand B, Rodriguez LM. Catheter-based cryoablation of postinfarction and idiopathic ventricular tachycardia: initial experience in a selected population. J Cardiovasc Electrophysiol 2009; 21:255-61. [PMID: 19804550 DOI: 10.1111/j.1540-8167.2009.01610.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Transvenous cryoablation has proven to be safe and effective for the treatment of supraventricular arrhythmias. The aim of this prospective study was to report the feasibility and safety of catheter-based cryoablation for the treatment of postinfarction and idiopathic ventricular tachycardia (VT). METHODS AND RESULTS Catheter-based cryoablation was performed in 17 patients (15 men, 58 +/- 18 years). VT occurred after a prior myocardial infarction in 10 and was idiopathic in 7 patients. Cryoablation was performed with a 10-F, 6.5-mm tipped catheter. The ablation site was selected using entrainment mapping techniques for postinfarction VT. The site of the earliest activation time with optimal pace mapping was used for ablation of idiopathic VT. All targeted VTs (12 postinfarction and 7 idiopathic) were acute successfully ablated after a median number of 2 applications of 5 minutes with an average temperature of -82 +/- 4 degrees C. Mean procedure and fluoroscopy times were 204 +/- 52 and 52 +/- 20 minutes for postinfarction VT and 203 +/- 24 and 38 +/- 15 minutes for idiopathic VT. No cryocatheter or cryoenergy complications were observed. After a follow-up of 6 months, 4 of the 10 patients with postinfarction VT had a recurrence. In 1 of the 7 patients with idiopathic VT the index arrhythmia recurred. CONCLUSION In this small patient population, catheter-based cryoablation of VT was safe and effective. Future studies are needed to evaluate the effect of cryothermy in a larger group of patients, especially those with postinfarction VT.
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Affiliation(s)
- Carl Timmermans
- Department of Cardiology, Academic Hospital Maastricht, Maastricht, the Netherlands.
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181
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Segal OR, Chow AWC, Peters NS, Davies DW. Mechanisms that initiate ventricular tachycardia in the infarcted human heart. Heart Rhythm 2009; 7:57-64. [PMID: 20129286 PMCID: PMC2806968 DOI: 10.1016/j.hrthm.2009.09.025] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2009] [Accepted: 09/16/2009] [Indexed: 11/29/2022]
Abstract
Background Precise mechanisms that initiate ventricular tachycardia (VT) in the intact infarcted human heart have not been defined. Objective The purpose of this study was to investigate the mechanisms that underlie human postinfarct VT initiation. Methods Noncontact mapping of the left ventricle was performed in 9 patients (age 67.1 ± 7.8 years, ejection fraction 34.4% ± 5%) with previous myocardial infarction and sustained monomorphic VT. Results Circuits in which ≥30% of the diastolic pathway (DP) could be defined were identified in 12 VTs (cycle length 357 ± 60 ms). Eighteen VT episodes were initiated with pacing, and one occurred spontaneously. Ten complete and two partial circuits were mapped (89% ± 25% of the DP). In all complete circuits, pacing led to the development of unidirectional conduction block at the location of the subsequent VT exit site and the formation of functional block creating a border(s) for subsequent DP. Wavefront velocity in the DP region slowed from 1.22 ± 0.2 m/s during sinus rhythm to 0.59 ± 0.14 m/s during VT (P <.005). In 11 initiation episodes, lines of functional block and areas of slow conduction developed progressively over one to six reentrant cycles before a stable DP was established and sustained monomorphic VT ensued. The formation of unidirectional or functional lines of block was not identified during identical pacing protocols that failed to initiate VT (n = 14). Conclusion Initiation of sustained monomorphic VT requires the development of unidirectional block and formation of lines of functional block creating borders for a DP in areas of slow conduction. A transitional stage often exists during the initiation process before a stable VT circuit is established.
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183
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184
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Aliot EM, Stevenson WG, Almendral-Garrote JM, Bogun F, Calkins CH, Delacretaz E, Bella PD, Hindricks G, Jais P, Josephson ME, Kautzner J, Kay GN, Kuck KH, Lerman BB, Marchlinski F, Reddy V, Schalij MJ, Schilling R, Soejima K, Wilber D. EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias: Developed in a partnership with the European Heart Rhythm Association (EHRA), a Registered Branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA). Europace 2009; 11:771-817. [DOI: 10.1093/europace/eup098] [Citation(s) in RCA: 283] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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185
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Raymond JM, Sacher F, Winslow R, Tedrow U, Stevenson WG. Catheter Ablation for Scar-related Ventricular Tachycardias. Curr Probl Cardiol 2009; 34:225-70. [DOI: 10.1016/j.cpcardiol.2009.01.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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186
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MRI with late gadolinium enhancement as a predictor of ventricular arrhythmias. CURRENT CARDIOVASCULAR IMAGING REPORTS 2009. [DOI: 10.1007/s12410-009-0015-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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187
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Roes SD, Borleffs CJW, van der Geest RJ, Westenberg JJM, Marsan NA, Kaandorp TAM, Reiber JHC, Zeppenfeld K, Lamb HJ, de Roos A, Schalij MJ, Bax JJ. Infarct tissue heterogeneity assessed with contrast-enhanced MRI predicts spontaneous ventricular arrhythmia in patients with ischemic cardiomyopathy and implantable cardioverter-defibrillator. Circ Cardiovasc Imaging 2009; 2:183-90. [PMID: 19808591 DOI: 10.1161/circimaging.108.826529] [Citation(s) in RCA: 341] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The relation between infarct tissue heterogeneity on contrast-enhanced MRI and the occurrence of spontaneous ventricular arrhythmia (or sudden cardiac death) is unknown. Therefore, the study purpose was to evaluate the predictive value of infarct tissue heterogeneity assessed with contrast-enhanced MRI on the occurrence of spontaneous ventricular arrhythmia with subsequent implantable cardioverter-defibrillator (ICD) therapy (as surrogate of sudden cardiac death) in patients with previous myocardial infarction. METHODS AND RESULTS Ninety-one patients (age, 65+/-11 years) with previous myocardial infarction scheduled for ICD implantation underwent cine MRI to evaluate left ventricular function and volumes and contrast-enhanced MRI for characterization of scar tissue (infarct gray zone as measure of infarct tissue heterogeneity, infarct core, and total infarct size). Appropriate ICD therapy was documented in 18 patients (20%) during a median follow-up of 8.5 months (interquartile range, 2.1 to 20.3). Multivariable Cox proportional hazards analysis revealed that infarct gray zone was the strongest predictor of the occurrence of spontaneous ventricular arrhythmia with subsequent ICD therapy (hazard ratio, 1.49/10 g; CI, 1.01 to 2.20; chi(2)=4.0; P=0.04). CONCLUSIONS Infarct tissue heterogeneity on contrast-enhanced MRI is the strongest predictor of spontaneous ventricular arrhythmia with subsequent ICD therapy (as surrogate of sudden cardiac death) among other clinical and MRI variables, that is, total infarct size and left ventricular function and volumes, in patients with previous myocardial infarction.
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Affiliation(s)
- Stijntje D Roes
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands.
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188
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Bhushan M, Asirvatham SJ. The conundrum of ventricular arrhythmia and cardiomyopathy: Which abnormality came first? Curr Heart Fail Rep 2009; 6:7-13. [DOI: 10.1007/s11897-009-0003-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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189
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Sivagangabalan G, Pouliopoulos J, Huang K, Lu J, Barry MA, Thiagalingam A, Ross DL, Thomas SP, Kovoor P. Comparison of Electroanatomic Contact and Noncontact Mapping of Ventricular Scar in a Postinfarct Ovine Model With Intramural Needle Electrode Recording and Histological Validation. Circ Arrhythm Electrophysiol 2008; 1:363-9. [DOI: 10.1161/circep.108.799619] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Substrate-based ablation is useful for nonhemodynamically tolerated postinfarct ventricular tachycardia. We assessed the accuracy of the CARTO contact and EnSite noncontact systems at identifying scar in a chronic ovine model with intramural plunge needle electrode recording and histological validation.
Methods and Results—
Scar mapping was performed on 8 male sheep with previous percutaneous-induced myocardial infarction. Up to 20 plunge needles were inserted into the left ventricle of each animal in areas of dense scar, scar border, and normal myocardium. A simultaneous CARTO map and EnSite geometry were acquired using a single catheter, and needle electrode locations were registered. A dynamic substrate map was constructed using ratiometric 50% peak negative voltage. The scar percentage around each needle location was quantified histologically. Analysis was performed on 152 plunge needles and corresponding histological blocks. Spearman correlation with histology was 0.690 (
P
<0.001) for needle electrode peak-to-peak voltage (PPV), 0.362 (
P
<0.001) and 0.492 (
P
<0.001) for CARTO bipolar and unipolar PPV, and 0.381 (
P
<0.001) for EnSite dynamic substrate map (≤40 mm from array). The area under the receiver operator characteristics curve (<50% and ≥50% scar) was 0.896 for needle electrode PPV, 0.726 and 0.697 for CARTO bipolar and unipolar PPV, and 0.703 for EnSite dynamic substrate map (≤40 mm from array).
Conclusions—
Both the CARTO contact and EnSite noncontact systems were moderately accurate in identifying postinfarct scar when compared with intramural electrodes and confirmed with histology. The EnSite dynamic substrate map was comparable to the CARTO contact bipolar PPV when points >40 mm from the array were excluded.
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Affiliation(s)
| | - Jim Pouliopoulos
- From the Cardiology Department, Westmead Hospital, Sydney, Australia
| | - Kaimin Huang
- From the Cardiology Department, Westmead Hospital, Sydney, Australia
| | - Juntang Lu
- From the Cardiology Department, Westmead Hospital, Sydney, Australia
| | - Michael A. Barry
- From the Cardiology Department, Westmead Hospital, Sydney, Australia
| | | | - David L. Ross
- From the Cardiology Department, Westmead Hospital, Sydney, Australia
| | - Stuart P. Thomas
- From the Cardiology Department, Westmead Hospital, Sydney, Australia
| | - Pramesh Kovoor
- From the Cardiology Department, Westmead Hospital, Sydney, Australia
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190
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ABDELWAHAB AMIR, SAPP JOHNL, BASTA MAGDYN, GARDNER MARTIN. Three Wide Complex Tachycardias. J Cardiovasc Electrophysiol 2008; 19:882-4. [DOI: 10.1111/j.1540-8167.2008.01176.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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191
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Liu A, Gardner MJ, Basta MN, Sapp JL. Tachycardia with a left bundle branch block morphology in a patient with arrhythmogenic right ventricular cardiomyopathy: What is the mechanism? Heart Rhythm 2008; 5:895-6. [PMID: 18534375 DOI: 10.1016/j.hrthm.2007.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2007] [Indexed: 10/22/2022]
Affiliation(s)
- Andrew Liu
- Section of Cardiac Electrophysiology, QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
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192
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Wilber DJ. Catheter ablation of ventricular tachycardia: Two decades of progress. Heart Rhythm 2008; 5:S59-63. [DOI: 10.1016/j.hrthm.2008.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Indexed: 11/28/2022]
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193
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Doppalapudi H, Yamada T, McElderry HT, Plumb VJ, Epstein AE, Kay GN. Ventricular Tachycardia Originating From the Posterior Papillary Muscle in the Left Ventricle. Circ Arrhythm Electrophysiol 2008; 1:23-9. [DOI: 10.1161/circep.107.742940] [Citation(s) in RCA: 168] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Several distinct forms of focal ventricular tachycardia (VT) from the left ventricle (LV) have been described. We report a new syndrome of VT arising from the base of the posterior papillary muscle in the LV.
Methods and Results—
Among 290 consecutive patients who underwent ablation for VT or symptomatic premature ventricular complexes (PVCs) based on a focal mechanism, 7 patients were found to have an ablation site at the base of the posterior papillary muscle in the LV. All patients had normal LV systolic function and a normal baseline electrocardiogram. The electrocardiogram during VT or PVCs demonstrated a right bundle-branch block and superior-axis QRS morphology in all patients. VT was not inducible by programmed atrial or ventricular stimulation. In 2 patients with sustained VT, overdrive pacing neither terminated VT nor demonstrated any criterion for transient entrainment. Activation mapping localized the earliest site of activation to the base of the posterior papillary muscle in all patients. When Purkinje potentials were recorded at the site of successful ablation, these potentials preceded local ventricular muscle potentials during sinus rhythm. During VT or PVCs, however, the ventricular muscle potential always preceded the Purkinje potentials. After recurrence of VT or PVCs with standard radiofrequency ablation, irrigated ablation was successful in eliminating the arrhythmia in all patients. Over a mean follow-up period of 9 months, all patients have been free of PVCs and VT.
Conclusion—
We present a distinct syndrome of VT arising from the base of the posterior papillary muscle in the LV by a nonreentrant mechanism. Ablation can be challenging, and irrigated ablation may be necessary for long-term success.
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Affiliation(s)
- Harish Doppalapudi
- From the Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham
| | - Takumi Yamada
- From the Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham
| | - H. Thomas McElderry
- From the Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham
| | - Vance J. Plumb
- From the Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham
| | - Andrew E. Epstein
- From the Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham
| | - G. Neal Kay
- From the Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham
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194
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ZEPPENFELD KATJA, STEVENSON WILLIAMG. Ablation of Ventricular Tachycardia in Patients with Structural Heart Disease. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:358-74. [DOI: 10.1111/j.1540-8159.2008.00999.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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195
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VEENHUYZEN GEORGED, MITCHELL LBRENT. Distinguishing Focal from Macroreentrant Atrial Tachycardias: Has This Job Just Become Easier? J Cardiovasc Electrophysiol 2008; 19:148-9. [DOI: 10.1111/j.1540-8167.2007.01027.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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196
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Antz M, Berodt K, Bänsch D, Ernst S, Chun KJ, Satomi K, Schmidt B, Boczor S, Ouyang F, Kuck KH. Catheter-ablation of ventricular tachycardia in patients with coronary artery disease: influence of the endocardial substrate size on clinical outcome. Clin Res Cardiol 2007; 97:110-7. [PMID: 18046530 DOI: 10.1007/s00392-007-0596-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2007] [Accepted: 09/18/2007] [Indexed: 10/22/2022]
Abstract
Ablation of symptomatic ventricular tachycardia (VT) in patients with coronary artery disease is frequently performed using the three dimensional mapping system CARTO. In the amplitude map, bipolar potentials of <1.5 mV are considered abnormal and represent damaged myocardium due to previous infarction. This pathological electrical area can be arrhythmogenic, serving as the substrate for reentrant VT. The purpose of this study was to correlate the size of the endocardial substrate with the success of VT catheter ablation. Included in this retrospective analysis were 69 consecutive patients with coronary artery disease who underwent ablation for symptomatic clinical VT using CARTO. The voltage maps were analyzed and the area with abnormal bipolar electrograms (<1.5 mV) was determined using geometric approximation models. The area of abnormal electrograms was divided into three sizes: small (<or=15 cm(2); 11 patients), medium (16-99 cm(2); 50 patients), and large (>or=100 cm(2); 8 patients). Patient characteristics were not different between the three substrate groups in regard to age, tachycardia cycle length, or number of radiofrequency applications, however differed significantly between the small, medium and large group in regard to left ventricular ejection fraction (44 +/- 12% vs. 32 +/- 9% vs. 21 +/- 7%, respectively; P = 0.001). Overall, there was a significant correlation between myocardial infarction locations and endocardial substrate sizes (P = 0.031), such that 73% of small substrates were found after inferior myocardial infarctions, and 100% of large substrates after anterior and multiple myocardial infarctions (P = 0.003). After ablation, inducibility of ventricular arrhythmias was more rare in patients with small substrates compared to patients with medium or large substrates (small substrates: 9%, medium and large substrates: 43%, P = 0.043). Although during follow-up of 25 +/- 17 months (1 day to 72 months) there was no significant difference between endocardial substrate sizes in regard to recurrence rates (small: 27%, medium: 38%, large: 50%, P = 0.588), patients with a small substrate did not have fast VT or ventricular fibrillation (VF), in contrast to 30% and 38% of patients with medium and large substrates, respectively. We conclude that in patients with coronary artery disease a small area of low amplitude bipolar potentials (<or=15 cm(2)) was seen more often after inferior myocardial infarction than after anterior and multiple infarctions. After ablation, patients with small substrates were rarely inducible and showed a more benign course during follow-up (trend towards fewer arrhythmia recurrences and no fast VT or VF). As a result smaller arrhythmogenic substrates appear to be better amenable to catheter ablation than larger substrates.
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Affiliation(s)
- Matthias Antz
- Medizinische Abteilung, Asklepios Klinik St. Georg, Hamburg, Germany.
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197
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Abstract
Background—
The causes of sustained monomorphic ventricular tachycardia (VT) after cardiac valve surgeries have not been studied extensively, although bundle-branch reentry has been reported.
Methods and Results—
Records of 496 patients referred for electrophysiology study and catheter ablation of recurrent VT were reviewed. Twenty patients (4%) had VT after aortic or mitral valve surgery in the absence of known myocardial infarction. The median age was 53 years, and the median ejection fraction was 45%. In 4 patients, VT occurred early after surgery, and electrophysiology study was performed 3 to 10 days later. In the remaining patients, electrophysiology study was performed a median of 12 years (interquartile range 5 to 15 years) after surgery. Sustained VT was inducible in 17 patients. VT was attributed to scar-related reentry in 14 patients (70%) and to bundle-branch reentry in 2 (10%). Multiple VTs were present in 9 of 14 patients with scar-related reentry. A total of 42 induced VTs were targeted for ablation. Of the 14 patients with scar-related reentry, 9 (64%) had periannular scar, and 10 (71%) had an identifiable endocardial circuit isthmus. Ablation abolished 41 (98%) of the 42 targeted VTs. At a median follow-up of 2.1 years, 3 deaths occurred 8 to 14 months after ablation. One patient with incessant VT early after valve surgery suffered a stroke with residual hemianopsia. Of the 20 patients, 3 required repeat ablation after recurrence, and 2 of these who were not inducible during electrophysiology study had clinical recurrence that necessitated ablation.
Conclusions—
Sustained VT after valve surgery appears to be bimodal in presentation, occurring either early after surgery or years later. In this referral population, reentry in a region of scar is more common than bundle-branch reentry. Catheter ablation can be successful.
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198
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Rajappan K, Schilling RJ. Non-contact mapping in the treatment of ventricular tachycardia after myocardial infarction. J Interv Card Electrophysiol 2007; 19:9-18. [PMID: 17597391 DOI: 10.1007/s10840-007-9128-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2007] [Accepted: 04/23/2007] [Indexed: 10/23/2022]
Abstract
The treatment of ventricular tachycardia (VT) in patients with underlying ischaemic heart disease (IHD) remains a challenge. Ablation of these arrhythmias may have a significant impact on quality of life for patients. For those patients with haemodynamically unstable VT, ablation success rates have been improved by the use of non-contact mapping. Care has to be taken in the analysis and interpretation of non-contact mapping studies, as chamber size and filter settings have a large effect on the appearance of the activation maps produced. Despite this limitation the majority of VT exit sites and part of the diastolic pathway can be identified with non-contact mapping techniques.
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Affiliation(s)
- Kim Rajappan
- Department of Cardiology, St Bartholomew's Hospital and Queen Mary University, London, UK
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199
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Schmidt A, Azevedo CF, Cheng A, Gupta SN, Bluemke DA, Foo TK, Gerstenblith G, Weiss RG, Marbán E, Tomaselli GF, Lima JAC, Wu KC. Infarct tissue heterogeneity by magnetic resonance imaging identifies enhanced cardiac arrhythmia susceptibility in patients with left ventricular dysfunction. Circulation 2007; 115:2006-14. [PMID: 17389270 PMCID: PMC2442229 DOI: 10.1161/circulationaha.106.653568] [Citation(s) in RCA: 596] [Impact Index Per Article: 35.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The extent of the peri-infarct zone by magnetic resonance imaging (MRI) has been related to all-cause mortality in patients with coronary artery disease. This relationship may result from arrhythmogenesis in the infarct border. However, the relationship between tissue heterogeneity in the infarct periphery and arrhythmic substrate has not been investigated. In the present study, we quantify myocardial infarct heterogeneity by contrast-enhanced MRI and relate it to an electrophysiological marker of arrhythmic substrate in patients with left ventricular (LV) systolic dysfunction undergoing prophylactic implantable cardioverter defibrillator placement. METHODS AND RESULTS Before implantable cardioverter defibrillator implantation for primary prevention of sudden cardiac death, 47 patients underwent cine and contrast-enhanced MRI to measure LV function, volumes, mass, and infarct size. A method for quantifying the heterogeneous infarct periphery and the denser infarct core is described. MRI indices were related to inducibility of sustained monomorphic ventricular tachycardia during electrophysiological or device testing. For the noninducible versus inducible patients, LV ejection fraction (30+/-10% versus 29+/-7%, P=0.79), LV end-diastolic volume (220+/-70 versus 228+/-57 mL, P=0.68), and infarct size by standard contrast-enhanced MRI definitions (P=NS) were similar. Quantification of tissue heterogeneity at the infarct periphery was strongly associated with inducibility for monomorphic ventricular tachycardia (noninducible versus inducible: 13+/-9 versus 19+/-8 g, P=0.015) and was the single significant factor in a stepwise logistic regression. CONCLUSIONS Tissue heterogeneity is present and quantifiable within human infarcts. More extensive tissue heterogeneity correlates with increased ventricular irritability by programmed electrical stimulation. These findings support the hypothesis that anatomic tissue heterogeneity increases susceptibility to ventricular arrhythmias in patients with prior myocardial infarction and LV dysfunction.
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MESH Headings
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/etiology
- Arrhythmias, Cardiac/therapy
- Defibrillators, Implantable
- Disease Susceptibility/diagnosis
- Electrophysiologic Techniques, Cardiac
- Female
- Humans
- Magnetic Resonance Imaging/methods
- Magnetic Resonance Imaging, Cine
- Male
- Middle Aged
- Myocardial Infarction/complications
- Myocardial Infarction/diagnosis
- Myocardial Infarction/physiopathology
- Predictive Value of Tests
- Tachycardia, Ventricular/diagnosis
- Tachycardia, Ventricular/etiology
- Tachycardia, Ventricular/therapy
- Ventricular Dysfunction, Left/complications
- Ventricular Dysfunction, Left/physiopathology
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Affiliation(s)
- André Schmidt
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
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200
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Volkmer M, Ouyang F, Deger F, Ernst S, Goya M, Bänsch D, Berodt K, Kuck KH, Antz M. Substrate mapping vs. tachycardia mapping using CARTO in patients with coronary artery disease and ventricular tachycardia: impact on outcome of catheter ablation. ACTA ACUST UNITED AC 2006; 8:968-76. [PMID: 17043071 DOI: 10.1093/europace/eul109] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
AIMS For ablation of ventricular tachycardia (VT) in patients after myocardial infarction, a three-dimensional mapping system is often used. We report on our overall success rate of VT ablation using CARTO in 47 patients, with a subgroup analysis comparing VT mapping with the results of mapping that had to be performed during sinus rhythm or pacing (substrate mapping). METHODS AND RESULTS A CARTO map was performed and VT ablation attempted using two strategies: Patients in the VT-mapping group had incessant VT (four patients) or inducible stable VT (18 patients) such that the circuit of the clinical VT could be reconstructed using CARTO. During VT, the critical area of slow conduction was identified using diastolic potentials and conventional concealed entrainment pacing. In contrast, patients in the substrate-mapping group had initially inducible VT. However, a complete VT map was not possible because of catheter-induced mechanical block (six patients) or because haemodynamics deteriorated during the ongoing VT (19 patients). Therefore, pathological myocardium was identified by fragmented, late- and/or low-amplitude (<1.5 mV) bipolar potentials during sinus rhythm or pacing, and the ablation site was primarily determined by pace mapping inside or at the border of this pathological myocardium. Acute ablation success in all patients with regard to non-inducibility of the clinical VT or any slower VT was 79% after a single ablation procedure, but increased to 95% after a mean of 1.2 ablation procedures. However, chronic success was 75%, when it was defined as freedom from any ventricular tachyarrhythmia (VT or VF) during a follow-up of 25+/-13 months. In the subgroup analysis, patients in the VT-mapping group were not significantly different from patients in the substrate-mapping group with regard to age (65+/-7 vs. 65+/-9 years), ejection fraction (30+/-7 vs. 30+/-8%), VT cycle length (448+/-81 vs. 429+/-82 ms), number of radiofrequency applications (17+/-9 vs. 14+/-6 applications), use of an irrigated tip catheter (23 vs. 32%), and ablation results. CONCLUSION When using a CARTO-guided approach for VT ablation in patients with coronary artery disease, the freedom from any ventricular arrhythmia is high (75%), but leaves the patient at a 23% risk of developing fast VT/VF during follow-up. Mapping during sinus rhythm or pacing is as successful as mapping during VT.
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Affiliation(s)
- Marius Volkmer
- Department of Cardiology, St Georg Hospital, Hamburg, Germany
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