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Omara S, Glashan CA, Tofig BJ, Leenknegt L, Dierckx H, Panfilov AV, Beukers HKC, van Waasbergen MH, Tao Q, Stevenson WG, Nielsen JC, Lukac P, Kristiansen SB, van der Geest RJ, Zeppenfeld K. Multisize Electrode Field-of-View: Validation by High Resolution Gadolinium-Enhanced Cardiac Magnetic Resonance. JACC Clin Electrophysiol 2024; 10:637-650. [PMID: 38276927 DOI: 10.1016/j.jacep.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Voltage mapping to detect ventricular scar is important for guiding catheter ablation, but the field-of-view of unipolar, bipolar, conventional, and microelectrodes as it relates to the extent of viable myocardium (VM) is not well defined. OBJECTIVES The purpose of this study was to evaluate electroanatomic voltage-mapping (EAVM) with different-size electrodes for identifying VM, validated against high-resolution ex-vivo cardiac magnetic resonance (HR-LGE-CMR). METHODS A total of 9 swine with early-reperfusion myocardial infarction were mapped with the QDOT microcatheter. HR-LGE-CMR (0.3-mm slices) were merged with EAVM. At each EAVM point, the underlying VM in multisize transmural cylinders and spheres was quantified from ex vivo CMR and related to unipolar and bipolar voltages recorded from conventional and microelectrodes. RESULTS In each swine, 220 mapping points (Q1, Q3: 216, 260 mapping points) were collected. Infarcts were heterogeneous and nontransmural. Unipolar and bipolar voltage increased with VM volumes from >175 mm3 up to >525 mm3 (equivalent to a 5-mm radius cylinder with height >6.69 mm). VM volumes in subendocardial cylinders with 1- or 3-mm depth correlated poorly with all voltages. Unipolar voltages recorded with conventional and microelectrodes were similar (difference 0.17 ± 2.66 mV) and correlated best to VM within a sphere of radius 10 and 8 mm, respectively. Distance-weighting did not improve the correlation. CONCLUSIONS Voltage increases with transmural volume of VM but correlates poorly with small amounts of VM, which limits EAVM in defining heterogeneous scar. Microelectrodes cannot distinguish thin from thick areas of subendocardial VM. The field-of-view for unipolar recordings for microelectrodes and conventional electrodes appears to be 8 to 10 mm, respectively, and unexpectedly similar.
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Affiliation(s)
- Sharif Omara
- Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden, the Netherlands, and Aarhus, Denmark; Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Claire A Glashan
- Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden, the Netherlands, and Aarhus, Denmark; Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Bawer J Tofig
- Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden, the Netherlands, and Aarhus, Denmark; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Lore Leenknegt
- Department of Mathematics, KU Leuven campus Kortrijk, Kortrijk, Belgium
| | - Hans Dierckx
- Department of Mathematics, KU Leuven campus Kortrijk, Kortrijk, Belgium
| | | | - Hans K C Beukers
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Qian Tao
- Department of Imaging Physics, Delft University of Technology, Delft, the Netherlands
| | - William G Stevenson
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jens C Nielsen
- Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden, the Netherlands, and Aarhus, Denmark; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Lukac
- Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden, the Netherlands, and Aarhus, Denmark; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Steen B Kristiansen
- Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden, the Netherlands, and Aarhus, Denmark; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Rob J van der Geest
- Department of Radiology, Division of Image Processing, Leiden University Medical Center, Leiden, the Netherlands
| | - Katja Zeppenfeld
- Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden, the Netherlands, and Aarhus, Denmark; Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.
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2
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Donahue JK, Chrispin J, Ajijola OA. Mechanism of Ventricular Tachycardia Occurring in Chronic Myocardial Infarction Scar. Circ Res 2024; 134:328-342. [PMID: 38300981 PMCID: PMC10836816 DOI: 10.1161/circresaha.123.321553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Cardiac arrest is the leading cause of death in the more economically developed countries. Ventricular tachycardia associated with myocardial infarct is a prominent cause of cardiac arrest. Ventricular arrhythmias occur in 3 phases of infarction: during the ischemic event, during the healing phase, and after the scar matures. Mechanisms of arrhythmias in these phases are distinct. This review focuses on arrhythmia mechanisms for ventricular tachycardia in mature myocardial scar. Available data have shown that postinfarct ventricular tachycardia is a reentrant arrhythmia occurring in circuits found in the surviving myocardial strands that traverse the scar. Electrical conduction follows a zigzag course through that area. Conduction velocity is impaired by decreased gap junction density and impaired myocyte excitability. Enhanced sympathetic tone decreases action potential duration and increases sarcoplasmic reticular calcium leak and triggered activity. These elements of the ventricular tachycardia mechanism are found diffusely throughout scar. A distinct myocyte repolarization pattern is unique to the ventricular tachycardia circuit, setting up conditions for classical reentry. Our understanding of ventricular tachycardia mechanisms continues to evolve as new data become available. The ultimate use of this information would be the development of novel diagnostics and therapeutics to reliably identify at-risk patients and prevent their ventricular arrhythmias.
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Affiliation(s)
| | - Jonathan Chrispin
- The Johns Hopkins University School of Medicine, Baltimore, MD (J.C.)
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA (O.A.A.)
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Assaf A, van der Graaf M, van Boven N, van Ettinger MJB, Diletti R, Hoogendijk MG, Szili-Torok T, Theuns DAMJ, Yap SC. Effect of myocardial scar size on the risk of ventricular arrhythmias in patients with chronic total coronary occlusion. Int J Cardiol 2023; 390:131205. [PMID: 37482094 DOI: 10.1016/j.ijcard.2023.131205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 06/28/2023] [Accepted: 07/19/2023] [Indexed: 07/25/2023]
Abstract
BACKGROUND The presence of an untreated chronic total coronary occlusion (CTO) is associated with a higher risk of ventricular arrhythmias (VAs). This increased risk may be modulated by the presence of an existing scar. OBJECTIVES To evaluate whether scar size is associated with VA in patients with an implantable cardioverter-defibrillator (ICD) and a CTO. METHODS In this retrospective study we included patients with a CTO that received an ICD between 2005 and 2015. Scar size was estimated using the Selvester QRS score on a baseline 12‑lead ECG. The primary endpoint was any appropriate ICD therapy. RESULTS Our study population comprised 148 CTO patients with a median scar size at baseline of 18% (IQR, 9-27%). Patients with a scar size ≥18% more often had a CTO located in the left anterior descending artery and a higher proportion of poor left ventricular function (<35%) and infarct-related CTO compared to patients with a smaller scar size (<18%). During a median follow-up of 35 months (interquartile range [IQR], 8-60 months), 42 patients (28%) received appropriate ICD therapy. The cumulative 5-year event rate was higher in the patients with a large scar in comparison to those with a smaller or no scar (36% versus 19%, P = 0.04). Multivariable Cox regression analysis demonstrated that large scar and diabetes mellitus were independent factors associated with appropriate ICD therapy. CONCLUSION In ICD recipients with an untreated CTO, a larger scar is an independent factor associated with an increased risk of VA.
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Affiliation(s)
- Amira Assaf
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Marisa van der Graaf
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Nick van Boven
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Maarten J B van Ettinger
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Roberto Diletti
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Mark G Hoogendijk
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Tamas Szili-Torok
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Dominic A M J Theuns
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Sing-Chien Yap
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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Pong T, Cyr KJ, Carlton C, Aparicio‐Valenzuela J, Wang H, Babakhanian M, Maiuolo A, Lucian H, Wang PJ, Woo YJ, Lee AM. Electrophysiological mapping of the epicardium via 3D-printed flexible arrays. Bioeng Transl Med 2023; 8:e10575. [PMID: 38023702 PMCID: PMC10658567 DOI: 10.1002/btm2.10575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 05/05/2023] [Accepted: 06/16/2023] [Indexed: 12/01/2023] Open
Abstract
Cardiac electrophysiology mapping and ablation are widely used to treat heart rhythm disorders such as atrial fibrillation (AF) and ventricular tachycardia (VT). Here, we describe an approach for rapid production of three dimensional (3D)-printed mapping devices derived from magnetic resonance imaging. The mapping devices are equipped with flexible electronic arrays that are shaped to match the epicardial contours of the atria and ventricle and allow for epicardial electrical mapping procedures. We validate that these flexible arrays provide high-resolution mapping of epicardial signals in vivo using porcine models of AF and myocardial infarction. Specifically, global coverage of the epicardial surface allows for mapping and ablation of myocardial substrate and the capture of premature ventricular complexes with precise spatial-temporal resolution. We further show, as proof-of-concept, the localization of sites of VT by means of beat-to-beat whole-chamber ventricular mapping of ex vivo Langendorff-perfused human hearts.
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Affiliation(s)
- Terrence Pong
- Department of Cardiothoracic SurgerySchool of Medicine, Stanford UniversityStanfordCaliforniaUSA
| | - Kevin J. Cyr
- Department of Cardiothoracic SurgerySchool of Medicine, Stanford UniversityStanfordCaliforniaUSA
| | - Cody Carlton
- Department of Cardiothoracic SurgerySchool of Medicine, Stanford UniversityStanfordCaliforniaUSA
| | - Joy Aparicio‐Valenzuela
- Department of Cardiothoracic SurgerySchool of Medicine, Stanford UniversityStanfordCaliforniaUSA
| | - Hanjay Wang
- Department of Cardiothoracic SurgerySchool of Medicine, Stanford UniversityStanfordCaliforniaUSA
| | - Meghedi Babakhanian
- Department of Cardiovascular MedicineSchool of Medicine, Stanford UniversityStanfordCaliforniaUSA
| | - Alessandro Maiuolo
- Department of Cardiothoracic SurgerySchool of Medicine, Stanford UniversityStanfordCaliforniaUSA
| | - Haley Lucian
- Department of Cardiothoracic SurgerySchool of Medicine, Stanford UniversityStanfordCaliforniaUSA
| | - Paul J. Wang
- Department of Cardiovascular MedicineSchool of Medicine, Stanford UniversityStanfordCaliforniaUSA
| | - Y. Joseph Woo
- Department of Cardiothoracic SurgerySchool of Medicine, Stanford UniversityStanfordCaliforniaUSA
| | - Anson M. Lee
- Department of Cardiothoracic SurgerySchool of Medicine, Stanford UniversityStanfordCaliforniaUSA
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Xu L, Zahid S, Khoshknab M, Moss J, Berger RD, Chrispin J, Callans D, Marchlinski FE, Zimmerman SL, Han Y, Desjardins B, Trayanova N, Nazarian S. Lipomatous Metaplasia Facilitates Slow Conduction in Critical Ventricular Tachycardia Corridors Within Postinfarct Myocardium. JACC Clin Electrophysiol 2023; 9:1235-1245. [PMID: 37227343 PMCID: PMC11168467 DOI: 10.1016/j.jacep.2023.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 02/10/2023] [Accepted: 02/15/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Myocardial lipomatous metaplasia (LM) has been reported to be associated with post-infarct ventricular tachycardia (VT) circuitry. OBJECTIVES This study examined the association of scar versus LM composition with impulse conduction velocity (CV) in putative VT corridors that traverse the infarct zone in post-infarct patients. METHODS The cohort included 31 post-infarct patients from the prospective INFINITY (Intra-Myocardial Fat Deposition and Ventricular Tachycardia in Cardiomyopathy) study. Myocardial scar, border zone, and potential viable corridors were defined by late gadolinium enhancement cardiac magnetic resonance (LGE-CMR), and LM was defined by computed tomography. Images were registered to electroanatomic maps, and the CV at each electroanatomic map point was calculated as the mean CV between that point and 5 adjacent points along the activation wave front. RESULTS Regions with LM exhibited lower CV than scar (median = 11.9 vs 13.5 cm/s; P < 0.001). Of 94 corridors computed from LGE-CMR and electrophysiologically confirmed to participate in VT circuitry, 93 traversed through or near LM. These critical corridors displayed slower CV (median 8.8 [IQR: 5.9-15.7] cm/s vs 39.2 [IQR: 28.1-58.5]) cm/s; P < 0.001) than 115 noncritical corridors distant from LM. Additionally, critical corridors demonstrated low-peripheral, high-center (mountain shaped, 23.3%) or mean low-level (46.7%) CV patterns compared with 115 noncritical corridors distant from LM that displayed high-peripheral, low-center (valley shaped, 19.1%) or mean high-level (60.9%) CV patterns. CONCLUSIONS The association of myocardial LM with VT circuitry is at least partially mediated by slowing nearby corridor CV thus facilitating an excitable gap that enables circuit re-entry.
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Affiliation(s)
- Lingyu Xu
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
| | - Sohail Zahid
- Department of Internal Medicine, New York University Langone Medical Center, New York, New York, USA
| | - Mirmilad Khoshknab
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Juwann Moss
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ronald D Berger
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA; Department of Cardiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jonathan Chrispin
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA; Department of Cardiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - David Callans
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Stefan L Zimmerman
- Department of Radiology and Radiological Sciences, Johns Hopkins University, Baltimore, Maryland, USA
| | - Yuchi Han
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Benoit Desjardins
- Department of Radiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Natalia Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Saman Nazarian
- Cardiovascular Medicine Division, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA. https://twitter.com/Dr_Nazarian_EP
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6
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Saadeh K, Nantha Kumar N, Fazmin IT, Edling CE, Jeevaratnam K. Anti-malarial drugs: Mechanisms underlying their proarrhythmic effects. Br J Pharmacol 2022; 179:5237-5258. [PMID: 36165125 PMCID: PMC9828855 DOI: 10.1111/bph.15959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 04/06/2022] [Accepted: 04/28/2022] [Indexed: 01/12/2023] Open
Abstract
Malaria remains the leading cause of parasitic death in the world. Artemisinin resistance is an emerging threat indicating an imminent need for novel combination therapy. Given the key role of mass drug administration, it is pivotal that the safety of anti-malarial drugs is investigated thoroughly prior to widespread use. Cardiotoxicity, most prominently arrhythmic risk, has been a concern for anti-malarial drugs. We clarify the likely underlying mechanisms by which anti-malarial drugs predispose to arrhythmias. These relate to disruption of (1) action potential upstroke due to effects on the sodium currents, (2) action potential repolarisation due to effects on the potassium currents, (3) cellular calcium homeostasis, (4) mitochondrial function and reactive oxygen species production and (5) cardiac fibrosis. Together, these alterations promote arrhythmic triggers and substrates. Understanding these mechanisms is essential to assess the safety of these drugs, stratify patients based on arrhythmic risk and guide future anti-malarial drug development.
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Affiliation(s)
- Khalil Saadeh
- Faculty of Health and Medical SciencesUniversity of SurreyGuildfordUK,School of Clinical Medicine, Addenbrooke's HospitalUniversity of CambridgeCambridgeUK
| | | | - Ibrahim Talal Fazmin
- Faculty of Health and Medical SciencesUniversity of SurreyGuildfordUK,School of Clinical Medicine, Addenbrooke's HospitalUniversity of CambridgeCambridgeUK
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7
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Tat E, Ball C, Camren GP, Wroblewski I, Dajani KA, Goldberg A, Kinno M, Sanagala T, Syed MA, Wilber DJ, Rabbat M. Impact of late gadolinium enhancement extent, location, and pattern on ventricular tachycardia and major adverse cardiac events in patients with ischemic vs. non-ischemic cardiomyopathy. Front Cardiovasc Med 2022; 9:1026215. [PMID: 36330014 PMCID: PMC9622951 DOI: 10.3389/fcvm.2022.1026215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 10/04/2022] [Indexed: 11/16/2022] Open
Abstract
Background Left ventricular late gadolinium enhancement (LGE) by cardiac magnetic resonance (CMR) has been associated with increased risk for life-threatening ventricular tachyarrhythmias. The differences in association between LGE characteristics and prognosis in patients with ischemic (ICM) vs. non-ischemic (NICM) cardiomyopathy is incompletely understood. Methods A total of 168 consecutive patients who underwent CMR imaging with either ICM or NICM were included in our study. LGE extent, location and pattern were examined for association to the primary endpoint of ventricular tachycardia (VT) and secondary endpoint of major adverse cardiac events (MACE). Results Of 68 (41%) patients with ICM and 97 (59%) patients with NICM, median LGE mass was 15% (IQR 9–28) for the ICM group and 10% (IQR 6–15) for the NICM group. On multivariate analysis for both groups, LGE characteristics were prognostic while LVEF was not. In patients with ICM, septal and apical segment LGE, and involvement of multiple walls predicted both endpoints on multivariate analysis. LGE extent (≥median) and inferior wall LGE independently predicted the primary endpoint. In patients with NICM, anterior, inferior and apical segment LGE, and involvement of multiple walls predicted both endpoints on multivariate analysis. LGE extent (≥median, number of LGE segments, LGE stratified per 5% increase) and midwall LGE were independent predictors of the primary endpoint. Conclusions Although LGE was an independent predictor of prognosis in both groups, LGE extent, location, and pattern characteristics were more powerful correlates to worse outcomes in patients with NICM than ICM.
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Affiliation(s)
- Emily Tat
- Department of Internal Medicine, Columbia University Medical Center, New York, NY, United States
| | - Caroline Ball
- Division of Cardiology, Loyola University Medical Center, Maywood, IL, United States
| | - Gerald P. Camren
- Department of Radiology, Loyola University Medical Center, Maywood, IL, United States
| | - Igor Wroblewski
- Division of Cardiology, Loyola University Medical Center, Maywood, IL, United States
| | - Khaled A. Dajani
- Division of Cardiology, Loyola University Medical Center, Maywood, IL, United States
| | - Ari Goldberg
- Department of Radiology, Loyola University Medical Center, Maywood, IL, United States
| | - Menhel Kinno
- Division of Cardiology, Loyola University Medical Center, Maywood, IL, United States
| | - Thriveni Sanagala
- Division of Cardiology, Loyola University Medical Center, Maywood, IL, United States
| | - Mushabbar A. Syed
- Division of Cardiology, Loyola University Medical Center, Maywood, IL, United States
| | - David J. Wilber
- Division of Cardiology, Loyola University Medical Center, Maywood, IL, United States
| | - Mark Rabbat
- Division of Cardiology, Loyola University Medical Center, Maywood, IL, United States
- *Correspondence: Mark Rabbat
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8
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Khwaounjoo P, Sands GB, LeGrice IJ, Ramulgun G, Ashton JL, Montgomery JM, Gillis AM, Smaill BH, Trew ML. Multimodal imaging shows fibrosis architecture and action potential dispersion are predictors of arrhythmic risk in spontaneous hypertensive rats. J Physiol 2022; 600:4119-4135. [PMID: 35984854 PMCID: PMC9544618 DOI: 10.1113/jp282526] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 08/08/2022] [Indexed: 11/08/2022] Open
Abstract
Hypertensive heart disease (HHD) increases risk of ventricular tachycardia (VT) and ventricular fibrillation (VF). The roles of structural vs. electrophysiological remodelling and age vs. disease progression are not fully understood. This cross-sectional study of cardiac alterations through HHD investigates mechanistic contributions to VT/VF risk. Risk was electrically assessed in Langendorff-perfused, spontaneously hypertensive rat hearts at 6, 12 and 18 months, and paced optical membrane voltage maps were acquired from the left ventricular (LV) free wall epicardium. Distributions of LV patchy fibrosis and 3D cellular architecture in representative anterior LV mid-wall regions were quantified from macroscopic and microscopic fluorescence images of optically cleared tissue. Imaging showed increased fibrosis from 6 months, particularly in the inner LV free wall. Myocyte cross-section increased at 12 months, while inter-myocyte connections reduced markedly with fibrosis. Conduction velocity decreased from 12 months, especially transverse to the myofibre direction, with rate-dependent anisotropy at 12 and 18 months, but not earlier. Action potential duration (APD) increased when clustered by age, as did APD dispersion at 12 and 18 months. Among 10 structural, functional and age variables, the most reliably linked were VT/VF risk, general LV fibrosis, a measure quantifying patchy fibrosis, and non-age clustered APD dispersion. VT/VF risk related to a quantified measure of patchy fibrosis, but age did not factor strongly. The findings are consistent with the notion that VT/VF risk is associated with rate-dependent repolarization heterogeneity caused by structural remodelling and reduced lateral electrical coupling between LV myocytes, providing a substrate for heterogeneous intramural activation as HHD progresses. KEY POINTS: There is heightened arrhythmic risk with progression of hypertensive heart disease. Risk is related to increasing left ventricular fibrosis, but the nature of this relationship has not been quantified. This study is a novel systematic characterization of changes in active electrical properties and fibrotic remodelling during progression of hypertensive heart disease in a well-established animal disease model. Arrhythmic risk is predicted by several left ventricular measures, in particular fibrosis quantity and structure, and epicardial action potential duration dispersion. Age alone is not a good predictor of risk. An improved understanding of links between arrhythmic risk and fibrotic architectures in progressive hypertensive heart disease aids better interpretation of late gadolinium-enhanced cardiac magnetic resonance imaging and electrical mapping signals.
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Affiliation(s)
| | - Gregory B. Sands
- Auckland Bioengineering InstituteUniversity of AucklandAucklandNew Zealand
| | - Ian J. LeGrice
- Auckland Bioengineering InstituteUniversity of AucklandAucklandNew Zealand,Department of PhysiologyUniversity of AucklandAucklandNew Zealand
| | - Girish Ramulgun
- Auckland Bioengineering InstituteUniversity of AucklandAucklandNew Zealand,IHU‐LirycUniversity of BordeauxBordeauxFrance
| | - Jesse L. Ashton
- Auckland Bioengineering InstituteUniversity of AucklandAucklandNew Zealand,Department of PhysiologyUniversity of AucklandAucklandNew Zealand
| | | | - Anne M. Gillis
- Libin Cardiovascular Institute of AlbertaUniversity of CalgaryCalgaryAlbertaCanada
| | - Bruce H. Smaill
- Auckland Bioengineering InstituteUniversity of AucklandAucklandNew Zealand
| | - Mark L. Trew
- Auckland Bioengineering InstituteUniversity of AucklandAucklandNew Zealand
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Multielectrode Unipolar Voltage Mapping and Electrogram Morphology to Identify Post-Infarct Scar Geometry: Validation by Histology. JACC Clin Electrophysiol 2022; 8:437-449. [PMID: 35450598 DOI: 10.1016/j.jacep.2021.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 10/27/2021] [Accepted: 11/17/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES This study sought to evaluate the ability of uni- and bipolar electrograms collected with a multielectrode catheter with smaller electrodes to: 1) delineate scar; and 2) determine local scar complexity. BACKGROUND Early reperfusion results in variable endocardial scar, often overlaid with surviving viable myocardium. Although bipolar voltage (BV) mapping is considered the pillar of substrate-based ablation, the role of unipolar voltage (UV) mapping has not been sufficiently explored. It has been suggested that bipolar electrograms collected with small electrode catheters can better identify complex scar geometries. METHODS Twelve swine with early reperfusion infarctions were mapped with the 48-electrode OctaRay catheter and a conventional catheter during sinus rhythm. BV electrograms with double components were identified. Transmural (n = 933) biopsy specimens corresponding to mapping points were obtained, histologically assessed, and classified by scar geometry. RESULTS OctaRay UV (UVOcta) and BV (BVOcta) amplitude were associated with the amount of viable myocardium at a given location, with a stronger association for UVOcta (R2 = 0.767 vs 0.473). Cutoff values of 3.7 mV and 1.0 mV could delineate scar (area under the curve: 0.803 and 0.728 for UVOcta and BVOcta, respectively). The morphology of bipolar electrograms collected with the OctaRay catheter more frequently identified areas with 2 layers of surviving myocardium than electrograms collected with the conventional catheter (84% vs 71%). CONCLUSIONS UV mapping can generate a map to delineate the area of interest when using a multielectrode catheter. Within this area of interest, the morphology of bipolar electrograms can identify areas in which a surviving epicardial layer may overlay a poorly coupled, potentially arrhythmogenic, endocardium.
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10
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Heterogeneous repolarization creates ventricular tachycardia circuits in healed myocardial infarction scar. Nat Commun 2022; 13:830. [PMID: 35149693 PMCID: PMC8837660 DOI: 10.1038/s41467-022-28418-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 01/14/2022] [Indexed: 11/30/2022] Open
Abstract
Arrhythmias originating in scarred ventricular myocardium are a major cause of death, but the underlying mechanism allowing these rhythms to exist remains unknown. This gap in knowledge critically limits identification of at-risk patients and treatment once arrhythmias become manifest. Here we show that potassium voltage-gated channel subfamily E regulatory subunits 3 and 4 (KCNE3, KCNE4) are uniquely upregulated at arrhythmia sites within scarred myocardium. Ventricular arrhythmias occur in areas with a distinctive cardiomyocyte repolarization pattern, where myocyte tracts with short repolarization times connect to myocytes tracts with long repolarization times. We found this unique pattern of repolarization heterogeneity only in ventricular arrhythmia circuits. In contrast, conduction abnormalities were ubiquitous within scar. These repolarization heterogeneities are consistent with known functional effects of KCNE3 and KCNE4 on the slow delayed-rectifier potassium current. We observed repolarization heterogeneity using conventional cardiac electrophysiologic techniques that could potentially translate to identification of at-risk patients. The neutralization of the repolarization heterogeneities could represent a potential strategy for the elimination of ventricular arrhythmia circuits. Ventricular arrhythmias after heart attack are a leading cause of death. Here the authors show, in a porcine model, that KCNE3 and KCNE4 upregulation and a unique pattern of repolarization heterogeneity in the scar facilitate reentrant ventricular tachycardia.
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11
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Zhu C, Rajendran PS, Hanna P, Efimov IR, Salama G, Fowlkes CC, Shivkumar K. High-resolution structure-function mapping of intact hearts reveals altered sympathetic control of infarct border zones. JCI Insight 2022; 7:153913. [PMID: 35132963 PMCID: PMC8855798 DOI: 10.1172/jci.insight.153913] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Remodeling of injured sympathetic nerves on the heart after myocardial infarction (MI) contributes to adverse outcomes such as sudden arrhythmic death, yet the underlying structural mechanisms are poorly understood. We sought to examine microstructural changes on the heart after MI and to directly link these changes with electrical dysfunction. We developed a high-resolution pipeline for anatomically precise alignment of electrical maps with structural myofiber and nerve-fiber maps created by customized computer vision algorithms. Using this integrative approach in a mouse model, we identified distinct structure-function correlates to objectively delineate the infarct border zone, a known source of arrhythmias after MI. During tyramine-induced sympathetic nerve activation, we demonstrated regional patterns of altered electrical conduction aligned directly with altered neuroeffector junction distribution, pointing to potential neural substrates for cardiac arrhythmia. This study establishes a synergistic framework for examining structure-function relationships after MI with microscopic precision that has potential to advance understanding of arrhythmogenic mechanisms.
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Affiliation(s)
- Ching Zhu
- Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Pradeep S Rajendran
- Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Peter Hanna
- Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Igor R Efimov
- Department of Biomedical Engineering, George Washington University, Washington, DC, USA
| | - Guy Salama
- Department of Medicine, Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Charless C Fowlkes
- Department of Computer Science, University of California, Irvine, Irvine, California, USA
| | - Kalyanam Shivkumar
- Cardiac Arrhythmia Center and Neurocardiology Research Program of Excellence, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
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12
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Verheule S, Schotten U. Electrophysiological Consequences of Cardiac Fibrosis. Cells 2021; 10:cells10113220. [PMID: 34831442 PMCID: PMC8625398 DOI: 10.3390/cells10113220] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/09/2021] [Accepted: 11/12/2021] [Indexed: 12/27/2022] Open
Abstract
For both the atria and ventricles, fibrosis is generally recognized as one of the key determinants of conduction disturbances. By definition, fibrosis refers to an increased amount of fibrous tissue. However, fibrosis is not a singular entity. Various forms can be distinguished, that differ in distribution: replacement fibrosis, endomysial and perimysial fibrosis, and perivascular, endocardial, and epicardial fibrosis. These different forms typically result from diverging pathophysiological mechanisms and can have different consequences for conduction. The impact of fibrosis on propagation depends on exactly how the patterns of electrical connections between myocytes are altered. We will therefore first consider the normal patterns of electrical connections and their regional diversity as determinants of propagation. Subsequently, we will summarize current knowledge on how different forms of fibrosis lead to a loss of electrical connectivity in order to explain their effects on propagation and mechanisms of arrhythmogenesis, including ectopy, reentry, and alternans. Finally, we will discuss a histological quantification of fibrosis. Because of the different forms of fibrosis and their diverging effects on electrical propagation, the total amount of fibrosis is a poor indicator for the effect on conduction. Ideally, an assessment of cardiac fibrosis should exclude fibrous tissue that does not affect conduction and differentiate between the various types that do; in this article, we highlight practical solutions for histological analysis that meet these requirements.
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13
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Han B, Trew ML, Zgierski-Johnston CM. Cardiac Conduction Velocity, Remodeling and Arrhythmogenesis. Cells 2021; 10:cells10112923. [PMID: 34831145 PMCID: PMC8616078 DOI: 10.3390/cells10112923] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 10/14/2021] [Accepted: 10/22/2021] [Indexed: 02/06/2023] Open
Abstract
Cardiac electrophysiological disorders, in particular arrhythmias, are a key cause of morbidity and mortality throughout the world. There are two basic requirements for arrhythmogenesis: an underlying substrate and a trigger. Altered conduction velocity (CV) provides a key substrate for arrhythmogenesis, with slowed CV increasing the probability of re-entrant arrhythmias by reducing the length scale over which re-entry can occur. In this review, we examine methods to measure cardiac CV in vivo and ex vivo, discuss underlying determinants of CV, and address how pathological variations alter CV, potentially increasing arrhythmogenic risk. Finally, we will highlight future directions both for methodologies to measure CV and for possible treatments to restore normal CV.
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Affiliation(s)
- Bo Han
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg-Bad Krozingen, 79110 Freiburg im Breisgau, Germany;
- Faculty of Medicine, University of Freiburg, 79110 Freiburg im Breisgau, Germany
- Spemann Graduate School of Biology and Medicine (SGBM), University of Freiburg, 79104 Freiburg im Breisgau, Germany
- Department of Cardiovascular Surgery, The Fourth People’s Hospital of Jinan, 250031 Jinan, China
| | - Mark L. Trew
- Auckland Bioengineering Institute, University of Auckland, Auckland 1010, New Zealand;
| | - Callum M. Zgierski-Johnston
- Institute for Experimental Cardiovascular Medicine, University Heart Center Freiburg-Bad Krozingen, 79110 Freiburg im Breisgau, Germany;
- Faculty of Medicine, University of Freiburg, 79110 Freiburg im Breisgau, Germany
- Correspondence:
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14
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Cardiac stereotactic ablative radiotherapy for refractory ventricular arrhythmias: A radical alternative? A narrative review of rationale and cardiological aspects. J Med Imaging Radiat Sci 2021; 52:626-635. [PMID: 34593358 DOI: 10.1016/j.jmir.2021.09.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/10/2021] [Accepted: 09/10/2021] [Indexed: 11/21/2022]
Abstract
Ventricular arrhythmias are serious life-threatening cardiac disorders. Despite many technological improvements, a non-negligible number of patients present refractory ventricular tachycardias, resistant to a catheter ablation procedure, placing these patients in a therapeutic impasse. Recently, a cardiac stereotactic radioablative technique has been developed to treat patients with refractory ventricular arrhythmias, as a bail out strategy. This new therapeutic option historically brings together two fields of expertise unknown to each other, pointing out the necessity of an optimal partnership between cardiologists and radiation oncologists. As described in this narrative review, the understanding of cardiological aspects of the technique for radiation oncologists and treatment technical aspects comprehension for cardiologists represent a major challenge for the application and the future development of this promising treatment.
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15
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Saito K, Kondo Y, Takahashi M, Kitahara H, Nakayama T, Fujimoto Y, Kobayashi Y. Factors that predict ventricular arrhythmias in the late phase after acute myocardial infarction. ESC Heart Fail 2021; 8:4152-4160. [PMID: 34173350 PMCID: PMC8497219 DOI: 10.1002/ehf2.13499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 05/25/2021] [Accepted: 06/16/2021] [Indexed: 11/07/2022] Open
Abstract
Aims Little is known regarding factors that predict the occurrence of lethal ventricular arrhythmias (VAs) occurring after acute myocardial infarction (AMI). This observational cohort study aimed to identify factors that predicted lethal VAs during the late phase after AMI in patients with reduced left ventricular ejection fraction (LVEF). Methods and results Data were collected from our AMI database regarding consecutive patients with an LVEF of ≤40% after AMI (January 2012 to July 2018). The ‘late phase’ was defined as ≥7 days after AMI onset, and the primary endpoint was defined as lethal VAs in the late phase. The study included 136 patients (82% men; mean age: 66 ± 13 years). The average LVEF at admission was 32.7 ± 8.2%. During a mean follow‐up period of 20.7 months, 14 patients (10%) experienced lethal VAs, including ventricular fibrillation (n = 8) and sustained ventricular tachycardia (n = 10). Univariate analyses revealed that lethal VAs were predicted by age and LVEF at admission. Receiver operating characteristic curve analysis indicated that the optimal cut‐off value was 23% for using the LVEF at admission to predict the primary endpoint (area under the curve: 0.77, P < 0.0001). Multivariable analysis also demonstrated that LVEF at admission was an independent predictor of the primary endpoint (risk ratio = 7.12, P = 0.001). Conclusions Lethal VAs in the late phase are common in patients with AMI, and reduced LVEF and cardiac function at admission play a significant role in the risk stratification for future lethal VAs in this population.
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Affiliation(s)
- Kan Saito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chiba, Chuo-ku, 260-8677, Japan
| | - Yusuke Kondo
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chiba, Chuo-ku, 260-8677, Japan
| | | | - Hideki Kitahara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chiba, Chuo-ku, 260-8677, Japan
| | - Takashi Nakayama
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chiba, Chuo-ku, 260-8677, Japan
| | - Yoshihide Fujimoto
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chiba, Chuo-ku, 260-8677, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chiba, Chuo-ku, 260-8677, Japan
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16
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Zhang XD, Thai PN, Lieu DK, Chiamvimonvat N. Model Systems for Addressing Mechanism of Arrhythmogenesis in Cardiac Repair. Curr Cardiol Rep 2021; 23:72. [PMID: 34050853 PMCID: PMC8164614 DOI: 10.1007/s11886-021-01498-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2021] [Indexed: 11/09/2022]
Abstract
PURPOSE OF REVIEW Cardiac cell-based therapy represents a promising approach for cardiac repair. However, one of the main challenges is cardiac arrhythmias associated with stem cell transplantation. The current review summarizes the recent progress in model systems for addressing mechanisms of arrhythmogenesis in cardiac repair. RECENT FINDINGS Animal models have been extensively developed for mechanistic studies of cardiac arrhythmogenesis. Advances in human induced pluripotent stem cells (hiPSCs), patient-specific disease models, tissue engineering, and gene editing have greatly enhanced our ability to probe the mechanistic bases of cardiac arrhythmias. Additionally, recent development in multiscale computational studies and machine learning provides yet another powerful tool to quantitatively decipher the mechanisms of cardiac arrhythmias. Advancing efforts towards the integrations of experimental and computational studies are critical to gain insights into novel mitigation strategies for cardiac arrhythmias in cell-based therapy.
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Affiliation(s)
- Xiao-Dong Zhang
- Division of Cardiovascular Medicine, Department of Internal Medicine, School of Medicine, University of California, Davis, Davis, CA 95616 USA
- Department of Veterans Affairs, Veterans Affairs Northern California Health Care System, Mather, CA 95655 USA
| | - Phung N. Thai
- Division of Cardiovascular Medicine, Department of Internal Medicine, School of Medicine, University of California, Davis, Davis, CA 95616 USA
- Department of Veterans Affairs, Veterans Affairs Northern California Health Care System, Mather, CA 95655 USA
| | - Deborah K. Lieu
- Division of Cardiovascular Medicine, Department of Internal Medicine, School of Medicine, University of California, Davis, Davis, CA 95616 USA
| | - Nipavan Chiamvimonvat
- Division of Cardiovascular Medicine, Department of Internal Medicine, School of Medicine, University of California, Davis, Davis, CA 95616 USA
- Department of Veterans Affairs, Veterans Affairs Northern California Health Care System, Mather, CA 95655 USA
- Department of Pharmacology, School of Medicine, University of California, Davis, Davis, CA 95616 USA
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17
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Tayal B, Delling FN, Malahfji M, Shah DJ. Cardiac Imaging for Risk Assessment of Malignant Ventricular Arrhythmias in Patients With Mitral Valve Prolapse. Front Cardiovasc Med 2021; 8:574446. [PMID: 33659277 PMCID: PMC7917057 DOI: 10.3389/fcvm.2021.574446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 01/06/2021] [Indexed: 11/28/2022] Open
Abstract
Recent studies have described the occurrence of complex ventricular arrhythmias and sudden cardiac death among patients with mitral valve prolapse (MVP). The reported incidence rate of sudden cardiac death or ventricular tachycardia is about 1–1.5% among patients with MVP. Various imaging markers have been associated with this increased risk, including mitral annular disjunction, replacement fibrosis by late gadolinium enhancement, and mechanical dispersion. In this review, we briefly discuss how multimodality cardiac imaging can be applied to identify MVP patients with high risk of sudden cardiac death and complex ventricular arrhythmias.
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Affiliation(s)
- Bhupendar Tayal
- Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart and Vascular Institute, Houston, TX, United States.,Department of Cardiolgy, Aalborg University Hospital, Aalborg, Denmark
| | - Francesa N Delling
- Department of Cardiolgy, University of California, San Francisco, San Francisco, CA, United States
| | - Maan Malahfji
- Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart and Vascular Institute, Houston, TX, United States
| | - Dipan J Shah
- Division of Cardiovascular Imaging, Houston Methodist DeBakey Heart and Vascular Institute, Houston, TX, United States
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18
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Saadeh K, Fazmin IT. Mitochondrial Dysfunction Increases Arrhythmic Triggers and Substrates; Potential Anti-arrhythmic Pharmacological Targets. Front Cardiovasc Med 2021; 8:646932. [PMID: 33659284 PMCID: PMC7917191 DOI: 10.3389/fcvm.2021.646932] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 01/26/2021] [Indexed: 12/31/2022] Open
Abstract
Incidence of cardiac arrhythmias increases significantly with age. In order to effectively stratify arrhythmic risk in the aging population it is crucial to elucidate the relevant underlying molecular mechanisms. The changes underlying age-related electrophysiological disruption appear to be closely associated with mitochondrial dysfunction. Thus, the present review examines the mechanisms by which age-related mitochondrial dysfunction promotes arrhythmic triggers and substrate. Namely, via alterations in plasmalemmal ionic currents (both sodium and potassium), gap junctions, cellular Ca2+ homeostasis, and cardiac fibrosis. Stratification of patients' mitochondrial function status permits application of appropriate anti-arrhythmic therapies. Here, we discuss novel potential anti-arrhythmic pharmacological interventions that specifically target upstream mitochondrial function and hence ameliorates the need for therapies targeting downstream changes which have constituted traditional antiarrhythmic therapy.
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Affiliation(s)
- Khalil Saadeh
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom.,Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Ibrahim Talal Fazmin
- School of Clinical Medicine, University of Cambridge, Cambridge, United Kingdom.,Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom.,Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
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19
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Berruezo A, Penela D, Jáuregui B, Soto-Iglesias D. The role of imaging in catheter ablation of ventricular arrhythmias. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1115-1125. [PMID: 33527461 DOI: 10.1111/pace.14183] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 01/15/2021] [Accepted: 01/24/2021] [Indexed: 02/01/2023]
Abstract
Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) and multidetector cardiac computed tomography (MDCT) have emerged as novel, fascinating imaging tools for arrhythmogenic substrate identification and characterization. The role of these techniques for aiding and guiding the catheter ablation of ventricular tachycardia, either as a complement or a surrogate of the electroanatomic map, has been rising in recent years. Integrating pixel signal intensity maps or wall thickness maps delivered from LGE-CMR or MDCT, respectively, into the navigation system has become a cornerstone for VT ablation procedures in a few centers of excellence around the world. The pre-procedure scar characterization offers some advantages, helping decide for the best procedure planning and approach; complete substrate identification and characterization, helping to focus electroanatomical mapping in regions of interest and also has a positive impact in procedure efficiency and outcomes. In the present article, we perform a review of the most practical aspects for using LGE-CMR or MDCT when a VT ablation procedure is planned, from the image acquisition to the integration into the navigation system, analyzing the current role of the LGE-CMR and MDCT for arrhythmogenic substrate characterization as well as for guiding VT ablation.
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Affiliation(s)
| | - Diego Penela
- Heart Institute, Teknon Medical Center, Barcelona, Spain
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20
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MD1 Depletion Predisposes to Ventricular Arrhythmias in the Setting of Myocardial Infarction. Heart Lung Circ 2020; 30:869-881. [PMID: 33257269 DOI: 10.1016/j.hlc.2020.09.938] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 09/21/2020] [Accepted: 09/23/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Myeloid differentiation protein 1 (MD1) is expressed in the human heart and is a negative regulator of Toll-like receptor 4 (TLR4) signalling. MD1 exerts anti-arrhythmic effects. AIM The aim of this study was to determine the role of MD1 in myocardial infarction (MI)-related ventricular arrhythmias (VAs). METHOD Myocardial infarction was induced by surgical ligation of the left anterior coronary artery in MD1 knockout (KO) mice and their wild-type littermates. Myocardial infarction-induced vulnerability to VAs and its underlying mechanisms were evaluated. RESULTS Myeloid differentiation protein 1 was downregulated in the MI mice. Myeloid differentiation protein 1 deficiency decreased post-MI left ventricular (LV) function and increased the infarct size. The MI mice exhibited prolonged action potential duration (APD), enhanced APD alternans thresholds, and a higher incidence of VAs. Myocardial infarction-induced LV fibrosis and inflammation decreased the expression levels of Kv4.2, Kv4.3, Kv1.5, and Kv2.1, increased Cav1.2 expression, and disturbed Ca2+ handling protein expression. These MI-induced adverse effects were further exacerbated in KO mice. Mechanistically, MD1 deletion markedly enhanced the activation of the TLR4/calmodulin-dependent protein kinase II (CaMKII) signalling pathway in post-MI mice. CONCLUSIONS Myeloid differentiation protein 1 deletion increases the vulnerability to VAs in post-MI mice. This is mainly caused by the aggravated maladaptive LV fibrosis and inflammation and interference with the expressions of ion channels and Ca2+ handling proteins, which is related to enhanced activation of the TLR4/CaMKII signalling pathway.
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21
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Sáenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Europace 2020; 21:1143-1144. [PMID: 31075787 DOI: 10.1093/europace/euz132] [Citation(s) in RCA: 222] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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22
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Bella PD, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. J Interv Card Electrophysiol 2020; 59:145-298. [PMID: 31984466 PMCID: PMC7223859 DOI: 10.1007/s10840-019-00663-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, IN, USA
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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23
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Assaf A, Diletti R, Hoogendijk MG, van der Graaf M, Zijlstra F, Szili-Torok T, Yap SC. Vulnerability for ventricular arrhythmias in patients with chronic coronary total occlusion. Expert Rev Cardiovasc Ther 2020; 18:487-494. [PMID: 32684000 DOI: 10.1080/14779072.2020.1793671] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The presence of a chronic total occlusion (CTO) is associated with an increased risk of ventricular arrhythmias. AREAS COVERED This review provides an overview of the relationship between CTO and ventricular arrhythmias, arrhythmogenic mechanisms, and the effect of revascularization. EXPERT OPINION Studies in recipients of an implantable cardioverter-defibrillator (ICD) have shown that a CTO is an independent predictor of appropriate ICD therapy. The myocardial territory supplied by a CTO is a pro-arrhythmogenic milieu characterized by scar tissue, large scar border zone, hibernating myocardium, residual ischemia despite collaterals, areas of slow conduction, and heterogeneity in repolarization. Restoring coronary flow by revascularization might be associated with electrical homogenization as reflected by a decrease in QT(c) dispersion, decrease in T wave peak-to-end interval, reduction of late potentials, and decrease in scar border zone area. Future research should explore whether CTO revascularization results in a lower burden of ventricular arrhythmias. Furthermore, risk stratification of CTO patients without severe LV dysfunction is interesting to identify potential ICD candidates. Potential tools for risk stratification are the use of electrocardiographic parameters, body surface mapping, electrophysiological study, and close rhythm monitoring using an insertable cardiac monitor.
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Affiliation(s)
- Amira Assaf
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands
| | - Roberto Diletti
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands
| | - Mark G Hoogendijk
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands
| | - Marisa van der Graaf
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands
| | - Felix Zijlstra
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands
| | - Tamas Szili-Torok
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands
| | - Sing-Chien Yap
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam , Rotterdam, The Netherlands
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Pham VT, Lin C, Tran TT, M Su MY, Lin YK, Nien CT, I Tseng WY, Lin JL, Lo MT, Lin LY. Predicting ventricular tachyarrhythmia in patients with systolic heart failure based on texture features of the gray zone from contrast-enhanced magnetic resonance imaging. J Cardiol 2020; 76:601-609. [PMID: 32675026 DOI: 10.1016/j.jjcc.2020.06.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 06/11/2020] [Accepted: 06/15/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Previous research showed that gray zone detected by late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) imaging could help identify high-risk patients. In this study, we investigated whether LGE-CMR gray zone heterogeneity measured by image texture features could predict cardiovascular events in patients with heart failure (HF). METHOD This is a retrospective cohort study. Patients with systolic HF undergoing CMR imaging were enrolled. Cine and LGE images were analyzed to derive left ventricular (LV) function and scar characteristics. Entropy and uniformity of gray zones were derived by texture analysis. RESULTS A total of 82 systolic HF patients were enrolled. After a median 1021 (25%-75% quartiles, 205-2066) days of follow-up, the entropy (0.60 ± 0.260 vs. 0.87 ± 0.28, p = 0.013) was significantly increased while the uniformity (0.68 ± 0.14 vs. 0.53±0.15, p = 0.016) was significantly decreased in patients with ventricular tachycardia or ventricular fibrillation (VT/VF). The percentage of core scar (21.9 ± 10.6 vs. 30.6 ± 10.4, p = 0.029) was higher in cardiac mortality group than survival group while the uniformity (0.55 ± 0.17 vs. 0.67 ± 0.14, p = 0.018) was lower in cardiac mortality group than survival group. A multivariate Cox regression model showed that higher percentage of gray zone area (HR = 8.805, 1.620-47.84, p = 0.045), higher entropy (>0.85) (HR = 1.391, 1.092-1.772, p = 0.024) and lower uniformity (≦0.54) (HR = 0.535, 0.340-0.842, p = 0.022) were associated with VT/VF attacks. Also, higher percentage of gray zone area (HR = 5.716, 1.379-23.68, p = 0.017), core scar zone (HR = 1.939, 1.056-3.561, p = 0.025), entropy (>0.85) (HR = 1.434, 1.076-1.911, p = 0.008) and lower uniformity (≦0.54) (HR = 0.513, 0.296-0.888, p = 0.009) were associated with cardiac mortality during follow-up. CONCLUSIONS Gray zone heterogeneity by texture analysis method could provide additional prognostic value to traditional LGE-CMR substrate analysis method.
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Affiliation(s)
- Van-Truong Pham
- School of Electrical Engineering, Hanoi University of Science and Technology, Hanoi, Vietnam; Department of Biomedical Sciences and Engineering, National Central University, Taoyuan, Taiwan
| | - Chen Lin
- Department of Biomedical Sciences and Engineering, National Central University, Taoyuan, Taiwan; Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.
| | - Thi-Thao Tran
- School of Electrical Engineering, Hanoi University of Science and Technology, Hanoi, Vietnam; Department of Biomedical Sciences and Engineering, National Central University, Taoyuan, Taiwan
| | - Mao-Yuan M Su
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Ying-Kuang Lin
- Department of Biomedical Sciences and Engineering, National Central University, Taoyuan, Taiwan; Department of Medicine, Taiwan Landseed Hospital, Taoyuan, Taiwan
| | - Chun-Tung Nien
- Department of Biomedical Sciences and Engineering, National Central University, Taoyuan, Taiwan; Department of Medicine, Taiwan Landseed Hospital, Taoyuan, Taiwan
| | - Wen-Yih I Tseng
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan; Center for Optoelectronic Biomedicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jiunn-Lee Lin
- Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Men-Tzung Lo
- Department of Biomedical Sciences and Engineering, National Central University, Taoyuan, Taiwan
| | - Lian-Yu Lin
- Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.
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25
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Wang G, Lee SE, Yang Q, Sadras V, Patel S, Yang HJ, Sharif B, Kali A, Cokic I, Xie G, Tighiouart M, Collins J, Li D, Berman DS, Chang HJ, Dharmakumar R. Multicenter Study on the Diagnostic Performance of Native-T1 Cardiac Magnetic Resonance of Chronic Myocardial Infarctions at 3T. Circ Cardiovasc Imaging 2020; 13:e009894. [PMID: 32507020 PMCID: PMC7363195 DOI: 10.1161/circimaging.119.009894] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Preclinical studies and pilot patient studies have shown that chronic infarctions can be detected and characterized from cardiac magnetic resonance without gadolinium-based contrast agents using native-T1 maps at 3T. We aimed to investigate the diagnostic capacity of this approach for characterizing chronic myocardial infarctions (MIs) in a multi-center setting. METHODS Patients with a prior MI (n=105) were recruited at 3 different medical centers and were imaged with native-T1 mapping and late gadolinium enhancement (LGE) at 3T. Infarct location, size, and transmurality were determined from native-T1 maps and LGE. Sensitivity, specificity, receiver-operating characteristic metrics, and inter- and intraobserver variabilities were assessed relative to LGE. RESULTS Across all subjects, T1 of MI territory was 1621±110 ms, and remote territory was 1225±75 ms. Sensitivity, specificity, and area under curve for detecting MI location based on native-T1 mapping relative to LGE were 88%, 92%, and 0.93, respectively. Native-T1 maps were not different for measuring infarct size (native-T1 maps: 12.1±7.5%; LGE: 11.8±7.2%, P=0.82) and were in agreement with LGE (R2=0.92, bias, 0.09±2.6%). Corresponding inter- and intraobserver assessments were also highly correlated (interobserver: R2=0.90, bias, 0.18±2.4%; and intraobserver: R2=0.91, bias, 0.28±2.1%). Native T1 maps were not different for measuring MI transmurality (native-T1 maps: 49.1±15.8%; LGE: 47.2±19.0%, P=0.56) and showed agreement (R2=0.71; bias, 1.32±10.2%). Corresponding inter- and intraobserver assessments were also in agreement (interobserver: R2=0.81, bias, 0.1±9.4%; and intraobserver: R2=0.91, bias, 0.28±2.1%, respectively). While the overall accuracy for detecting MI with native-T1 maps at 3T was high, logistic regression analysis showed that MI location was a prominent confounder. CONCLUSIONS Native-T1 mapping can be used to image chronic MI with high degree of accuracy, and as such, it is a viable alternative for scar imaging in patients with chronic MI who are contraindicated for LGE. Technical advancements may be needed to overcome the imaging confounders that currently limit native-T1 mapping from reaching equivalent detection levels as LGE.
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Affiliation(s)
- Guan Wang
- Department of Biomedical Sciences, Biomedical Imaging Research Institute (G.W., Q.Y., V.S., S.P., H.-J.Y., B.S., A.K., I.C., D.L., D.S.B., R.D.), Cedars-Sinai Medical Center, Los Angeles, CA.,Department of Radiology, The First Affiliated Hospital of China Medical University, Shenyang (G.W.)
| | - Sang-Eun Lee
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea (S.-E.L., H.-J.C.).,Division of Cardiology, Department of Internal Medicine, Ewha Womans University Seoul Hospital, South Korea (S.-E.L.)
| | - Qi Yang
- Department of Biomedical Sciences, Biomedical Imaging Research Institute (G.W., Q.Y., V.S., S.P., H.-J.Y., B.S., A.K., I.C., D.L., D.S.B., R.D.), Cedars-Sinai Medical Center, Los Angeles, CA.,Department of Radiology, Xuanwu Hospital, Beijing, China (Q.Y.)
| | - Vignesh Sadras
- Department of Biomedical Sciences, Biomedical Imaging Research Institute (G.W., Q.Y., V.S., S.P., H.-J.Y., B.S., A.K., I.C., D.L., D.S.B., R.D.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Suraj Patel
- Department of Biomedical Sciences, Biomedical Imaging Research Institute (G.W., Q.Y., V.S., S.P., H.-J.Y., B.S., A.K., I.C., D.L., D.S.B., R.D.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Hsin-Jung Yang
- Department of Biomedical Sciences, Biomedical Imaging Research Institute (G.W., Q.Y., V.S., S.P., H.-J.Y., B.S., A.K., I.C., D.L., D.S.B., R.D.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Behzad Sharif
- Department of Biomedical Sciences, Biomedical Imaging Research Institute (G.W., Q.Y., V.S., S.P., H.-J.Y., B.S., A.K., I.C., D.L., D.S.B., R.D.), Cedars-Sinai Medical Center, Los Angeles, CA.,Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles (B.S., I.C., D.L., D.S.B., R.D.)
| | - Avinash Kali
- Department of Biomedical Sciences, Biomedical Imaging Research Institute (G.W., Q.Y., V.S., S.P., H.-J.Y., B.S., A.K., I.C., D.L., D.S.B., R.D.), Cedars-Sinai Medical Center, Los Angeles, CA
| | - Ivan Cokic
- Department of Biomedical Sciences, Biomedical Imaging Research Institute (G.W., Q.Y., V.S., S.P., H.-J.Y., B.S., A.K., I.C., D.L., D.S.B., R.D.), Cedars-Sinai Medical Center, Los Angeles, CA.,Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles (B.S., I.C., D.L., D.S.B., R.D.)
| | - Guoxi Xie
- Guangzhou Medical University, China (G.X.)
| | - Mourad Tighiouart
- Biostatistics and Bioinformatics Research Center (M.T.), Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Debiao Li
- Department of Biomedical Sciences, Biomedical Imaging Research Institute (G.W., Q.Y., V.S., S.P., H.-J.Y., B.S., A.K., I.C., D.L., D.S.B., R.D.), Cedars-Sinai Medical Center, Los Angeles, CA.,Department of Imaging (D.L., D.S.B.), Cedars-Sinai Medical Center, Los Angeles, CA.,Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles (B.S., I.C., D.L., D.S.B., R.D.)
| | - Daniel S Berman
- Department of Biomedical Sciences, Biomedical Imaging Research Institute (G.W., Q.Y., V.S., S.P., H.-J.Y., B.S., A.K., I.C., D.L., D.S.B., R.D.), Cedars-Sinai Medical Center, Los Angeles, CA.,Cedars-Sinai Heart Institute (D.S.B., R.D.), Cedars-Sinai Medical Center, Los Angeles, CA.,Department of Imaging (D.L., D.S.B.), Cedars-Sinai Medical Center, Los Angeles, CA.,Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles (B.S., I.C., D.L., D.S.B., R.D.)
| | - Hyuk-Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea (S.-E.L., H.-J.C.)
| | - Rohan Dharmakumar
- Department of Biomedical Sciences, Biomedical Imaging Research Institute (G.W., Q.Y., V.S., S.P., H.-J.Y., B.S., A.K., I.C., D.L., D.S.B., R.D.), Cedars-Sinai Medical Center, Los Angeles, CA.,Cedars-Sinai Heart Institute (D.S.B., R.D.), Cedars-Sinai Medical Center, Los Angeles, CA.,Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles (B.S., I.C., D.L., D.S.B., R.D.)
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Mendonca Costa C, Anderson GC, Meijborg VMF, O’Shea C, Shattock MJ, Kirchhof P, Coronel R, Niederer S, Pavlovic D, Dhanjal T, Winter J. The Amplitude-Normalized Area of a Bipolar Electrogram as a Measure of Local Conduction Delay in the Heart. Front Physiol 2020; 11:465. [PMID: 32508676 PMCID: PMC7248250 DOI: 10.3389/fphys.2020.00465] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 04/16/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Re-entrant ventricular tachycardia may be non-inducible or haemodynamically compromising, requiring assessment of the electrophysiological properties of the myocardium during sinus rhythm (i.e., substrate mapping). Areas of heart tissue with slow conduction can act as a critical isthmus for re-entrant electrical excitation and are a potential target for ablation therapy. AIM To develop and validate a novel metric of local conduction delay in the heart, the amplitude-normalized electrogram area (norm_EA). METHODS A computational model of a propagating mouse action potential was used to establish the impact of altering sodium channel conductance, intracellular conductivity, fibrosis density, and electrode size/orientation on bipolar electrogram morphology. Findings were then validated in experimental studies in mouse and guinea pig hearts instrumented for the recording of bipolar electrograms from a multipolar linear mapping catheter. norm_EA was calculated by integrating the absolute area of a bipolar electrogram divided by the electrogram amplitude. Electrogram metrics were correlated with the local conduction delay during sodium channel block, gap junction inhibition, and acute ischemia. RESULTS In computational simulations, reducing sodium channel conductance and intracellular conductivity resulted in a decrease in signal amplitude and increase in norm_EA (reflecting a broadening of electrogram morphology). For larger electrodes (3 mm diameter/7.1 mm2 area), the change in norm_EA was essentially linear with the change in local conduction delay. Experimental studies supported this finding, showing that the magnitude of change in norm_EA induced by flecainide (1-4 μM), carbenoxolone (10-50 μM), and low-flow ischemia (25% of initial flow rate) was linearly correlated with the local conduction delay in each condition (r 2 = 0.92). Qualitatively similar effects were observed in guinea pig hearts perfused with flecainide. Increasing fibrosis density in the computational model also resulted in a decrease in signal amplitude and increase in norm_EA. However, this remains to be validated using experimental/clinical data of chronic infarct. CONCLUSION norm_EA is a quantitative measure of local conduction delay between the electrode pair that generates a bipolar electrogram, which may have utility in electrophysiological substrate mapping of non-inducible or haemodynamically compromising tachyarrhythmia.
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Affiliation(s)
- Caroline Mendonca Costa
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Grace C. Anderson
- School of Cardiovascular Medicine & Sciences, King’s College London, London, United Kingdom
| | | | - Christopher O’Shea
- Department of Cardiology, UHB NHS Foundation Trust, Institute of Cardiovascular Science, University of Birmingham, Birmingham, United Kingdom
| | - Michael J. Shattock
- School of Cardiovascular Medicine & Sciences, King’s College London, London, United Kingdom
| | - Paulus Kirchhof
- Department of Cardiology, UHB NHS Foundation Trust, Institute of Cardiovascular Science, University of Birmingham, Birmingham, United Kingdom
- Department of Cardiology, SWBH NHS Trust, Institute of Cardiovascular Science, University of Birmingham, Birmingham, United Kingdom
| | - Ruben Coronel
- Department of Experimental Cardiology, Academic Medical Center, Amsterdam, Netherlands
- LIRYC, Heart Arrhythmia and Modeling Institute, Pessac, France
| | - Steven Niederer
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
| | - Davor Pavlovic
- Department of Cardiology, UHB NHS Foundation Trust, Institute of Cardiovascular Science, University of Birmingham, Birmingham, United Kingdom
| | - Tarvinder Dhanjal
- Department of Cardiology, University Hospitals Coventry and Warwickshire, Coventry, United Kingdom
| | - James Winter
- Department of Cardiology, UHB NHS Foundation Trust, Institute of Cardiovascular Science, University of Birmingham, Birmingham, United Kingdom
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Abstract
Experimental models of cardiac disease play a key role in understanding the pathophysiology of the disease and developing new therapies. The features of the experimental models should reflect the clinical phenotype, which can have a wide spectrum of underlying mechanisms. We review characteristics of commonly used experimental models of cardiac physiology and pathophysiology in all translational steps including in vitro, small animal, and large animal models. Understanding their characteristics and relevance to clinical disease is the key for successful translation to effective therapies.
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28
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Park KM. Editorial: Simple Maneuver for Estimating the Depth of the Focal Activation Source in Myocardium. Korean Circ J 2020; 50:430-431. [PMID: 32216176 PMCID: PMC7098825 DOI: 10.4070/kcj.2020.0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 02/14/2020] [Indexed: 11/11/2022] Open
Affiliation(s)
- Kyoung Min Park
- Division of Cardiology, Heart Vascular and Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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29
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Aronis KN, Ali RL, Prakosa A, Ashikaga H, Berger RD, Hakim JB, Liang J, Tandri H, Teng F, Chrispin J, Trayanova NA. Accurate Conduction Velocity Maps and Their Association With Scar Distribution on Magnetic Resonance Imaging in Patients With Postinfarction Ventricular Tachycardias. Circ Arrhythm Electrophysiol 2020; 13:e007792. [PMID: 32191131 DOI: 10.1161/circep.119.007792] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Characterizing myocardial conduction velocity (CV) in patients with ischemic cardiomyopathy (ICM) and ventricular tachycardia (VT) is important for understanding the patient-specific proarrhythmic substrate of VTs and therapeutic planning. The objective of this study is to accurately assess the relation between CV and myocardial fibrosis density on late gadolinium-enhanced cardiac magnetic resonance imaging (LGE-CMR) in patients with ICM. METHODS We enrolled 6 patients with ICM undergoing VT ablation and 5 with structurally normal left ventricles (controls) undergoing premature ventricular contraction or VT ablation. All patients underwent LGE-CMR and electroanatomic mapping (EAM) in sinus rhythm (2960 electroanatomic mapping points analyzed). We estimated CV from electroanatomic mapping local activation time using the triangulation method that provides an accurate estimate of CV as it accounts for the direction of wavefront propagation. We evaluated the association between LGE-CMR intensity and CV with multilevel linear mixed models. RESULTS Median CV in patients with ICM and controls was 0.41 m/s and 0.65 m/s, respectively. In patients with ICM, CV in areas with no visible fibrosis was 0.81 m/s (95% CI, 0.59-1.12 m/s). For each 25% increase in normalized LGE intensity, CV decreased by 1.34-fold (95% CI, 1.25-1.43). Dense scar areas have, on average, 1.97- to 2.66-fold slower CV compared with areas without dense scar. Ablation lesions that terminated VTs were localized in areas of slow conduction on CV maps. CONCLUSIONS CV is inversely associated with LGE-CMR fibrosis density in patients with ICM. Noninvasive derivation of CV maps from LGE-CMR is feasible. Integration of noninvasive CV maps with electroanatomic mapping during substrate mapping has the potential to improve procedural planning and outcomes. Visual Overview: A visual overview is available for this article.
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Affiliation(s)
- Konstantinos N Aronis
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University (K.N.A., R.L.A., A.P., J.B.H., J.L., F.T., N.A.T.).,Section of Electrophysiology, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD (K.N.A., H.A., R.D.B., H.T., J.C.)
| | - Rheeda L Ali
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University (K.N.A., R.L.A., A.P., J.B.H., J.L., F.T., N.A.T.)
| | - Adityo Prakosa
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University (K.N.A., R.L.A., A.P., J.B.H., J.L., F.T., N.A.T.)
| | - Hiroshi Ashikaga
- Section of Electrophysiology, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD (K.N.A., H.A., R.D.B., H.T., J.C.)
| | - Ronald D Berger
- Section of Electrophysiology, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD (K.N.A., H.A., R.D.B., H.T., J.C.)
| | - Joe B Hakim
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University (K.N.A., R.L.A., A.P., J.B.H., J.L., F.T., N.A.T.)
| | - Jialiu Liang
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University (K.N.A., R.L.A., A.P., J.B.H., J.L., F.T., N.A.T.)
| | - Harikrishna Tandri
- Section of Electrophysiology, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD (K.N.A., H.A., R.D.B., H.T., J.C.)
| | - Fei Teng
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University (K.N.A., R.L.A., A.P., J.B.H., J.L., F.T., N.A.T.)
| | - Jonathan Chrispin
- Section of Electrophysiology, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD (K.N.A., H.A., R.D.B., H.T., J.C.)
| | - Natalia A Trayanova
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University (K.N.A., R.L.A., A.P., J.B.H., J.L., F.T., N.A.T.)
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Percutaneous Epicardial Approach to Catheter Ablation of Cardiac Arrhythmias. JACC Clin Electrophysiol 2020; 6:1-20. [PMID: 31971898 DOI: 10.1016/j.jacep.2019.10.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/22/2019] [Accepted: 10/25/2019] [Indexed: 11/23/2022]
Abstract
Since their introduction >2 decades ago, percutaneous catheter-based epicardial mapping and ablation have become widely adopted by cardiac electrophysiologists around the world. Although epicardial mapping has been used for catheter ablation of a wide variety of cardiac arrhythmias, its most common use is for ablation of intramural and subepicardial substrates that give rise to ventricular tachycardia, particularly in patients with nonischemic cardiomyopathy. As such, the subxiphoid percutaneous epicardial approach has emerged as an important adjunct, and, in some cases, is the preferred strategy in this regard. This review discusses the rationale and indications for epicardial catheter mapping and/or ablation. This paper also reviews the prevalence of epicardial arrhythmias and their electrocardiographic criteria. In addition, it examines the anatomy of the pericardium and commonly used epicardial access techniques, as well as the optimal methodologies for epicardial mapping and ablation and the impact of epicardial fat. Finally, this review discusses the potential of the various complications associated with the percutaneous epicardial approach, in addition to patient-specific risk factors, and potential strategies to mitigate the risk of complications.
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Anderson RD, Lee G, Trivic I, Campbell T, Pham T, Nalliah C, Kizana E, Thomas SP, Trivedi SJ, Watts T, Kalman J, Kumar S. Focal Ventricular Tachycardias in Structural Heart Disease: Prevalence, Characteristics, and Clinical Outcomes After Catheter Ablation. JACC Clin Electrophysiol 2019; 6:56-69. [PMID: 31971907 DOI: 10.1016/j.jacep.2019.09.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 07/29/2019] [Accepted: 09/04/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This study sought to summarize the procedural characteristics and outcomes of patients with structural heart disease (SHD) who have focal ventricular tachycardia (VT). BACKGROUND Scar-mediated re-entry is the predominant mechanism of VT in SHD. Some SHD patients may have a focal VT mechanism that remains poorly described. METHODS An extended induction protocol incorporating programmed electrical stimulation, right ventricular burst pacing and isoprenaline was used to elucidate both re-entrant and focal VT mechanisms. RESULTS Eighteen of 112 patients (16%) with SHD undergoing VT ablation over 2 years had a focal VT mechanism elucidated (mean age 66±13 years; ejection fraction 46±14%; nonischemic cardiomyopathy 10). Repetitive failure of termination with antitachycardia pacing (ATP) (69% of patients) or defibrillator shocks (56%) was a common feature of focal VTs. A median of 3 VTs per patient were inducible (28 focal VTs, 34 re-entrant VTs; 53% of patients had both focal and re-entrant VT mechanism). Focal VTs more commonly originated from the right ventricle (RV) than the left ventricle (LV) (67% vs. 33%, respectively). In the RV, the RV outflow tract was the most common site (33% of all focal VTs), followed by the RV moderator band (22%), apical septal RV (6%), and lateral tricuspid annulus (6%). The lateral LV (non-Purkinje) was the most common LV focal VT site (16%), followed by the papillary muscles (17%). After median follow-up of 289 days, 78% of patients remained arrhythmia-free; no patients had recurrence of focal VT at repeat procedure. In patients with recurrence, defibrillator therapies were significantly reduced from a median of 53 ATP episodes pre-ablation to 10 ATP episodes post-ablation. During follow-up, 2 patients (11%) underwent repeat VT ablation; none had recurrence of focal VT. CONCLUSIONS Focal VTs are common in patients with SHD and often coexist with re-entrant forms of VT. High failure rate of defibrillator therapies was a common feature of focal VT mechanisms. Uncovering and abolishing focal VT may further improve outcomes of catheter ablation in SHD.
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Affiliation(s)
- Robert D Anderson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Australia; Department of Cardiology, Westmead Hospital, Sydney, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Australia
| | - Ivana Trivic
- Department of Cardiology, Westmead Hospital, Sydney, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, Australia
| | - Timothy Campbell
- Department of Cardiology, Westmead Hospital, Sydney, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, Australia
| | - Timmy Pham
- Department of Cardiology, Westmead Hospital, Sydney, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, Australia
| | | | - Eddy Kizana
- Department of Cardiology, Westmead Hospital, Sydney, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, Australia
| | - Stuart P Thomas
- Department of Cardiology, Westmead Hospital, Sydney, Australia
| | - Siddharth J Trivedi
- Department of Cardiology, Westmead Hospital, Sydney, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, Australia
| | - Troy Watts
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Australia
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Sydney, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, Australia.
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Glashan CA, Tofig BJ, Tao Q, Blom SA, Jongbloed MR, Nielsen JC, Lukac P, Kristiansen SB, Zeppenfeld K. Multisize Electrodes for Substrate Identification in Ischemic Cardiomyopathy. JACC Clin Electrophysiol 2019; 5:1130-1140. [DOI: 10.1016/j.jacep.2019.06.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 05/10/2019] [Accepted: 06/06/2019] [Indexed: 11/30/2022]
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Heart Rhythm 2019; 17:e2-e154. [PMID: 31085023 PMCID: PMC8453449 DOI: 10.1016/j.hrthm.2019.03.002] [Citation(s) in RCA: 186] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Indexed: 01/10/2023]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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Li B, Liu C, Wang L, Wang J, Hu Y, Gu C. Open chest epicardial and transapical endocardial substrate ablation for ventricular tachycardia with left ventricular aneurysm in a porcine model. Perfusion 2018; 34:154-163. [PMID: 30445894 DOI: 10.1177/0267659118814689] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Endo-epicardial radiofrequency catheter ablation (RFCA) of ventricular tachycardia (VT) as a first-line strategy has been shown to improve outcomes. This study sought to evaluate the feasibility and validity of open-chest epicardial and transapical endocardial substrate ablation for VT with left ventricular aneurysm (LVA) applying to routine cardiac surgery. METHODS Porcine models of LVA with VT were developed and were divided into a study group (RFCA from the epicardium via direct-view and endocardium via transapical access) and a control group (endocardial RFCA via retrograde transaortic access). Substrate-based mapping and ablation targeting abnormal potentials were performed under thoracotomy. Outcomes, including procedural success and acute freedom from VT, were analysed. RESULTS Twenty-four of 35 (68.57%) acute myocardial infarction (AMI) pigs developed LVA with VT in a 6-week survival period and were randomly divided into a study group (n=12) and a control group (n=12). All animals in the study group successfully underwent endocardial mapping and ablation by transapical access. The scar size of the endocardium and the left ventricular chamber volume were similar in the two groups. Acute freedom from VT in the study group was remarkably superior to that in the control group (88.33% vs. 58.33%, p=0.04). CONCLUSIONS Combined, direct epicardial and transapical endocardial substrate mapping and ablation appeared to be feasible and effective for treating VT with LVA under thoracotomy.
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Affiliation(s)
- Bo Li
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,2 Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Changcheng Liu
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,2 Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Liangshan Wang
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,2 Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Jin Wang
- 2 Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China.,3 Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yucai Hu
- 4 Department of Cardiology, the First-affiliated Hospital of Henan University of Traditional Chinese Medicine, Henan, China
| | - Chengxiong Gu
- 1 Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.,2 Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
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Catheter Ablation of Post-Infarct VT: Mechanisms, Strategies and Outcomes. Heart Lung Circ 2018; 28:76-83. [PMID: 30482686 DOI: 10.1016/j.hlc.2018.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/02/2018] [Accepted: 10/03/2018] [Indexed: 12/29/2022]
Abstract
Ventricular arrhythmias are one of the leading causes of death in patients with a prior myocardial infarction. Implantable cardioverter-defibrillators (ICDs) are very effective in the prevention of sudden cardiac death but the risk of recurrence remains an issue since defibrillation does not alter the underlying substrate. Recurrent ICD shocks are distressing and are associated with an increase in mortality. Catheter ablation is an effective treatment for recurrent ventricular tachycardia in these patients, particularly when antiarrhythmic therapy produces side effects or is ineffective. This paper reviews the underlying mechanisms of VT in patients with a prior myocardial infarction, and the indications, strategies and outcomes of catheter ablation.
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Sramko M, Hoogendoorn JC, Glashan CA, Zeppenfeld K. Advancement in cardiac imaging for treatment of ventricular arrhythmias in structural heart disease. Europace 2018; 21:383-403. [DOI: 10.1093/europace/euy150] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 07/23/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
- Marek Sramko
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, ZA, Leiden, The Netherlands
| | - Jarieke C Hoogendoorn
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, ZA, Leiden, The Netherlands
| | - Claire A Glashan
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, ZA, Leiden, The Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, ZA, Leiden, The Netherlands
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Maury P, Rollin A, Waintraub X, Capellino S, Gandjbakhch E. Crossroads or “Flyovers” novel insights into ventricular tachycardia mechanisms: The path is twisting. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:1564-1567. [DOI: 10.1111/pace.13433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 06/17/2018] [Accepted: 06/20/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Philippe Maury
- University Hospital Rangueil; Toulouse France
- Unité Inserm U 1048; Toulouse France
| | - Anne Rollin
- University Hospital Rangueil; Toulouse France
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DL-3-n-butylphthalide improves ventricular function, and prevents ventricular remodeling and arrhythmias in post-MI rats. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2018; 391:627-637. [DOI: 10.1007/s00210-018-1490-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 03/23/2018] [Indexed: 11/27/2022]
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Myocardial wall thinning predicts transmural substrate in patients with scar-related ventricular tachycardia. Heart Rhythm 2018; 14:155-163. [PMID: 28104088 DOI: 10.1016/j.hrthm.2016.11.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Scar-related ventricular tachycardia (VT) arises from specific substrate according to etiology. OBJECTIVE The purpose of this study was to evaluate the relationship between wall thinning (WT) on multidetector computed tomography (MDCT) and local abnormal ventricular activity (LAVA) in patients with ischemic cardiomyopathy (ICM), postmyocarditis (PMC), and dilated cardiomyopathy (DCM). METHODS Forty-two patients (40 male, age 58 ± 13 years, 22 ICM, 11 PMC, 9 DCM) underwent MDCT before a combined endo-/epicardial VT ablation procedure. WT (<5 mm) and severe wall thinning (SWT) (<2 mm) area on MDCT were compared to the prevalence of endo-/epicardial LAVA during sinus rhythm. RESULTS WT and SWT were found on MDCT in 36 (86%) and 20 (48%) with 42 ± 37 cm2 and 26 ± 24 cm2, respectively. SWT was frequently detected in ICM (ICM 77% vs PMC 27% vs DCM 0%, P <.001). LAVA were frequently observed on the endocardium in ICM and on the epicardium in PMC. Endo-/epicardial facing LAVA were frequently found within SWT areas (91% in <2 mm, 9% in 2-5 mm, and 0% in >5 mm, P < .001). In SWT areas, the presence of endocardial LAVA in ICM and epicardial LAVA in PMC predicted opposite facing LAVA with sensitivity and specificity of 78% and 48% and 79% and 98%, respectively. SWT predicted epicardial LAVA in ICM and endocardial LAVA in PMC with sensitivity and specificity of 89% and 100%, and 100% and 100%, respectively. CONCLUSION SWT is frequently found in ICM and PMC but is not common in DCM. SWT predicts LAVA on the opposite side of the wall (epicardial in ICM and endocardial in PMC), indicating transmural VT substrate. MDCT is useful for identifying VT substrate and helpful for understanding the mechanisms of the location of VT substrate domain.
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Nayyar S, Wilson L, Ganesan A, Sullivan T, Kuklik P, Young G, Sanders P, Roberts-Thomson KC. Electrophysiologic features of protected channels in late postinfarction patients with and without spontaneous ventricular tachycardia. J Interv Card Electrophysiol 2017; 51:13-24. [PMID: 29236200 DOI: 10.1007/s10840-017-0299-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 11/16/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Protected channels of surviving myocytes in late postinfarction ventricular scar predispose to ventricular tachycardia (VT). However, only a few patients develop VT spontaneously. We studied differences in electric remodeling and protected channels in late postinfarction patients with and without spontaneous VT. METHODS Patients with ischemic cardiomyopathy (ICM) with recurrent sustained monomorphic VT (n = 22) were compared with stable ICM patients without spontaneous VT (control group; n = 5). Left ventricular mapping was performed with a 20-pole catheter. Detailed pace mapping was used to identify channels of protected conduction, and confirmed, when feasible, by entrainment. Anatomical and electrophysiological properties of VT channels and non-VT channels in VT patients and channels in controls were evaluated. RESULTS Seventy-three (median 3) VTs were inducible in VT patients compared to two (median 0) in controls. The VT channels in VT patients (n = 57, 3 ± 1 per patient) were lengthier (mean ± SEM 53 ± 5 vs. 33 ± 4 vs. 24 ± 8 mm), had longer S-QRS (73 ± 4 vs. 63 ± 3 vs. 44 ± 8 ms), longer conduction time (103 ± 13 vs. 33 ± 4 vs. 24 ± 8 ms), and slower conduction velocity (CV) (0.85 ± 0.21 vs. 1.39 ± 0.20 vs. 1.31 ± 0.41 m/s) than non-VT channels in VT patients (n = 183, 8 ± 6 per patient) (p ≤ 0.01) and channels in controls (n = 46, 9 ± 8 per patient) (p ≤ 0.01). Additionally, non-VT channels in VT patients had longer S-QRS (p = 0.02); however, they were similar in length, conduction time, and CV compared to channels in controls. CONCLUSIONS Channels supporting VT are lengthier, with longer conduction times and slower CV compared to channels in patients without spontaneous VT. These observations may explain why some ICM patients have spontaneous VT and others do not.
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Affiliation(s)
- Sachin Nayyar
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Level 5, McEwin Building, North Terrace, Adelaide, SA, 5000, Australia
| | - Lauren Wilson
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Level 5, McEwin Building, North Terrace, Adelaide, SA, 5000, Australia
| | - Anand Ganesan
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Level 5, McEwin Building, North Terrace, Adelaide, SA, 5000, Australia
| | - Thomas Sullivan
- School of Public Health, University of Adelaide, Adelaide, Australia
| | - Pawel Kuklik
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Level 5, McEwin Building, North Terrace, Adelaide, SA, 5000, Australia
| | - Glenn Young
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Level 5, McEwin Building, North Terrace, Adelaide, SA, 5000, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Level 5, McEwin Building, North Terrace, Adelaide, SA, 5000, Australia
| | - Kurt C Roberts-Thomson
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Level 5, McEwin Building, North Terrace, Adelaide, SA, 5000, Australia.
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Surgical treatment for endocardial radiofrequency ablation-resistant sustained monomorphic ventricular tachycardia with mural thrombus including dense calcification in the left ventricle. Gen Thorac Cardiovasc Surg 2017; 66:471-475. [PMID: 29188428 DOI: 10.1007/s11748-017-0853-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 10/19/2017] [Indexed: 12/26/2022]
Abstract
Catheter ablation provides effective results for sustained monomorphic ventricular tachycardia (VT), but the presence of mural thrombus including dense calcification occasionally causes unfavorable outcomes. The case of a 67-year-old man in whom sustained monomorphic VT, which was resistant to endocardial radiofrequency ablation, in the presence of mural thrombus including dense calcification after coronary artery bypass grafting was successfully treated by left ventricular reconstruction with cryoablation is reported.
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The Rapidly Evolving Concept of Whole Heart Engineering. Stem Cells Int 2017; 2017:8920940. [PMID: 29250121 PMCID: PMC5700515 DOI: 10.1155/2017/8920940] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 09/12/2017] [Indexed: 01/10/2023] Open
Abstract
Whole heart engineering represents an incredible journey with as final destination the challenging aim to solve end-stage cardiac failure with a biocompatible and living organ equivalent. Its evolution started in 2008 with rodent organs and is nowadays moving closer to clinical application thanks to scaling-up strategies to human hearts. This review will offer a comprehensive examination on the important stages to be reached for the bioengineering of the whole heart, by describing the approaches of organ decellularization, repopulation, and maturation so far applied and the novel technologies of potential interest. In addition, it will carefully address important demands that still need to be satisfied in order to move to a real clinical translation of the whole bioengineering heart concept.
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Nofi C, Bogatyryov Y, Dedkov EI. Preservation of Functional Microvascular Bed Is Vital for Long-Term Survival of Cardiac Myocytes Within Large Transmural Post-Myocardial Infarction Scar. J Histochem Cytochem 2017; 66:99-120. [PMID: 29116876 DOI: 10.1369/0022155417741640] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
This study was aimed to understand the mechanism of persistent cardiac myocyte (CM) survival in myocardial infarction (MI) scars. A transmural MI was induced in 12-month-old Sprague-Dawley rats by permanent coronary artery ligation. The hearts were collected 3 days, 1, 2, 4, 8, and 12 weeks after MI and evaluated with histology, immunohistochemistry, and quantitative morphometry. Vasculature patency was assessed in 4-, 8-, and 12-week-old scars by infusion of 15-micron microspheres into the left ventricle before euthanasia. The infarcted/scarred area has a small continually retained population of surviving CMs in subendocardial and subepicardial regions. Surprisingly, whereas the transverse area of subepicardial CMs remained relatively preserved or even enlarged over 12 post-MI weeks, subendocardial CMs underwent progressive atrophy. Nevertheless, the fractional volume of viable CMs remained comparable in mature scars 4, 8, and 12 weeks after MI (3.6 ± 0.4%, 3.4 ± 0.5%, and 2.5 ± 0.3%, respectively). Despite the opposite dynamics of changes in size, CMs of both regions displayed sarcomeres and gap junctions. Most importantly, surviving CMs were always accompanied by patent microvessels linked to a venous network composed of Thebesian veins, intramural sinusoids, and subepicardial veins. Our findings reveal that long-term survival of CMs in transmural post-MI scars is sustained by a local microcirculatory bed.
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Affiliation(s)
- Colleen Nofi
- Department of Biomedical Sciences, College of Osteopathic Medicine, New York Institute of Technology, Old Westbury, New York
| | - Yevgen Bogatyryov
- Department of Biomedical Sciences, College of Osteopathic Medicine, New York Institute of Technology, Old Westbury, New York
| | - Eduard I Dedkov
- Department of Biomedical Sciences, Cooper Medical School of Rowan University, Camden, New Jersey
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Samanta R, Kumar S, Chik W, Qian P, Barry MA, Al Raisi S, Bhaskaran A, Farraha M, Nadri F, Kizana E, Thiagalingam A, Kovoor P, Pouliopoulos J. Influence of Intramyocardial Adipose Tissue on the Accuracy of Endocardial Contact Mapping of the Chronic Myocardial Infarction Substrate. Circ Arrhythm Electrophysiol 2017; 10:CIRCEP.116.004998. [PMID: 29038101 DOI: 10.1161/circep.116.004998] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 08/17/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recent studies have demonstrated that intramyocardial adipose tissue (IMAT) may contribute to ventricular electrophysiological remodeling in patients with chronic myocardial infarction. Using an ovine model of myocardial infarction, we aimed to determine the influence of IMAT on scar tissue identification during endocardial contact mapping and optimal voltage-based mapping criteria for defining IMAT dense regions. METHOD AND RESULTS In 7 sheep, left ventricular endocardial and transmural mapping was performed 84 weeks (15-111 weeks) post-myocardial infarction. Spearman rank correlation coefficient was used to assess the relationship between endocardial contact electrogram amplitude and histological composition of myocardium. Receiver operator characteristic curves were used to derive optimal electrogram thresholds for IMAT delineation during endocardial mapping and to describe the use of endocardial mapping for delineation of IMAT dense regions within scar. Endocardial electrogram amplitude correlated significantly with IMAT (unipolar r=-0.48±0.12, P<0.001; bipolar r=-0.45±0.22, P=0.04) but not collagen (unipolar r=-0.36±0.24, P=0.13; bipolar r=-0.43±0.31, P=0.16). IMAT dense regions of myocardium reliably identified using endocardial mapping with thresholds of <3.7 and <0.6 mV, respectively, for unipolar, bipolar, and combined modalities (single modality area under the curve=0.80, P<0.001; combined modality area under the curve=0.84, P<0.001). Unipolar mapping using optimal thresholding remained significantly reliable (area under the curve=0.76, P<0.001) during mapping of IMAT, confined to putative scar border zones (bipolar amplitude, 0.5-1.5 mV). CONCLUSIONS These novel findings enhance our understanding of the confounding influence of IMAT on endocardial scar mapping. Combined bipolar and unipolar voltage mapping using optimal thresholds may be useful for delineating IMAT dense regions of myocardium, in postinfarct cardiomyopathy.
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Affiliation(s)
- Rahul Samanta
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Saurabh Kumar
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - William Chik
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Pierre Qian
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Michael A Barry
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Sara Al Raisi
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Abhishek Bhaskaran
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Melad Farraha
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Fazlur Nadri
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Eddy Kizana
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Aravinda Thiagalingam
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Pramesh Kovoor
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.)
| | - Jim Pouliopoulos
- From the Department of Cardiology, Westmead Hospital, New South Wales, Australia (R.S., S.K., W.C., P.Q., M.A.B., S.A.R., A.B., F.N., E.K., A.T., P.K., J.P.); and Sydney Medical School, University of Sydney, Australia (R.S., W.C., S.A.R., A.B., M.F., E.K., A.T., P.K., J.P.).
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45
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Jacobson JT, Iwai S, Aronow WS. Treatment of Ventricular Arrhythmias and Use of Implantable Cardioverter-Defibrillators to Improve Survival in Older Adult Patients with Cardiac Disease. Heart Fail Clin 2017; 13:589-605. [PMID: 28602374 DOI: 10.1016/j.hfc.2017.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Ventricular arrhythmia (VA) and sudden cardiac death (SCD) are well-recognized problems in the overall heart failure population, but treatment decisions can be more complex and nuanced in older patients. Sustained VA does not always lead to SCD, but identifies a higher risk population and may cause significant symptoms. Antiarrhythmic drugs (AAD) and catheter ablation are the mainstays for prevention of VA, but have not been shown to improve mortality. The value of implantable cardiac defibrillators (ICDs) may be influenced by patient age. This article discusses long-term treatment of VA and the use of ICDs in the elderly.
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Affiliation(s)
- Jason T Jacobson
- Division of Cardiology, Department of Medicine, Westchester Medical Center, New York Medical College, Macy Pavilion, 100 Woods Road, Valhalla, NY 10595, USA
| | - Sei Iwai
- Division of Cardiology, Department of Medicine, Westchester Medical Center, New York Medical College, Macy Pavilion, 100 Woods Road, Valhalla, NY 10595, USA
| | - Wilbert S Aronow
- Division of Cardiology, Department of Medicine, Westchester Medical Center, New York Medical College, Macy Pavilion, 100 Woods Road, Valhalla, NY 10595, USA.
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46
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Halliday BP, Gulati A, Ali A, Guha K, Newsome S, Arzanauskaite M, Vassiliou VS, Lota A, Izgi C, Tayal U, Khalique Z, Stirrat C, Auger D, Pareek N, Ismail TF, Rosen SD, Vazir A, Alpendurada F, Gregson J, Frenneaux MP, Cowie MR, Cleland JGF, Cook SA, Pennell DJ, Prasad SK. Association Between Midwall Late Gadolinium Enhancement and Sudden Cardiac Death in Patients With Dilated Cardiomyopathy and Mild and Moderate Left Ventricular Systolic Dysfunction. Circulation 2017; 135:2106-2115. [PMID: 28351901 PMCID: PMC5444425 DOI: 10.1161/circulationaha.116.026910] [Citation(s) in RCA: 244] [Impact Index Per Article: 34.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 03/13/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Current guidelines only recommend the use of an implantable cardioverter defibrillator in patients with dilated cardiomyopathy for the primary prevention of sudden cardiac death (SCD) in those with a left ventricular ejection fraction (LVEF) <35%. However, registries of out-of-hospital cardiac arrests demonstrate that 70% to 80% of such patients have an LVEF >35%. Patients with an LVEF >35% also have low competing risks of death from nonsudden causes. Therefore, those at high risk of SCD may gain longevity from successful implantable cardioverter defibrillator therapy. We investigated whether late gadolinium enhancement (LGE) cardiovascular magnetic resonance identified patients with dilated cardiomyopathy without severe LV systolic dysfunction at high risk of SCD. METHODS We prospectively investigated the association between midwall LGE and the prespecified primary composite outcome of SCD or aborted SCD among consecutive referrals with dilated cardiomyopathy and an LVEF ≥40% to our center between January 2000 and December 2011 who did not have a preexisting indication for implantable cardioverter defibrillator implantation. RESULTS Of 399 patients (145 women, median age 50 years, median LVEF 50%, 25.3% with LGE) followed for a median of 4.6 years, 18 of 101 (17.8%) patients with LGE reached the prespecified end point, compared with 7 of 298 (2.3%) without (hazard ratio [HR], 9.2; 95% confidence interval [CI], 3.9-21.8; P<0.0001). Nine patients (8.9%) with LGE compared with 6 (2.0%) without (HR, 4.9; 95% CI, 1.8-13.5; P=0.002) died suddenly, whereas 10 patients (9.9%) with LGE compared with 1 patient (0.3%) without (HR, 34.8; 95% CI, 4.6-266.6; P<0.001) had aborted SCD. After adjustment, LGE predicted the composite end point (HR, 9.3; 95% CI, 3.9-22.3; P<0.0001), SCD (HR, 4.8; 95% CI, 1.7-13.8; P=0.003), and aborted SCD (HR, 35.9; 95% CI, 4.8-271.4; P<0.001). Estimated HRs for the primary end point for patients with an LGE extent of 0% to 2.5%, 2.5% to 5%, and >5% compared with those without LGE were 10.6 (95% CI, 3.9-29.4), 4.9 (95% CI, 1.3-18.9), and 11.8 (95% CI, 4.3-32.3), respectively. CONCLUSIONS Midwall LGE identifies a group of patients with dilated cardiomyopathy and an LVEF ≥40% at increased risk of SCD and low risk of nonsudden death who may benefit from implantable cardioverter defibrillator implantation. CLINICAL TRIAL REGISTRATION URL: http://clinicaltrials.gov. Unique identifier: NCT00930735.
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MESH Headings
- Adult
- Aged
- Cardiomyopathy, Dilated/diagnostic imaging
- Cardiomyopathy, Dilated/epidemiology
- Cardiomyopathy, Dilated/mortality
- Death, Sudden, Cardiac/pathology
- Endothelium, Vascular/diagnostic imaging
- Female
- Follow-Up Studies
- Gadolinium/administration & dosage
- Humans
- Magnetic Resonance Imaging, Cine
- Male
- Middle Aged
- Prospective Studies
- Risk Factors
- Stroke Volume/physiology
- Ventricular Dysfunction, Left/diagnostic imaging
- Ventricular Dysfunction, Left/epidemiology
- Ventricular Dysfunction, Left/mortality
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Affiliation(s)
- Brian P Halliday
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - Ankur Gulati
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - Aamir Ali
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - Kaushik Guha
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - Simon Newsome
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - Monika Arzanauskaite
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - Vassilios S Vassiliou
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - Amrit Lota
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - Cemil Izgi
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - Upasana Tayal
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - Zohya Khalique
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - Colin Stirrat
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - Dominique Auger
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - Nilesh Pareek
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - Tevfik F Ismail
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - Stuart D Rosen
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - Ali Vazir
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - Francisco Alpendurada
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - John Gregson
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - Michael P Frenneaux
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - Martin R Cowie
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - John G F Cleland
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - Stuart A Cook
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
| | - Dudley J Pennell
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.).
| | - Sanjay K Prasad
- From National Institute for Health Research Cardiovascular Biomedical Research Unit and Cardiovascular Magnetic Resonance Unit (B.P.H., A.G., A.A., M.A., V.S.V., A.L. C.I., U.T. Z.K., D.A., F.A., J.G.F.C., S.A.C., D.J.P., S.K.P.), Department of Cardiology (K.G., N.P., S.D.R., A.V., M.R.C.), Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom (B.P.H., A.A., K.G., V.S.V., A.L., U.T., S.D.R., A.V., F.A., M.R.C., J.G.F.C., S.A.C., D.J.P., S.K.P.); London School of Hygiene and Tropical Medicine, United Kingdom (S.N., J.G.); Norwich Medical School, University of East Anglia, United Kingdom (V.S.V., M.P.F); Centre for Cardiovascular Science, University of Edinburgh, United Kingdom (C.S.); King's College London and Department of Cardiology, Guy's and St Thomas' Hospital, London, United Kingdom (T.F.I.); Department of Cardiology, Ealing Hospital, London, United Kingdom (S.D.R.); and National Heart Centre Singapore (S.A.C.)
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Applications of Advanced Imaging in Cardiac Electrophysiology. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:66. [DOI: 10.1007/s11936-016-0491-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Jacobson JT, Iwai S, Aronow W. Medical therapy to prevent recurrence of ventricular arrhythmia in normal and structural heart disease patients. Expert Rev Cardiovasc Ther 2016; 14:1251-1262. [PMID: 27494263 DOI: 10.1080/14779072.2016.1221342] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Recurrent ventricular arrhythmias (VA) are a source of significant morbidity in patients without structural heart disease (SHD) and also mortality in patients with SHD. The treatment goals for these two patient populations differ greatly. Areas covered: The secondary prevention of recurrent VA in patients without and with SHD will be reviewed, focusing on clinical data (especially randomized, controlled trials) in the literature as determined through searches in PubMed and ClinicalTrials.gov. This will include β blockers, non-dihydropyridine calcium channel blockers and antiarrhythmic drugs in both subgroups and non-antiarrhythmic medications in SHD. Expert commentary: The available options for medical therapy for VA in both normal hearts and SHD are insufficient, due to substandard efficacy and toxicities. While non-pharmacologic therapies may provide an excellent option, further drug development and randomized trials are needed, as is a reappraisal of the current mode of utilization.
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Affiliation(s)
- Jason T Jacobson
- a Division of Cardiology, Department of Medicine, Westchester Medical Center , New York Medical College , Valhalla , NY , USA
| | - Sei Iwai
- a Division of Cardiology, Department of Medicine, Westchester Medical Center , New York Medical College , Valhalla , NY , USA
| | - Wilbert Aronow
- a Division of Cardiology, Department of Medicine, Westchester Medical Center , New York Medical College , Valhalla , NY , USA
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Garabelli P, Stavrakis S, Po SS. Ablation of Ventricular Tachycardia in Patients with Ischemic Cardiomyopathy. Card Electrophysiol Clin 2016; 8:121-9. [PMID: 26920180 DOI: 10.1016/j.ccep.2015.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Ventricular tachycardias (VTs) occurring after prior myocardial infarction are usually caused by reentrant circuits formed by surviving myocardial bundles. Although part of the reentrant circuits may be located in the midmyocardium or epicardium, most of the VTs can be safely and successfully ablated by endocardial ablation targeting the late potentials/local abnormal ventricular activation, which are surrogates for the surviving myocardial bundles. A combination of activation, substrate, pace, and entrainment mapping, as well as the use of contact force catheters, further improves ablation success and safety.
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Affiliation(s)
- Paul Garabelli
- Department of Medicine, Heart Rhythm Institute, University of Oklahoma Health Sciences Center, 1200 Everett Drive, Oklahoma City, OK 73104, USA
| | - Stavros Stavrakis
- Department of Medicine, Heart Rhythm Institute, University of Oklahoma Health Sciences Center, 1200 Everett Drive, Oklahoma City, OK 73104, USA
| | - Sunny S Po
- Department of Medicine, Heart Rhythm Institute, University of Oklahoma Health Sciences Center, 1200 Everett Drive, Oklahoma City, OK 73104, USA.
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50
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Gouadon E, Moore-Morris T, Smit NW, Chatenoud L, Coronel R, Harding SE, Jourdon P, Lambert V, Rucker-Martin C, Pucéat M. Concise Review: Pluripotent Stem Cell-Derived Cardiac Cells, A Promising Cell Source for Therapy of Heart Failure: Where Do We Stand? Stem Cells 2016; 34:34-43. [PMID: 26352327 DOI: 10.1002/stem.2205] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 08/24/2015] [Indexed: 12/29/2022]
Abstract
Heart failure is still a major cause of hospitalization and mortality in developed countries. Many clinical trials have tested the use of multipotent stem cells as a cardiac regenerative medicine. The benefit for the patients of this therapeutic intervention has remained limited. Herein, we review the pluripotent stem cells as a cell source for cardiac regeneration. We more specifically address the various challenges of this cell therapy approach. We question the cell delivery systems, the immune tolerance of allogenic cells, the potential proarrhythmic effects, various drug mediated interventions to facilitate cell grafting and, finally, we describe the pathological conditions that may benefit from such an innovative approach. As members of a transatlantic consortium of excellence of basic science researchers and clinicians, we propose some guidelines to be applied to cell types and modes of delivery in order to translate pluripotent stem cell cardiac derivatives into safe and effective clinical trials.
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Affiliation(s)
- Elodie Gouadon
- INSERM UMR-S999, LabEx LERMIT, IPSIT Centre Chirurgical Marie Lanelongue, Le Plessis Robinson, Paris, France
| | | | - Nicoline W Smit
- Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, Amsterdam, The Netherlands
| | - Lucienne Chatenoud
- INSERM U1151, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Ruben Coronel
- Department of Clinical and Experimental Cardiology, Academic Medical Center, Amsterdam, Amsterdam, The Netherlands
| | | | - Philippe Jourdon
- INSERM UMR-S999, LabEx LERMIT, IPSIT Centre Chirurgical Marie Lanelongue, Le Plessis Robinson, Paris, France
| | - Virginie Lambert
- INSERM UMR-S999, LabEx LERMIT, IPSIT Centre Chirurgical Marie Lanelongue, Le Plessis Robinson, Paris, France
| | - Catherine Rucker-Martin
- INSERM UMR-S999, LabEx LERMIT, IPSIT Centre Chirurgical Marie Lanelongue, Le Plessis Robinson, Paris, France
| | - Michel Pucéat
- INSERM GMGF, a UMRS_910, Université Aix Marseille, Marseille, France
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