Newer Methods for VT Ablation and When to Use Them

Relationship Between Epicardial Adipose Tissue Volume and Recurrence After Ablation in Premature Ventricular Complexes

BACKGROUND

Epicardial adipose tissue (EAT) is recognized as a clinical diagnostic marker for cardiometabolic disease. Thicker EAT may be associated with recurrence of ventricular tachycardia after ablation. The association between EAT volume and recurrence of premature ventricular complexes (PVC) following ablation has not been clarified. We investigated the association between EAT volume and PVC recurrence following radiofrequency catheter ablation.Methods and Results: This retrospective study included 401 patients with PVC undergoing catheter ablation with preprocedural non-contrast computed tomography between 2017 and 2022. The impact of EAT volume in predicting PVC recurrence after ablation was analyzed. The mean (±SD) age of patients was 50.2±13.3 years. Multivariable Cox analysis revealed that a large EAT volume was an independent predictor of PVC recurrence after ablation during a median follow-up of 16.3 months. Kaplan-Meier analysis showed a difference in postablation PVC recurrence between the 2 groups dichotomized around the EAT volume cut-off. The risk of recurrence increased with increasing EAT volume according to restricted cubic spline regression. Furthermore, PVC originating from epicardial locations had larger EAT volumes than those originating from the right ventricular outflow tract.

CONCLUSIONS

A large EAT volume was independently associated with PVC recurrence following ablation. Patients with PVC originating from epicardial sites had large EAT volumes. EAT volume may help stratify patients according to their risk of PVC recurrence after ablation.

Ultra-Low-Temperature Cryoablation for Ventricular Tachycardia: An Early Single-Centre Report of Acute Results

Background

Endocardial catheter ablation for ventricular tachycardia (VT) may fail because of the inability to deliver transmural lesions. Ultra-low-temperature cryoablation (ULTC) uses near-critical nitrogen and can generate temperatures as low as -196 °C. We report a series of 18 patients who underwent ULTC at the McGill University Health Centre (MUHC), representing the largest single-centre experience to date.

Methods

Eighteen patients with monomorphic drug-refractory VT underwent VT ablation with ULTC at our institution as part of the first-in-human CryoCure-VT trial (NCT04893317). After voltage map, the mapping catheter was replaced with the ULTC catheter, and lesions were applied over a fixed duration of time (60-180 seconds), followed by a 60-second thaw and another application at the original duration (freeze-thaw-freeze). Duration of ablation time was selected depending on the wall thickness of the left ventricle monitored with intracardiac echo to achieve tissue depths of 4.5 to 7.5 mm.

Results

Baseline left ventricular ejection fraction was 32%, mean age 71 years, 94% were male. A total of 32 sustained VTs were induced in 16 of 18 patients. A total of 177 cryoablation lesions were delivered (9.8 lesions per patient). Of the 16 patients with inducible VT, 15 (94%) were rendered noninducible postablation, and 1 was inducible only for a nonclinical VT. Complications included 1 pericardial effusion that required drainage. From 18 patients, 16 (89%) were discharged within the first 24 hours postablation.

Conclusions

ULTC is feasible and permits acute control of monomorphic VT during VT ablation procedures in drug-refractory patients.

Role of activation signatures in re-entrant ventricular tachycardia circuits

INTRODUCTION

Development of a rapid means to verify the ventricular tachycardia (VT) isthmus location from heart surface electrogram recordings would be a helpful tool for the electrophysiologist.

METHOD

Myocardial infarction was induced in 22 canines by left anterior descending coronary artery ligation under general anesthesia. After 3-5 days, VT was inducible via programmed electrical stimulation at the anterior left ventricular epicardial surface. Bipolar VT electrograms were acquired from 196 to 312 recording sites using a multielectrode array. Electrograms were marked for activation time, and activation maps were constructed. The activation signal, or signature, is defined as the cumulative number of recording sites that have activated per millisecond, and it was utilized to segment each circuit into inner and outer circuit pathways, and as an estimate of best ablation lesion location to prevent VT.

RESULTS

VT circuit components were differentiable by activation signals as: inner pathway (mean: 0.30 sites activating/ms) and outer pathway (mean: 2.68 sites activating/ms). These variables were linearly related (p < .001). Activation signal characteristics were dependent in part upon the isthmus exit site. The inner circuit pathway determined by the activation signal overlapped and often extended beyond the activation map isthmus location for each circuit. The best lesion location estimated by the activation signal would likely block an electrical impulse traveling through the isthmus, to prevent VT in all circuits.

CONCLUSIONS

The activation signal algorithm, simple to implement for real-time computer display, approximates the VT isthmus location and shape as determined from activation marking, and best ablation lesion location to prevent reinduction.

Evaluation of Saline-Enhanced Radiofrequency Needle-Tip Ablation for Ventricular Tachycardia (SERF VT CANADA Trial)

BACKGROUND

Endocardial catheter ablation for ventricular tachycardia (VT) may fail owing to the inability to deliver transmural lesions. Saline-enhanced radiofrequency (SERF) ablation uses a needle-tip catheter that is placed at varying depths into the myocardial tissue and heated saline solution is injected along with radiofrequency power (RF), creating fully transmural lesions. We report the first in-human SERF ablation for VT in Canada.

METHODS

Twenty-five patients with ischemic and nonischemic cardiomyopathy, with recurrent monomorphic drug-refractory VT who had failed a prior catheter ablation underwent SERF ablation in 3 different centres in Canada. After a voltage map, the mapping catheter was replaced with the needle-tipped ablation catheter, which was located perpendicular to the myocardium and extended either 6 or 8 mm into the tissue. Sterile saline solution was infused at a flow rate of 10 mL/min and at 60 °C, and 20-50 W RF was used.

RESULTS

Baseline left ventricular ejection fraction was 33.3 ± 8.6%, mean age was 69.5 ± 6.4 years; 92% were male. From 43 clinical VTs induced, 42 were ablated and 266 SERF lesions were delivered (10.6 ± 4.9 per patient). Of the 42 treated clinical VTs, 41 VTs (98%) were noninducible and 24 patients (96%) had their VT eliminated. At 6 months' follow-up, 42% of patients were free from VT and there was a 73% reduction in shocks.

CONCLUSIONS

SERF ablation is feasible and permits control of symptomatic monomorphic VT in drug-refractory patients with a prior failed ablation.