1
|
Burger JC, Hopman LHGA, Kemme MJB, Hoeksema W, Takx RAP, Figueras I Ventura RM, Campos FO, Plank G, Planken RN, Allaart CP, van Halm VP, Postema PG, Götte MJW, Bishop MJ, Bhagirath P. Optimizing ventricular tachycardia ablation through imaging-based assessment of arrhythmic substrate: A comprehensive review and roadmap for the future. Heart Rhythm O2 2024; 5:561-572. [PMID: 39263615 PMCID: PMC11385403 DOI: 10.1016/j.hroo.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2024] Open
Abstract
Ventricular tachycardia (VT) is a life-threatening heart rhythm and has long posed a complex challenge in the field of cardiology. Recent developments in advanced imaging modalities have aimed to improve comprehension of underlying arrhythmic substrate for VT. To this extent, high-resolution cardiac magnetic resonance (CMR) and cardiac computed tomography (CCT) have emerged as tools for accurately visualizing and characterizing scar tissue, fibrosis, and other critical structural abnormalities within the heart, providing novel insights into VT triggers and substrate. However, clinical implementation of knowledge derived from these advanced imaging techniques in improving VT treatment and guiding invasive therapeutic strategies continues to pose significant challenges. A pivotal concern lies in the absence of standardized imaging protocols and analysis methodologies, resulting in a large variance in data quality and consistency. Furthermore, the clinical significance and outcomes associated with VT substrate characterization through CMR and CCT remain dynamic and subject to ongoing evolution. This highlights the need for refinement of these techniques before their reliable integration into routine patient care can be realized. The primary objectives of this study are twofold: firstly, to provide a comprehensive overview of the studies conducted over the last 15 years, summarizing the current available literature on imaging-based assessment of VT substrate. Secondly, to critically analyze and evaluate the selected studies, with the aim of providing valuable insights that can inform current clinical practice and future research.
Collapse
Affiliation(s)
- Janneke C Burger
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Luuk H G A Hopman
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Michiel J B Kemme
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Wiert Hoeksema
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Richard A P Takx
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Fernando O Campos
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Gernot Plank
- Gottfried Schatz Research Center, Division of Biophysics, Medical University of Graz, Graz, Austria
| | - R Nils Planken
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Cornelis P Allaart
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Vokko P van Halm
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Pieter G Postema
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Marco J W Götte
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Martin J Bishop
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Pranav Bhagirath
- Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| |
Collapse
|
2
|
Haberl C, Crean AM, Zelt JGE, Redpath CJ, deKemp RA. Role of Nuclear Imaging in Cardiac Stereotactic Body Radiotherapy for Ablation of Ventricular Tachycardia. Semin Nucl Med 2024; 54:427-437. [PMID: 38658301 DOI: 10.1053/j.semnuclmed.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 04/26/2024]
Abstract
Ventricular tachycardia (VT) is a life-threatening arrhythmia common in patients with structural heart disease or nonischemic cardiomyopathy. Many VTs originate from regions of fibrotic scar tissue, where delayed electrical signals exit scar and re-enter viable myocardium. Cardiac stereotactic body radiotherapy (SBRT) has emerged as a completely noninvasive alternative to catheter ablation for the treatment of recurrent or refractory ventricular tachycardia. While there is no common consensus on the ideal imaging workflow, therapy planning for cardiac SBRT often combines information from a plurality of imaging modalities including MRI, CT, electroanatomic mapping and nuclear imaging. MRI and CT provide detailed anatomic information, and late enhancement contrast imaging can indicate regions of fibrosis. Electroanatomic maps indicate regions of heterogenous conduction voltage or early activation which are indicative of arrhythmogenic tissue. Some early clinical adopters performing cardiac SBRT report the use of myocardial perfusion and viability nuclear imaging to identify regions of scar. Nuclear imaging of hibernating myocardium, inflammation and sympathetic innervation have been studied for ventricular arrhythmia prognosis and in research relating to catheter ablation of VT but have yet to be studied in their potential applications for cardiac SBRT. The integration of information from these many imaging modalities to identify a target for ablation can be challenging. Multimodality image registration and dedicated therapy planning tools may enable higher target accuracy, accelerate therapy planning workflows and improve patient outcomes. Understanding the pathophysiology of ventricular arrhythmias, and localizing the arrhythmogenic tissues, is vital for successful ablation with cardiac SBRT. Nuclear imaging provides an arsenal of imaging strategies to identify regional scar, hibernation, inflammation, and sympathetic denervation with some advantages over alternative imaging strategies.
Collapse
Affiliation(s)
- Connor Haberl
- University of Ottawa Heart Institute, Ottawa, ON; Carleton University, Ottawa, ON
| | - Andrew M Crean
- University of Ottawa Heart Institute, Ottawa, ON; North West Heart Center, University of Manchester Foundation NHS Trust, Manchester, UK
| | - Jason G E Zelt
- The Ottawa Hospital, Ottawa, ON; Department of Medicine, University of Ottawa, Ottawa, ON
| | | | | |
Collapse
|
3
|
Vázquez-Calvo S, Roca-Luque I, Althoff TF. Management of Ventricular Arrhythmias in Heart Failure. Curr Heart Fail Rep 2023; 20:237-253. [PMID: 37227669 DOI: 10.1007/s11897-023-00608-y] [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] [Accepted: 05/08/2023] [Indexed: 05/26/2023]
Abstract
PURPOSE OF REVIEW Despite substantial progress in medical and device-based heart failure (HF) therapy, ventricular arrhythmias (VA) and sudden cardiac death (SCD) remain a major challenge. Here we review contemporary management of VA in the context of HF with one particular focus on recent advances in imaging and catheter ablation. RECENT FINDINGS Besides limited efficacy of antiarrhythmic drugs (AADs), their potentially life-threatening side effects are increasingly acknowledged. On the other hand, with tremendous advances in catheter technology, electroanatomical mapping, imaging, and understanding of arrhythmia mechanisms, catheter ablation has evolved into a safe, efficacious therapy. In fact, recent randomized trials support early catheter ablation, demonstrating superiority over AAD. Importantly, CMR imaging with gadolinium contrast has emerged as a central tool for the management of VA complicating HF: CMR is not only essential for an accurate diagnosis of the underlying entity and subsequent treatment decisions, but also improves risk stratification for SCD prevention and patient selection for ICD therapy. Finally, 3-dimensional characterization of arrhythmogenic substrate by CMR and imaging-guided ablation approaches substantially enhance procedural safety and efficacy. VA management in HF patients is highly complex and should be addressed in a multidisciplinary approach, preferably at specialized centers. While recent evidence supports early catheter ablation of VA, an impact on mortality remains to be demonstrated. Moreover, risk stratification for ICD therapy may have to be reconsidered, taking into account imaging, genetic testing, and other parameters beyond left ventricular function.
Collapse
Affiliation(s)
- Sara Vázquez-Calvo
- Arrhythmia Section, Cardiovascular Institute (ICCV), CLÍNIC Barcelona University Hospital, C/Villarroel N° 170, 08036, Barcelona, Catalonia, Spain
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Ivo Roca-Luque
- Arrhythmia Section, Cardiovascular Institute (ICCV), CLÍNIC Barcelona University Hospital, C/Villarroel N° 170, 08036, Barcelona, Catalonia, Spain
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Till F Althoff
- Arrhythmia Section, Cardiovascular Institute (ICCV), CLÍNIC Barcelona University Hospital, C/Villarroel N° 170, 08036, Barcelona, Catalonia, Spain.
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.
| |
Collapse
|
4
|
Atreya AR, Yalagudri SD, Subramanian M, Rangaswamy VV, Saggu DK, Narasimhan C. Best Practices for the Catheter Ablation of Ventricular Arrhythmias. Card Electrophysiol Clin 2022; 14:571-607. [PMID: 36396179 DOI: 10.1016/j.ccep.2022.08.007] [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] [Indexed: 06/16/2023]
Abstract
Techniques for catheter ablation have evolved to effectively treat a range of ventricular arrhythmias. Pre-operative electrocardiographic and cardiac imaging data are very useful in understanding the arrhythmogenic substrate and can guide mapping and ablation. In this review, we focus on best practices for catheter ablation, with emphasis on tailoring ablation strategies, based on the presence or absence of structural heart disease, underlying clinical status, and hemodynamic stability of the ventricular arrhythmia. We discuss steps to make ablation safe and prevent complications, and techniques to improve the efficacy of ablation, including optimal use of electroanatomical mapping algorithms, energy delivery, intracardiac echocardiography, and selective use of mechanical circulatory support.
Collapse
Affiliation(s)
- Auras R Atreya
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India; Division of Cardiovascular Medicine, Electrophysiology Section, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sachin D Yalagudri
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India
| | - Muthiah Subramanian
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India
| | | | - Daljeet Kaur Saggu
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India
| | - Calambur Narasimhan
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India.
| |
Collapse
|
5
|
Kattel S, Enriquez AD. Contemporary approach to catheter ablation of ventricular tachycardia in nonischemic cardiomyopathy. J Interv Card Electrophysiol 2022; 66:793-805. [PMID: 36056222 DOI: 10.1007/s10840-022-01363-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 08/29/2022] [Indexed: 11/30/2022]
Abstract
Nonischemic cardiomyopathy (NICM) comprises a heterogenous group of disorders with myocardial dysfunction unrelated to significant coronary disease. As the use of implantable defibrillators has increased in this patient population, catheter ablation is being utilized more frequently to treat NICM patients with ventricular tachycardia (VT). Progress has been made in identifying multiple subtypes of NICM with variable scar patterns. The distribution of scar is often mid-myocardial and subepicardial, and identifying and ablating this substrate can be challenging. Here, we will review the current understanding of NICM subtypes and the outcomes of VT ablation in this population. We will discuss the use of cardiac imaging, electrocardiography, and electroanatomic mapping to define the VT substrate and the ablation techniques required to successfully prevent VT recurrence.
Collapse
Affiliation(s)
- Sharma Kattel
- Cardiovascular Medicine, Yale University School of Medicine, PO Box 208017, New Haven, CT, 06520-8017, USA
| | - Alan D Enriquez
- Cardiovascular Medicine, Yale University School of Medicine, PO Box 208017, New Haven, CT, 06520-8017, USA.
| |
Collapse
|
6
|
Richardson TD, Stevenson WG. High Density Pace-Mapping for Scar-related Ventricular Tachycardia Ablation. J Cardiovasc Electrophysiol 2022; 33:1810-1812. [PMID: 35665563 DOI: 10.1111/jce.15585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 05/26/2022] [Indexed: 11/28/2022]
Abstract
Despite advances in medical and interventional therapies, ventricular tachycardia (VT) due to reentrant activity within complex regions of myocardial scar remains a common late complication of myocardial infarction This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Travis D Richardson
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - William G Stevenson
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| |
Collapse
|
7
|
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.
Collapse
|