1
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Raad M, Supple GE. Epicardial Ventricular Tachycardia Ablation: Patient Selection, Access, and Ablation Techniques and Strategies to Manage Complications. JACC Clin Electrophysiol 2024; 10:142-164. [PMID: 37921791 DOI: 10.1016/j.jacep.2023.09.007] [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] [Received: 07/02/2023] [Revised: 08/21/2023] [Accepted: 09/08/2023] [Indexed: 11/04/2023]
Abstract
Epicardial ventricular tachycardia ablation is an important treatment modality for refractory ventricular tachycardia. This comprehensive review guides clinicians through optimized strategies for improved procedural outcomes and patient safety during epicardial ventricular tachycardia ablation. Patient selection criteria, including cardiomyopathy type, electrocardiogram findings, and prior ablation history, are discussed. Detailed techniques for safe pericardial access are provided. Potential complications and strategies for prevention and management are explored. The review also addresses challenges and pitfalls of epicardial mapping and ablation.
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Affiliation(s)
- Mohamad Raad
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory E Supple
- Electrophysiology Section, Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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2
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Deshmukh A, Romano MA, Oral H. Hybrid ventricular tachycardia ablation: Choosing the right tool for the job. Heart Rhythm 2023; 20:1718-1719. [PMID: 37774775 DOI: 10.1016/j.hrthm.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 10/01/2023]
Affiliation(s)
- Amrish Deshmukh
- Cardiac Arrhythmia Service, University of Michigan, Ann Arbor, Michigan
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Hakan Oral
- Cardiac Arrhythmia Service, University of Michigan, Ann Arbor, Michigan.
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3
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Serra F, Philpott JM, Neuber JU, Shih E, Etheridge JC, Varghese F, Rushing GD, Zemlin CW. Nanosecond Pulsed Electric Field Ablation With a Bipolar Clamp Creates Durable Transmural Lesions in Cardiac Tissue. Circ Arrhythm Electrophysiol 2023; 16:e012300. [PMID: 37920983 DOI: 10.1161/circep.123.012300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Affiliation(s)
- Federica Serra
- Department of Electrical and Computer Engineering (F.S., J.U.N., F.V., C.W.Z.), Old Dominion University, Norfolk, VA
- Center for Bioelectrics (F.S., J.U.N., F.V., C.W.Z.), Old Dominion University, Norfolk, VA
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (F.S., C.W.Z.)
| | - Jonathan M Philpott
- Moanalua Medical Center, Department of Cardiothoracic Surgery, Honolulu, HI (J.M.P.)
- Department of Surgery, Eastern Virginia Medical School, Norfolk (J.M.P., E.S., J.C.E.)
| | - Johanna U Neuber
- Department of Electrical and Computer Engineering (F.S., J.U.N., F.V., C.W.Z.), Old Dominion University, Norfolk, VA
- Center for Bioelectrics (F.S., J.U.N., F.V., C.W.Z.), Old Dominion University, Norfolk, VA
| | - Emily Shih
- Mid-Atlantic Thoracic Surgeons, Sentara Heart Hospital, Norfolk, VA (J.M.P.)
- Department of General Surgery, University Hospitals, Baylor University Medical Center, Dallas, TX (E.S.)
- Department of Surgery, Eastern Virginia Medical School, Norfolk (J.M.P., E.S., J.C.E.)
| | - James C Etheridge
- Department of Surgery, Eastern Virginia Medical School, Norfolk (J.M.P., E.S., J.C.E.)
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (J.C.E.)
| | - Frency Varghese
- Department of Electrical and Computer Engineering (F.S., J.U.N., F.V., C.W.Z.), Old Dominion University, Norfolk, VA
- Center for Bioelectrics (F.S., J.U.N., F.V., C.W.Z.), Old Dominion University, Norfolk, VA
| | - Gregory D Rushing
- Division of Cardiac Surgery, University Hospitals, Case Western Reserve University School of Medicine, Cleveland, OH (G.D.R.)
| | - Christian W Zemlin
- Department of Electrical and Computer Engineering (F.S., J.U.N., F.V., C.W.Z.), Old Dominion University, Norfolk, VA
- Center for Bioelectrics (F.S., J.U.N., F.V., C.W.Z.), Old Dominion University, Norfolk, VA
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO (F.S., C.W.Z.)
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4
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Open chest ablation of a right anterior epicardial accessory pathway. HeartRhythm Case Rep 2023. [DOI: 10.1016/j.hrcr.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023] Open
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5
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Nakagawa H, Ikeda A, Yokoyama K, An Y, Hussein AA, Saliba WI, Wazni OM, Castellvi Q. Improvement in Lesion Formation with Radiofrequency Energy and Utilization of Alternate Energy Sources (Cryoablation and Pulsed Field Ablation) for Ventricular Arrhythmia Ablation. Card Electrophysiol Clin 2022; 14:757-767. [PMID: 36396191 DOI: 10.1016/j.ccep.2022.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Current ablation systems rely on thermal energy to produce ablation lesions (heating: RF, laser and ultrasound, and cooling: cryo-thermia). While thermal ablation has been proven to be effective, there are several limitations: 1) relatively long procedural times; 2) high recurrence rate of ventricular arrhythmias; and 3) excessive heating potentially leading to serious complications, including steam pop (perforation), coronary arterial injury and thrombo-embolism. Pulsed field ablation (PFA)/irreversible electroporation (IRE) offers a unique non-thermal ablation strategy which has the potential to overcome these limitations. Recent pre-clinical studies suggest that PFA/IRE might be effective and safe for the treatment of cardiac arrhythmias.
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Affiliation(s)
- Hiroshi Nakagawa
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA.
| | - Atsushi Ikeda
- Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Katsuaki Yokoyama
- Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yoshimori An
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Ayman A Hussein
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Walid I Saliba
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Oussama M Wazni
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Quim Castellvi
- Department of Information and Communications Technologies, Pompeu Fabra University, Barcelona, Spain
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6
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Higuchi S, Im SI, Stillson C, Buck ED, Jerrell S, Schneider CW, Speltz M, Gerstenfeld EP. Effect of Epicardial Pulsed Field Ablation Directly on Coronary Arteries. JACC Clin Electrophysiol 2022; 8:1486-1496. [PMID: 36779624 DOI: 10.1016/j.jacep.2022.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/10/2022] [Accepted: 09/07/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND The unique tissue selectivity of pulsed field ablation (PFA) allows for minimizing collateral damage to the nerves/esophagus. However, the safety profile of epicardial PFA on coronary arteries (CAs) has not been well defined. OBJECTIVES This study sought to evaluate the effect of epicardial PFA directly on CAs in a swine model. METHODS In 4 swine, an 8-F linear quadripolar PFA catheter (FARAPULSE Inc) was introduced into the pericardial space via a subxiphoid puncture. After coronary angiography (Angio), QRS synchronized, biphasic, bipolar PFA was delivered directly on the left anterior descending artery, left circumflex artery, or normal myocardium (control) (2.0 kV × 4 applications per site). Angio was repeated immediately after ablation and repeated every 5 minutes to quantify the degree of CA narrowing. After 4- or 8-week survival, repeat Angio was performed followed by gross and histologic lesion analyses. RESULTS A total of 15 lesions were delivered (8 left anterior descending arteries, 3 left circumflexes, and 4 controls). Target site Angio revealed median of 47% (IQR: 38%-69%) acute luminal narrowing immediately after PFA, which gradually resolved over 30 minutes. Epicardial PFA lesions extended into the myocardium with a median depth of 4.1 mm (IQR: 3.6-5.6 mm) passing across the CAs and adipose tissue. However, 87.5% of the CAs demonstrated minimal to mild CA stenosis associated with neointimal hyperplasia and tunica media fibrosis. CONCLUSIONS In a swine model, epicardial PFA directly on CAs allowed the creation of myocardial lesions but led to a CA response characterized by acute moderate spasm and chronic mild stenosis via neointimal hyperplasia.
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Affiliation(s)
- Satoshi Higuchi
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California San Francisco, California, USA
| | - Sung Il Im
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California San Francisco, California, USA
| | - Carol Stillson
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California San Francisco, California, USA
| | | | | | | | - Molly Speltz
- R. and M. Speltz, LLC, Pathology Services, Stanchfield, Minnesota, USA
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California San Francisco, California, USA.
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7
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Zhang C, Zhu L, Tang S, Wang J, Li Y, Chen X, Bian C, Liu D, Ao G, Luo T. Feasibility and safety of trans-biliary cryoablation: Preclinical evaluation of a novel flexible cryoprobe. Cryobiology 2022:S0011-2240(22)00354-6. [PMID: 36414042 DOI: 10.1016/j.cryobiol.2022.11.239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 11/11/2022] [Accepted: 11/16/2022] [Indexed: 11/21/2022]
Abstract
Cryoablation, as a well-characterized technology, has multifarious clinical applications in solid malignancy. However, trans-biliary cryoablation for malignant biliary obstruction has not been reported yet. Thus, this study aimed to determine the efficacy and safety of trans-biliary cryoablation with a novel CO2 gas-based flexible cryoprobe in standardized preclinical settings. For fresh porcine liver ex vivo, the freezing efficacy of cryoablation was evaluated by using fresh porcine liver. The real-time CO2 flow rate, freezing temperature and freezing range were examined and the frozen appearance was visualized. In vivo study, acute and chronical effects were investigated by using the models of canine bile duct. Histopathology and laboratory examination were performed. The lowest temperature that the electrode could deliver to the tissue was -60.7 °C. At 60s after freezing, the tissue temperature dropped to -22.6 °C and -4.3 °C at 0.1 and 0.2 cm from the electrode center, respectively. The frozen size was greater in liver tissue ex vivo than that in bile duct tissue in vivo. No biliary hemorrhage, perforation, stricture, obstruction, and adjacent organ injury were observed. With histopathologic examination, acute intercellular vacuoles were observed in the lamina propria adjacent to the lumen. Chronic changes, including uneven coagulative necrosis, fibro-proliferation, inflammatory infiltration and connective tissue thickening were observed in the lamina propria of the all biliary samples. The results demonstrated CO2 gas-based trans-biliary cryoablation is safe and efficacious. These findings may provide a potential new modality for primary malignant biliary obstruction and malignant obstruction within a biliary stent and contribute to cryoablation of clinical practice.
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Affiliation(s)
- Chao Zhang
- Department of General Surgery, Xuanwu Hospital of Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, PR China
| | - Linzhong Zhu
- Department of General Surgery, Xuanwu Hospital of Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, PR China
| | - Shousheng Tang
- CAS Key Laboratory of Cryogenics, Technical Institute of Physics and Chemistry, Chinese Academy of Sciences, Beijing, 100080, 100091, PR China
| | - Jukun Wang
- Department of General Surgery, Xuanwu Hospital of Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, PR China
| | - Yu Li
- Department of General Surgery, Xuanwu Hospital of Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, PR China
| | - Xin Chen
- Department of General Surgery, Xuanwu Hospital of Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, PR China
| | - Chunjing Bian
- Department of General Surgery, Xuanwu Hospital of Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, PR China
| | - Dongbin Liu
- Department of General Surgery, Xuanwu Hospital of Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, PR China
| | - Guokun Ao
- Department of General Surgery, Xuanwu Hospital of Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, PR China
| | - Tao Luo
- Department of General Surgery, Xuanwu Hospital of Capital Medical University, National Clinical Research Center for Geriatric Diseases, Beijing, 100053, PR China.
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8
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Ghannam M, Chugh A, Thomas M, Liang JJ, Bogun F. Cryoablation for the treatment of ventricular tachycardia in close proximity to coronary arteries. HeartRhythm Case Rep 2022; 8:707-710. [PMID: 36310726 PMCID: PMC9596360 DOI: 10.1016/j.hrcr.2022.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Michael Ghannam
- Address reprint requests and correspondence: Dr Michael Ghannam, Cardiovascular Center, SPC 5853, 1500 E. Medical Center Dr, Ann Arbor, MI 48109-5853.
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9
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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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10
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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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11
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Epicardial Ablation Biophysics and Novel Radiofrequency Energy Delivery Techniques. Card Electrophysiol Clin 2020; 12:401-408. [PMID: 32771193 DOI: 10.1016/j.ccep.2020.05.006] [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: 11/20/2022]
Abstract
Important physiologic and anatomic differences exist between the epicardium and endocardium, particularly of the ventricles, and these differences affect ablation biophysics. Absence of passive convective effects conferred by circulating blood as well as the presence of epicardial fat and vessels and absence of intracavitary ridges and structures affect ablation lesion size when performing epicardial catheter-based ablation, whether using radiofrequency or cryothermal energy. Understanding differential effects in each environment is important in informing strategies to increase ablation lesion depth. When using actively cooled radiofrequency ablation, local impedance can be altered to selectively augment energy delivery.
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12
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Edward JA, Nguyen DT. Patient Selection for Epicardial Ablation-Part II: The Epicardial Approach and Current Challenges Associated with Epicardial Ablation. J Innov Card Rhythm Manag 2020; 10:3906-3912. [PMID: 32477711 PMCID: PMC7252684 DOI: 10.19102/icrm.2019.101105] [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: 03/04/2019] [Accepted: 03/29/2019] [Indexed: 12/03/2022] Open
Abstract
Since their inception, percutaneous epicardial approaches have become increasingly common in clinical practice with the advent of new technology and the growth of catheter ablation for both ventricular and supraventricular arrhythmias. In addition to identifying the arrhythmogenic foci, there remain challenges to successful epicardial ablation such as the choice of energy source, optimizing irrigation during ablation, and anatomic barriers such as epicardial fat and coronary vessels. The performance of continued translational studies to understand how each of these factors contribute to lesion formation will be essential to guide future advances in the field of epicardial ablation.
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Affiliation(s)
- Justin A Edward
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado Denver, Aurora, CO, USA
| | - Duy T Nguyen
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado Denver, Aurora, CO, USA
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13
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Qian PC, Barry MA, Tran VT, Lu J, McEwan A, Thiagalingam A, Thomas SP. Irrigated Microwave Catheter Ablation Can Create Deep Ventricular Lesions Through Epicardial Fat With Relative Sparing of Adjacent Coronary Arteries. Circ Arrhythm Electrophysiol 2020; 13:e008251. [PMID: 32299229 DOI: 10.1161/circep.119.008251] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Radiofrequency ablation depth can be inadequate to reach intramural or epicardial substrate, and energy delivery in the pericardium is limited by penetration through epicardial fat and coronary anatomy. We hypothesized that open irrigated microwave catheter ablation can create deep myocardial lesions endocardially and epicardially though fat while acutely sparing nearby the coronary arteries. METHODS In-house designed and constructed irrigated microwave catheters were tested in in vitro phantom models and in 15 sheep. Endocardial ablations were performed at 140 to 180 W for 4 minutes; epicardial ablations via subxiphoid access were performed at 90 to 100 W for 4 minutes at sites near coronary arteries. RESULTS Epicardial ablations at 90 to 100 W produced mean lesion depth of 10±4 mm, width 18±10 mm, and length 29±8 mm through median epicardial fat thickness of 1.2 mm. Endocardial ablations at 180 W reached depths of 10.7±3.3 mm, width of 16.6±5 mm, and length of 20±5 mm. Acute coronary occlusion or spasm was not observed at a median separation distance of 2.7 mm (IQR, 1.2-3.4 mm). Saline electrodes recorded unipolar and bipolar electrograms; microwave ablation caused reductions in voltage and changes in electrogram morphology with loss of pace-capture. In vitro models demonstrated the heat sink effect of coronary flow, as well as preferential microwave coupling to myocardium and blood as opposed to lung and epicardial fat phantoms. CONCLUSIONS Irrigated microwave catheter ablation may be an effective ablation modality for deep ventricular lesion creation with capacity for fat penetration and sparing of nearby coronary arteries because of cooling endoluminal flow. Clinical translation could improve the treatment of ventricular tachycardia arising from mid myocardial or epicardial substrates.
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Affiliation(s)
- Pierre C Qian
- Cardiology Department, Westmead Hospital (P.C.Q., M.A.B., V.T.T., J.L., A.T., S.P.T.), University of Sydney, Australia.,Sydney Medical School (P.C.Q., A.T., S.P.T.), University of Sydney, Australia.,The Westmead Institute for Medical Research (P.C.Q., A.T., S.P.T.), University of Sydney, Australia
| | - Michael A Barry
- Cardiology Department, Westmead Hospital (P.C.Q., M.A.B., V.T.T., J.L., A.T., S.P.T.), University of Sydney, Australia.,School of Electrical and Information Engineering (M.A.B., A.M.), University of Sydney, Australia
| | - Vu T Tran
- Cardiology Department, Westmead Hospital (P.C.Q., M.A.B., V.T.T., J.L., A.T., S.P.T.), University of Sydney, Australia
| | - Juntang Lu
- Cardiology Department, Westmead Hospital (P.C.Q., M.A.B., V.T.T., J.L., A.T., S.P.T.), University of Sydney, Australia
| | - Alistair McEwan
- Cardiology Department, Westmead Hospital (P.C.Q., M.A.B., V.T.T., J.L., A.T., S.P.T.), University of Sydney, Australia.,School of Electrical and Information Engineering (M.A.B., A.M.), University of Sydney, Australia
| | - Aravinda Thiagalingam
- Sydney Medical School (P.C.Q., A.T., S.P.T.), University of Sydney, Australia.,The Westmead Institute for Medical Research (P.C.Q., A.T., S.P.T.), University of Sydney, Australia
| | - Stuart P Thomas
- Cardiology Department, Westmead Hospital (P.C.Q., M.A.B., V.T.T., J.L., A.T., S.P.T.), University of Sydney, Australia.,Sydney Medical School (P.C.Q., A.T., S.P.T.), University of Sydney, Australia.,The Westmead Institute for Medical Research (P.C.Q., A.T., S.P.T.), University of Sydney, Australia
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14
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Morosawa S, Yamamoto H, Hirano M, Amamizu H, Uzuka H, Ohyama K, Hasebe Y, Nakano M, Fukuda K, Takayama K, Shimokawa H. Development of a Shock-Wave Catheter Ablation System for Ventricular Tachyarrhythmias: Validation Study in Pigs In Vivo. J Am Heart Assoc 2020; 8:e011038. [PMID: 30638120 PMCID: PMC6497350 DOI: 10.1161/jaha.118.011038] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Although radiofrequency catheter ablation is the current state‐of‐the‐art treatment for ventricular tachyarrhythmias, it has limited success for several reasons, including insufficient lesion depth, prolonged inflammation with subsequent recurrence, and thromboembolisms due to myoendocardial thermal injury. Because shock waves can be applied to deep lesions without heat, we have been developing a shock‐wave catheter ablation (SWCA) system to overcome these fundamental limitations of radiofrequency catheter ablation. In this study, we evaluated the efficacy and safety of our SWCA system for clinical application to treat ventricular tachyarrhythmia. Methods and Results In 33 pigs, we examined SWCA in vivo for the following 4 protocols. First, in an epicardial substrate model (n=8), endocardial SWCA significantly decreased the sensing threshold (pre‐ versus postablation: 11.4±3.8 versus 6.8±3.6 mV; P<0.05) and increased the pacing threshold (pre‐ versus postablation: 1.6±0.8 versus 2.0±1.1 V; P<0.05), whereas endocardial radiofrequency catheter ablation failed to do so. Second, in a myocardial infarction model (n=3), epicardial SWCA of the border zone of the infarcted lesion was as effective as ablation of the normal myocardium. Third, in a coronary artery application model (n=10), direct application of shock waves to the epicardial coronary arteries caused no adverse effects in either the acute or chronic phase. Fourth, with an epicardial approach (n=8), we found that 90 shots per site provided an ideal therapeutic condition to create deep lesions with less superficial damage. Conclusions These results indicate that our new SWCA system is effective and safe for treatment of ventricular tachyarrhythmias with deep arrhythmogenic substrates.
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Affiliation(s)
- Susumu Morosawa
- 1 Department of Cardiovascular Medicine Tohoku University Graduate School of Medicine Sendai Japan
| | - Hiroaki Yamamoto
- 1 Department of Cardiovascular Medicine Tohoku University Graduate School of Medicine Sendai Japan
| | - Michinori Hirano
- 1 Department of Cardiovascular Medicine Tohoku University Graduate School of Medicine Sendai Japan
| | - Hirokazu Amamizu
- 1 Department of Cardiovascular Medicine Tohoku University Graduate School of Medicine Sendai Japan
| | - Hironori Uzuka
- 1 Department of Cardiovascular Medicine Tohoku University Graduate School of Medicine Sendai Japan
| | - Kazuma Ohyama
- 1 Department of Cardiovascular Medicine Tohoku University Graduate School of Medicine Sendai Japan
| | - Yuhi Hasebe
- 1 Department of Cardiovascular Medicine Tohoku University Graduate School of Medicine Sendai Japan
| | - Makoto Nakano
- 1 Department of Cardiovascular Medicine Tohoku University Graduate School of Medicine Sendai Japan
| | - Koji Fukuda
- 1 Department of Cardiovascular Medicine Tohoku University Graduate School of Medicine Sendai Japan
| | - Kazuyoshi Takayama
- 1 Department of Cardiovascular Medicine Tohoku University Graduate School of Medicine Sendai Japan
| | - Hiroaki Shimokawa
- 1 Department of Cardiovascular Medicine Tohoku University Graduate School of Medicine Sendai Japan
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15
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Abrich VA, Shen WK, Mulpuru SK, Srivathsan K. Percutaneous epicardial cryoablation of idiopathic premature ventricular contractions near the left anterior descending artery. HeartRhythm Case Rep 2019; 5:367-370. [PMID: 31341778 PMCID: PMC6630181 DOI: 10.1016/j.hrcr.2019.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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16
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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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17
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Cardoso R, Aryana A, Singh SM, Tandri H, d'Avila A. Epicardial Ablation of Ventricular Tachycardia: a Review. Korean Circ J 2018; 48:778-791. [PMID: 30088360 PMCID: PMC6110707 DOI: 10.4070/kcj.2018.0210] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Accepted: 07/04/2018] [Indexed: 01/29/2023] Open
Abstract
For over 3 decades, it has been known that reentry circuits for ventricular tachycardia (VT) are not limited to the subendocardial myocardium. Rather, intramural or subepicardial substrates may also give rise to VT, particularly in those with non-ischemic cardiomyopathy. Percutaneous epicardial mapping and ablation has been successfully introduced for the treatment of such subepicardial VT. Herein, we review the indications for epicardial ablation and the identification of epicardial VT by electrocardiographic and imaging modalities. We also discuss the optimal technique for epicardial access and the implications of epicardial fat which has the potential to mimic scar, decreasing the specificity of electrogram morphology and impeding energy delivery to the tissue. Finally, we also report on possible complications of the procedure and strategies to mitigate adverse events.
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Affiliation(s)
- Rhanderson Cardoso
- Center of Excellence for ARVC and Complex Ventricular Arrhythmias, Johns Hopkins University, Baltimore, MD, USA
| | - Arash Aryana
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, CA, USA
| | - Sheldon M Singh
- Schulich Heart Program, Sunnybrook Health Sciences Centre, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Harikrishna Tandri
- Center of Excellence for ARVC and Complex Ventricular Arrhythmias, Johns Hopkins University, Baltimore, MD, USA
| | - Andre d'Avila
- Hospital Cardiológico SOS Cardio - Florianópolis, Florianópolis, SC, Brazil.
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18
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Upadhyay S, Walsh EP, Cecchin F, Triedman JK, Villafane J, Saul JP. Epicardial ablation of tachyarrhythmia in children: Experience at two academic centers. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2017; 40:1017-1026. [PMID: 28744873 DOI: 10.1111/pace.13152] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Revised: 05/30/2017] [Accepted: 06/27/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Experience with percutaneous epicardial ablation of tachyarrhythmia in pediatrics is limited. This case series addresses the feasibility, safety, and complications of the procedure in children. METHODS A total of nine patients underwent 10 epicardial ablation procedures from 2002 to 2013 at two academic centers. Activation mapping was performed in all cases, and electroanatomic map was utilized in nine of the 10 procedures. Patients had undergone one to three failed endocardial catheter ablations in addition to medical management, and all had symptoms, a high-risk accessory pathway (AP), aborted cardiac arrest with Wolff-Parkinson-White syndrome (WPW), or ventricular dysfunction. A standard epicardial approach was used for access in all cases, using a 7- or 8- Fr sheath. Epicardial ablation modality was radiofrequency (RF) in seven, cryoablation (CRYO) in one, and CRYO plus RF in one. RESULTS Median age was 14 (range 8-19) years. INDICATIONS drug refractory ectopic atrial tachycardia (one), ventricular tachycardia (VT) (five), high-risk AP (two), and aborted cardiac arrest from WPW - (one). Epicardial ablation was not performed in one case despite access due to an inability to maneuver the catheter around a former pericardial scar. VT foci included the right ventricular outflow tract septum, high posterior left ventricle (LV), LV outflow tract, postero-basal LV, and scar from previous rhabdomyoma surgery. WPW foci were in the area of the posterior septum and coronary sinus in all three cases. Overall procedural success was 70% (7/10), with epicardial ablation success in five and endocardial ablation success after epicardial mapping in two. The VT focus was close to the left anterior descending coronary artery in one of the unsuccessful cases in which both RF and CRYO were used. There was one recurrence after a successful epicardial VT ablation, which was managed with a second successful epicardial procedure. There were no other recurrences at more than 1 year of follow-up. Complications were minimal, with one case of inadvertent pleural access requiring no specific therapy. No pericarditis or effusion was seen in any of the patients who underwent epicardial ablation. CONCLUSION Epicardial ablation in pediatric patients can be performed with low complications and acceptable success. It can be considered for a spectrum of tachycardia mechanisms after failed endocardial ablation attempts and suspected epicardial foci. Success and recurrence may be related to foci in proximity to the epicardial coronaries, pericardial scar, or a distant location from the closest epicardial location. Repeat procedures may be necessary.
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Affiliation(s)
- Shailendra Upadhyay
- Department of Pediatrics, Connecticut Children's Medical Center, University of Connecticut School of Medicine, Hartford, CT, USA
| | - Edward P Walsh
- Department of Pediatrics, Boston Children's Hospital, Harvard University, Boston, MA, USA
| | - Frank Cecchin
- Department of Pediatrics, New York University School of Medicine, New York, NY, USA
| | - John K Triedman
- Department of Pediatrics, Boston Children's Hospital, Harvard University, Boston, MA, USA
| | - Juan Villafane
- Department of Pediatrics, University of Kentucky, Louisville, KY, USA
| | - J Philip Saul
- Department of Pediatrics, University of West Virginia School of Medicine, Morgantown, WV, USA
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19
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Abstract
Over the last two decades, epicardial catheter ablation has evolved into a practical approach for treatment of ventricular tachycardia (VT). There are certain considerations when performing this procedure. First, presence of epicardial fat can diminish peak-to-peak electrogram amplitude and also impede radiofrequency energy delivery. Hence, epicardial VT ablation should be performed with cooled-tip radiofrequency using reduced irrigation flow within a relatively 'dry' pericardial milieu. Furthermore, catheter orientation is key when performing epicardial ablation. Lastly, hemo-pericardium remains the most common major adverse event of epicardial ablation and its presenting timeline may be used to identify the precise nature of this complication.
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Affiliation(s)
- Arash Aryana
- Department of Cardiology and Cardiovascular Surgery, Mercy General Hospital, Dignity Health Heart and Vascular Institute, 3941 J Street, Suite #350, Sacramento, CA 95819, USA
| | - André d'Avila
- Cardiac Arrhythmia Service, Instituto de Pesquisa em Arritmia Cardiaca, Hospital Cardiologico - Florianopolis, Florianopolis, Rodovia SC 401, 121 - Itacorubi, Florianópolis - Santa Catarina 88030, Brazil.
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20
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Philip Saul J, Kanter RJ, Abrams D, Asirvatham S, Bar-Cohen Y, Blaufox AD, Cannon B, Clark J, Dick M, Freter A, Kertesz NJ, Kirsh JA, Kugler J, LaPage M, McGowan FX, Miyake CY, Nathan A, Papagiannis J, Paul T, Pflaumer A, Skanes AC, Stevenson WG, Von Bergen N, Zimmerman F. PACES/HRS expert consensus statement on the use of catheter ablation in children and patients with congenital heart disease. Heart Rhythm 2016; 13:e251-89. [DOI: 10.1016/j.hrthm.2016.02.009] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Indexed: 11/15/2022]
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21
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Araki M, Lee T, Murai T, Kakuta T. Serial examinations of right coronary artery directly injured by radiofrequency catheter ablation with optical coherence tomography and intravascular ultrasound. Cardiovasc Interv Ther 2015; 32:62-65. [PMID: 26581491 DOI: 10.1007/s12928-015-0368-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 11/04/2015] [Indexed: 11/29/2022]
Abstract
A 42-year-old man was referred for ablation. The origin of VT was localized close to the right coronary ostium. During ablation, the catheter tip inadvertently fell into a RCA ostium. The patient developed chest discomfort and ST-segment elevation in the inferior leads was observed. Coronary angiography confirmed severe narrowing of the ostial RCA. Stenting was deferred after satisfactory dilatation by a balloon. The patient discharged with eventless clinical course afterward. Follow-up coronary angiographic, FD-OCT, IVUS, and iMap examinations were performed at 3, 6, and 15 months after index procedure. The lesion showed progressive positive remodeling associated with intimal proliferation, medial thickening, and lumen narrowing up to 6 months. The patient underwent stenting at 15 months after the index procedure. The lesion required high-pressure post dilatation to obtain optimal stent expansion.
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Affiliation(s)
- Makoto Araki
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Manabeshin-machi 11-7, Tsuchiura, Ibaraki, 300-0053, Japan
| | - Tetsumin Lee
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Manabeshin-machi 11-7, Tsuchiura, Ibaraki, 300-0053, Japan
| | - Tadashi Murai
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Manabeshin-machi 11-7, Tsuchiura, Ibaraki, 300-0053, Japan
| | - Tsunekazu Kakuta
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Manabeshin-machi 11-7, Tsuchiura, Ibaraki, 300-0053, Japan.
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22
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CHEN YIHE, LIN JIAFENG. Catheter Ablation of Idiopathic Epicardial Ventricular Arrhythmias Originating from the Vicinity of the Coronary Sinus System. J Cardiovasc Electrophysiol 2015; 26:1160-7. [PMID: 26175213 DOI: 10.1111/jce.12756] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 06/18/2015] [Accepted: 07/08/2015] [Indexed: 11/28/2022]
Affiliation(s)
- YI-HE CHEN
- Department of Cardiology; Second Affiliated Hospital of Wenzhou Medical College; Wenzhou Zhejiang China
| | - JIA-FENG LIN
- Department of Cardiology; Second Affiliated Hospital of Wenzhou Medical College; Wenzhou Zhejiang China
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23
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Surgical ablation for atrial fibrillation as a concomitant cardiac surgery procedure. A single-centre study with 1-year follow-up. COR ET VASA 2015. [DOI: 10.1016/j.crvasa.2015.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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24
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Surgical cryoablation for ventricular tachyarrhythmia arising from the left ventricular outflow tract region. Heart Rhythm 2015; 12:1128-36. [DOI: 10.1016/j.hrthm.2015.02.016] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Indexed: 11/24/2022]
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25
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Neven K, van Driel V, van Wessel H, van Es R, Doevendans PA, Wittkampf F. Epicardial linear electroporation ablation and lesion size. Heart Rhythm 2014; 11:1465-70. [DOI: 10.1016/j.hrthm.2014.04.031] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Indexed: 10/25/2022]
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26
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Crosson JE, Callans DJ, Bradley DJ, Dubin A, Epstein M, Etheridge S, Papez A, Phillips JR, Rhodes LA, Saul P, Stephenson E, Stevenson W, Zimmerman F. PACES/HRS expert consensus statement on the evaluation and management of ventricular arrhythmias in the child with a structurally normal heart. Heart Rhythm 2014; 11:e55-78. [PMID: 24814375 DOI: 10.1016/j.hrthm.2014.05.010] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Indexed: 01/02/2023]
Affiliation(s)
- Jane E Crosson
- Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - David J Callans
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Anne Dubin
- Lucile Packard Children's Hospital, Stanford School of Medicine, Stanford, California
| | | | - Susan Etheridge
- University of Utah and Primary Children's Medical Center, Salt Lake City, Utah
| | - Andrew Papez
- Phoenix Children's Hospital/Arizona Pediatric Cardiology Consultants Phoenix, Arizona
| | | | | | - Philip Saul
- Nationwide Children's Hospital, Ohio State University, Columbus, Ohio
| | | | - William Stevenson
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Frank Zimmerman
- Advocate Heart Institute for Children Advocate Children's Hospital, Oak Lawn, Illinois.
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27
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Leo M, De Maria GL, Betts TR, Banning AP. Management and optical coherence tomography imaging of an acute coronary artery injury induced by radiofrequency catheter ablation. Int J Cardiol 2014; 174:e44-6. [PMID: 24768386 DOI: 10.1016/j.ijcard.2014.04.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 04/02/2014] [Indexed: 10/25/2022]
Affiliation(s)
- Milena Leo
- Oxford Heart Centre, Oxford University Hospitals, Oxford, UK; Cardiovascular Medicine Department, Catholic University of the Sacred Heart, Rome, Italy
| | - Giovanni Luigi De Maria
- Oxford Heart Centre, Oxford University Hospitals, Oxford, UK; Cardiovascular Medicine Department, Catholic University of the Sacred Heart, Rome, Italy
| | - Timothy R Betts
- Oxford Heart Centre, Oxford University Hospitals, Oxford, UK
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28
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Stavrakis S, Jackman WM, Nakagawa H, Sun Y, Xu Q, Beckman KJ, Lockwood D, Scherlag BJ, Lazzara R, Po SS. Risk of Coronary Artery Injury With Radiofrequency Ablation and Cryoablation of Epicardial Posteroseptal Accessory Pathways Within the Coronary Venous System. Circ Arrhythm Electrophysiol 2014; 7:113-9. [DOI: 10.1161/circep.113.000986] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Ablation of epicardial posteroseptal accessory pathways requires ablation within the coronary venous system. We assessed the risk of coronary artery (CA) injury with radiofrequency ablation (RFA) within the coronary venous system as a function of the distance between the CA and ablation site. We also examined the efficacy and safety of cryoablation close to a CA.
Methods and Results—
Two-hundred forty patients underwent ablation for epicardial posteroseptal accessory pathways. Coronary angiography was performed before ablation in the last 169 patients and was repeated after ablation if performed in the coronary venous system within 5 mm of a significant CA. The distance between the ideal ablation site and closest CA was <2 mm in 100 (59%), 3 to 5 mm in 28 (16%), and >5 mm in 41 of 169 (25%) patients. CA injury was observed in 11 of 22 (50%) and 1 of 15 (7%) patients when RFA was performed within 2 and 3 to 5 mm of a CA, respectively. Cryoablation was performed in 26 patients with a significant CA located within 5 mm. Cryoablation alone eliminated epicardial posteroseptal accessory pathway conduction in 17 of 26 (65%) patients and in 8 patients with additional RFA without CA narrowing in any patient. During a follow-up period of 3 to 6 months, single procedure success rates were 90% and 77% for RFA and cryoablation at the ideal site, respectively.
Conclusions—
The risk of CA injury with RFA is correlated inversely with the distance from the ablation site. Cryoablation is a safe and reasonably effective alternative when a significant CA is located close to the ideal ablation site.
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Affiliation(s)
- Stavros Stavrakis
- From the Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Warren M. Jackman
- From the Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Hiroshi Nakagawa
- From the Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Yingxian Sun
- From the Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Qingke Xu
- From the Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Karen J. Beckman
- From the Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Deborah Lockwood
- From the Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Benjamin J. Scherlag
- From the Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Ralph Lazzara
- From the Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City
| | - Sunny S. Po
- From the Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City
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29
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Affiliation(s)
- Noel G Boyle
- UCLA Cardiac Arrhythmia Center, 100 UCLA Medical Plaza, Suite 660, Westwood Blvd, Los Angeles CA 90095-7392, USA.
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30
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JAUREGUI-ABULARACH MIGUELE, CAMPOS BIEITO, BETENSKY BRIANP, MICHELE JOHN, GERSTENFELD EDWARDP. Comparison of Epicardial Cryoablation and Irrigated Radiofrequency Ablation in a Swine Infarct Model. J Cardiovasc Electrophysiol 2012; 23:1016-23. [DOI: 10.1111/j.1540-8167.2012.02334.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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31
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Viles-Gonzalez JF, de Castro Miranda R, Scanavacca M, Sosa E, d'Avila A. Acute and Chronic Effects of Epicardial Radiofrequency Applications Delivered on Epicardial Coronary Arteries. Circ Arrhythm Electrophysiol 2011; 4:526-31. [PMID: 21685298 DOI: 10.1161/circep.110.961508] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Epicardial coronary injury is by far the most feared complication of epicardial ablation. Little information is available regarding the chronic effects of delivering radiofrequency in the vicinity of large coronary vessels, and the long-term impact of this approach for mapping and ablation on epicardial vessel integrity is poorly understood. Therefore, the aim of this study was to characterize the acute and chronic histopathologic changes produced by in vivo epicardial pulses of radiofrequency ablation on coronary artery of porcine hearts.
Methods and Results—
Seven pigs underwent a left thoracotomy. The catheter was sutured adjacent to the left anterior descending artery and left circumflex artery, and 20 pulses of radiofrequency energy were applied. Radiofrequency lesions located no more than 1 mm of the vessel were used for this analysis. Three animals were euthanized 20 days (acute phase) after the procedure and 4 animals after 70 days (chronic phase). The following parameters were obtained in each vessel analyzed: (1) internal and external perimeter; (2) vessel wall thickness; (3) tunica media thickness, and (4) tunica intima thickness. The presence of adipose tissue around the coronary arteries, the distance between the artery and the epicardium, and the anatomic relationship of the artery with the coronary vein was also documented for each section. Sixteen of 20 (80%) sections analyzed, showed intimal thickening with a mean of 0.18±0.14 mm compared with 0.13±0.16 mm in the acute phase (
P
=0.331). The mean tunica media thickness was 0.25±0.10 mm in the chronic phase animals compared with 0.18±0.03 mm in the acute phase animals (
P
=0.021). A clear protective effect of pericardial fat and coronary veins was also present. A positive correlation between depth of radiofrequency lesion and the degree of vessel injury expressed as intimal and media thickening (
P
=0.001) was present. A negative correlation was identified (
r
=−0.83;
P
=0.002) between intimal thickening and distance between epicardium and coronary artery.
Conclusions—
In this porcine model of in vivo epicardial radiofrequency ablation in proximity to coronary arteries leads to acute and chronic histopathologic changes characterized by tunica intima and media thickening, with replacement of smooth muscle cells with extracellular matrix, but no significant stenosis was observed up to 70 days after the ablation. The absence of acute coronary occlusion or injury does not preclude subsequent significant arterial damage, which frequently occurs when epicardial radiofrequency applications are delivered in close vicinity to the vessels.
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Affiliation(s)
- Juan F. Viles-Gonzalez
- From the Helsmely Cardiac Arrhythmia Service, Mount Sinai Medical Center, New York, NY (J.F.V.-G., A.d'A.); and the Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil (R.d.C.M., M.S., E.S.)
| | - Reynaldo de Castro Miranda
- From the Helsmely Cardiac Arrhythmia Service, Mount Sinai Medical Center, New York, NY (J.F.V.-G., A.d'A.); and the Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil (R.d.C.M., M.S., E.S.)
| | - Mauricio Scanavacca
- From the Helsmely Cardiac Arrhythmia Service, Mount Sinai Medical Center, New York, NY (J.F.V.-G., A.d'A.); and the Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil (R.d.C.M., M.S., E.S.)
| | - Eduardo Sosa
- From the Helsmely Cardiac Arrhythmia Service, Mount Sinai Medical Center, New York, NY (J.F.V.-G., A.d'A.); and the Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil (R.d.C.M., M.S., E.S.)
| | - Andre d'Avila
- From the Helsmely Cardiac Arrhythmia Service, Mount Sinai Medical Center, New York, NY (J.F.V.-G., A.d'A.); and the Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil (R.d.C.M., M.S., E.S.)
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Di Biase L, Al-Ahamad A, Santangeli P, Hsia HH, Sanchez J, Bai R, Bailey S, Horton R, Gallinghouse GJ, Burkhardt DJ, Lakkireddy D, Yang Y, Badhwar N, Scheinman M, Tung R, Dello Russo A, Pelargonio G, Casella M, Tomassoni G, Shivkumar K, Natale A. Safety and outcomes of cryoablation for ventricular tachyarrhythmias: Results from a multicenter experience. Heart Rhythm 2011; 8:968-74. [DOI: 10.1016/j.hrthm.2011.02.038] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Accepted: 02/24/2011] [Indexed: 10/18/2022]
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Koruth JS, Dukkipati S, Carrillo RG, Coffey J, Teng J, Eby TB, Reddy VY, D'Avila A. Safety and efficacy of high-intensity focused ultrasound atop coronary arteries during epicardial catheter ablation. J Cardiovasc Electrophysiol 2011; 22:1274-80. [PMID: 21676047 DOI: 10.1111/j.1540-8167.2011.02084.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Coronary arterial injury continues to be a limitation of epicardial catheter ablation using currently available energy sources. Application of high intensity focused ultrasound (HIFU) energy may avoid such injury due to its theoretical ability to focus energy beyond the ablation element and create lesions at depth. OBJECTIVE This study evaluated the safety of HIFU applications delivered directly over the left anterior descending (LAD) artery in an open-chest swine model. METHODS Ten swine underwent median sternotomy. A prototype HIFU probe was placed atop the LAD. Forty-three therapies along the LAD (60-seconds/6 watt) were analyzed. Three, 3, and 4 swine were studied at 2, 4, and 8 weeks and subsequently sacrificed. Lesions were scored (0-4) depending on the percent circumferential involvement of arteries. RESULTS Lesion area increased minimally from 54.5 ± 18.0 mm(2) at 2 weeks to 56.9 ± 20.6 mm(2) at 8 weeks, and depth increased moderately from 13.2 ± 2.5 mm to 15.5 ± 3.4 mm. At 2, 4, and 8 weeks, the mean injury score of the LAD was 0.8 ± 0.3, 1.5 ± 0.9, and 2.0 ± 0.7. No/minimal arterial injury was seen in 64% of all sections. However, a progressive increase in injury resulted in 89% of all sections showing any injury at 8 weeks. One animal developed occlusion of the distal LAD. CONCLUSIONS HIFU has the potential to create deep ventricular lesions with relative sparing of the LAD. The incremental arterial damage noted over time warrants further evaluation to support the viability of focusing ultrasound energy beyond vulnerable critical structures to ablate deeper targets.
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Affiliation(s)
- Jacob S Koruth
- Helmsley Cardiac Arrhythmia Service, Mount Sinai Medical Center, New York, New York, USA
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34
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Gallegos RP, Rivard AL, Rajab TK, Chir B, Schmitto JD, Lahti MT, Kirchhof N, Bianco RW. Transmural Atrial Fibrosis after Epicardial and Endocardial Argon-Powered CryoMaze Ablation. J Card Surg 2011; 26:240-3. [PMID: 21395689 DOI: 10.1111/j.1540-8191.2011.01214.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Tedrow U, Stevenson WG. Epicardial Ablation of Ischemic Ventricular Tachycardia. Card Electrophysiol Clin 2010; 2:69-79. [PMID: 28770737 DOI: 10.1016/j.ccep.2009.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Endocardial catheter ablation for ventricular arrhythmias in patients with ischemic cardiomyopathy decreases ventricular tachycardia (VT) episodes, and painful implantable defibrillator shocks and can be lifesaving in the context of VT storm. Unfortunately, up to approximately one-third of postinfarction VTs are not accessible for ablation from the endocardium. Percutaneous access to the epicardial space has allowed ablation of a portion of these circuits, although anatomic barriers, such as the phrenic nerve, coronary arteries, and intramural circuits, still limit success in some cases. Adhesions, most often due to prior cardiac surgery, frequently necessitate a surgical approach to the pericardial space.
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Affiliation(s)
- Usha Tedrow
- The Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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36
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Natale A, Raviele A, Al-Ahmad A, Alfieri O, Aliot E, Almendral J, Breithardt G, Brugada J, Calkins H, Callans D, Cappato R, Camm JA, Della Bella P, Guiraudon GM, Haïssaguerre M, Hindricks G, Ho SY, Kuck KH, Marchlinski F, Packer DL, Prystowsky EN, Reddy VY, Ruskin JN, Scanavacca M, Shivkumar K, Soejima K, Stevenson WJ, Themistoclakis S, Verma A, Wilber D. Venice Chart International Consensus document on ventricular tachycardia/ventricular fibrillation ablation. J Cardiovasc Electrophysiol 2010; 21:339-79. [PMID: 20082650 DOI: 10.1111/j.1540-8167.2009.01686.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
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37
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Lockwood D, Nakagawa H, Peyton MD, Edgerton JR, Scherlag BJ, Sivaram CA, Po SS, Beckman KJ, Abedin M, Jackman WM. Linear left atrial lesions in minimally invasive surgical ablation of persistent atrial fibrillation: Techniques for assessing conduction block across surgical lesions. Heart Rhythm 2009; 6:S50-63. [DOI: 10.1016/j.hrthm.2009.09.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Indexed: 10/20/2022]
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38
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Gage AA, Baust JM, Baust JG. Experimental cryosurgery investigations in vivo. Cryobiology 2009; 59:229-43. [PMID: 19833119 DOI: 10.1016/j.cryobiol.2009.10.001] [Citation(s) in RCA: 174] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2009] [Revised: 09/30/2009] [Accepted: 10/01/2009] [Indexed: 12/16/2022]
Abstract
Cryosurgery is the use of freezing temperatures to elicit an ablative response in a targeted tissue. This review provides a global overview of experimentation in vivo which has been the basis of advancement of this widely applied therapeutic option. The cellular and tissue-related events that underlie the mechanisms of destruction, including direct cell injury (cryolysis), vascular stasis, apoptosis and necrosis, are described and are related to the optimal methods of technique of freezing to achieve efficacious therapy. In vivo experiments with major organs, including wound healing, the putative immunological response following thawing, and the use of cryoadjunctive strategies to enhance cancer cell sensitivity to freezing, are described.
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Affiliation(s)
- A A Gage
- Department of Surgery, SUNY Buffalo, Buffalo, NY, USA
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40
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Aliot EM, Stevenson WG, Almendral-Garrote JM, Bogun F, Calkins CH, Delacretaz E, Bella PD, Hindricks G, Jais P, Josephson ME, Kautzner J, Kay GN, Kuck KH, Lerman BB, Marchlinski F, Reddy V, Schalij MJ, Schilling R, Soejima K, Wilber D. EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias: Developed in a partnership with the European Heart Rhythm Association (EHRA), a Registered Branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA). Europace 2009; 11:771-817. [DOI: 10.1093/europace/eup098] [Citation(s) in RCA: 283] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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41
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Raymond JM, Sacher F, Winslow R, Tedrow U, Stevenson WG. Catheter Ablation for Scar-related Ventricular Tachycardias. Curr Probl Cardiol 2009; 34:225-70. [DOI: 10.1016/j.cpcardiol.2009.01.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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42
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Hashimoto K, Watanabe I, Okumura Y, Ohkubo K, Ashino S, Kofune M, Nakai T, Kunimoto S, Kasamaki Y, Hirayama A. Comparison of Endocardial and Epicardial Lesion Size Following Large-Tip and Extra-Large-Tip Transcatheter Cryoablation. Circ J 2009; 73:1619-26. [DOI: 10.1253/circj.cj-08-1211] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kenichi Hashimoto
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Ichiro Watanabe
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Kimie Ohkubo
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Sonoko Ashino
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Masayoshi Kofune
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Toshiko Nakai
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Satoshi Kunimoto
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Yuji Kasamaki
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Atsushi Hirayama
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
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D'AVILA ANDRÉ, ARYANA ARASH, THIAGALINGAM ARAVINDA, HOLMVANG GODTFRED, SCHMIDT EHUD, GUTIERREZ PAULO, RUSKIN JEREMYN, REDDY VIVEKY. Focal and Linear Endocardial and Epicardial Catheter-Based Cryoablation of Normal and Infarcted Ventricular Tissue. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:1322-31. [DOI: 10.1111/j.1540-8159.2008.01184.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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ZEPPENFELD KATJA, STEVENSON WILLIAMG. Ablation of Ventricular Tachycardia in Patients with Structural Heart Disease. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:358-74. [DOI: 10.1111/j.1540-8159.2008.00999.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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LEMOLA KRISTINA, DUBUC MARC, KHAIRY PAUL. Transcatheter Cryoablation Part II: Clinical Utility. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:235-44. [DOI: 10.1111/j.1540-8159.2007.00975.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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46
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Garcia FC, Valles E, Dhruvakumar S, Marchlinski FE. Ablation of ventricular tachycardia. Herzschrittmacherther Elektrophysiol 2007; 18:225-233. [PMID: 18084796 DOI: 10.1007/s00399-007-0583-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2007] [Accepted: 11/08/2007] [Indexed: 05/25/2023]
Abstract
Ablation is an important management tool for the treatment of ventricular arrhythmias. Even at experienced centers ventricular tachycardia ablation carries a minor but significant risk for potential complications, including vascular and thromboembolic complications, air embolism, volume overload and the precipitation of congestive heart failure, cardiac tamponade from catheter perforation or from steam pop with RF energy delivery, valve or subvalvular support structure disruption, conduction system disruption with development of heart block, coronary artery injury when ablating in the coronary cusps region or trying to gain access to the LV chamber, precipitation of cardiogenic shock from ablation of viable myocardium in patients with marginal reserve and failure to resuscitate or precipitation of cardiogenic shock from repeated VT induction, and with epicardial ablation the potential complications of epicardial access, coronary arteries and phrenic nerve damage. Recognition of these risks is paramount for their avoidance with careful pre-procedure planning and intraprocedural technique being essential to minimize the potential for complications.
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Affiliation(s)
- F C Garcia
- Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders Building 9th floor, Philadelphia, PA 19104, USA.
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47
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Hasdemir C, Yavuzgil O, Payzin S, Aydin M, Ulucan C, Kayikcioglu M, Can LH, Turkoglu C, Kultursay H. Angiographic analysis of the anatomic relation of coronary arteries to mitral and tricuspid annulus and implications for radiofrequency ablation. Am J Cardiol 2007; 100:666-71. [PMID: 17697826 DOI: 10.1016/j.amjcard.2007.03.082] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2006] [Revised: 03/13/2007] [Accepted: 03/13/2007] [Indexed: 11/24/2022]
Abstract
Coronary artery (CA) narrowings and/or occlusions after radiofrequency ablation (RFA) have been reported. The aim of this study was to describe the in vivo topographic anatomy of CAs and their anatomic relation to the mitral and tricuspid annulus using selective coronary angiography. Fifty consecutive patients undergoing RFA for narrow QRS complex tachycardia were included in the study. Multipolar electrode catheters were inserted into the right atrial appendage, His bundle region, distal coronary sinus (CS), and right ventricle. A mapping catheter was placed across the subeustachian isthmus (SEI). Selective coronary angiography was performed. The maximum and minimum distances between the distal CAs and the mapping catheter located along the mitral and tricuspid annulus were measured during systole and diastole and in right and left anterior oblique projections. The large (> or =1.5 mm) distal right CA was < or =5 mm from the mapping catheter in the SEI in 4 patients (8%). The large posterolateral branch of the right CA was < or =2 mm from the CS Os-middle cardiac vein in 10 patients (20%). The large left circumflex CA was < or =2 mm from the floor or ceiling of the CS in 7 patients (14%) and < or =2 mm from the CS catheter at the lateral and anterolateral mitral annulus in 12 patients (24%). RFA was canceled in 2 patients because of the close proximity (< or =2 mm) of the distal CA to the ablation site. In conclusion, large CAs are frequently located in close proximity to the common ablation sites. Coronary angiography should be considered in children and adults who may develop any signs or symptoms suggestive of acute CA occlusion until larger controlled series are available.
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Affiliation(s)
- Can Hasdemir
- Department of Cardiology, Ege University School of Medicine, Izmir, Turkey.
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48
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Affiliation(s)
- William G Stevenson
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA.
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49
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Vaseghi M, Cesario DA, Mahajan A, Wiener I, Boyle NG, Fishbein MC, Horowitz BN, Shivkumar K. Catheter Ablation of Right Ventricular Outflow Tract Tachycardia: Value of Defining Coronary Anatomy. J Cardiovasc Electrophysiol 2006; 17:632-7. [PMID: 16836713 DOI: 10.1111/j.1540-8167.2006.00483.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Thermal damage to coronary arteries during catheter ablation has been previously reported. Coronary artery damage during LV outflow tract ventricular tachycardia is well recognized. However, the relationship of the coronary arteries to the RV outflow tract during catheter ablation has not been delineated. The purpose of this study was to define the relationship between the RV outflow tract and the coronary arteries utilizing arteriography, echocardiography, CT angiography, and gross anatomic pathology. METHODS The relationship of the coronaries to the RV outflow tract was analyzed in three patients groups: Group 1: patients (n = 10) undergoing RV outflow tract ventricular tachycardia; Group 2: patients (n = 50) undergoing CT coronary angiography; Group 3: patients (n = 4) undergoing echocardiography during open heart surgery and intracardiac echocardiography (ICE) during catheter ablation of atrial fibrillation (n = 5). RESULTS Group 1: The left main coronary artery was found to be 3.8 +/- 1.2 mm from the right ventricular outflow tract in patients undergoing ablation. Group 2: The minimum distance between the left main, left anterior descending, and right coronary artery to the RV outflow tract endocardial wall were 4.1 +/- 1.9 mm, 2.0 +/- 0.6 mm, and 4.3 +/- 1.9 mm (average +/- SD) respectively. Group 3: During open heart surgery using echocardiography, the minimum distance between the left main and the right coronary artery to the RV outflow tract were 3.4 +/- 0.35 mm and 2.0 +/- 0.1 mm, respectively. The distance between the let main coronary artery and the RVOT by ICE was 3.8 +/- 0.45 mm. CONCLUSIONS The major coronary arteries lie in close proximity of the RVOT, and their anatomic course should be taken into consideration during ablation of ventricular tachycardias arising from the RV outflow tract.
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Affiliation(s)
- Marmar Vaseghi
- UCLA Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California 90095-1679, USA
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50
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Daniels DV, Lu YY, Morton JB, Santucci PA, Akar JG, Green A, Wilber DJ. Idiopathic Epicardial Left Ventricular Tachycardia Originating Remote From the Sinus of Valsalva. Circulation 2006; 113:1659-66. [PMID: 16567566 DOI: 10.1161/circulationaha.105.611640] [Citation(s) in RCA: 262] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Despite the success of catheter ablation for treatment of idiopathic ventricular tachycardia (VT), occasional patients have been reported in whom VT could not be ablated from the right or left ventricular endocardium or from the aortic sinus of Valsalva (ASOV).
Methods and Results—
In 12 of 138 patients (9%) with idiopathic VT referred for ablation, an epicardial left ventricular site of origin was identified >10 mm from the ASOV. Coronary venous mapping demonstrated epicardial preceding endocardial activation by >10 ms (41±7 versus 15±11 ms before QRS onset;
P
<0.001). VT induction was facilitated by catecholamines and terminated by adenosine. Ablation through the coronary veins or via percutaneous transpericardial catheterization was successful in 9 patients; 2 required direct surgical ablation as a result of anatomic constraints. No ECG pattern was specific for epicardial VT. However, slowed initial precordial QRS activation, as quantified by a novel metric, the maximum deflection index, was more useful. A delayed precordial maximum deflection index ≥0.55 identified epicardial VT remote from the ASOV with a sensitivity of 100% and a specificity of 98.7% relative to all other sites of origin (
P
<0.001).
Conclusions—
Although clinically underrecognized, idiopathic VT may originate from the perivascular sites on the left ventricular epicardium. The mechanism is consistent with triggered activity. It is amenable to ablation by transvenous or transpericardial approaches, although technical challenges remain. Recognition of a prolonged precordial maximum deflection index and early use of transvenous epicardial mapping are critical to avoid protracted and unsuccessful ablation elsewhere in the ventricles.
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Affiliation(s)
- David V Daniels
- Cardiovascular Institute, Loyola University Medical Center, Maywood, IL 60153, USA
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