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Vázquez-Calvo S, Garre P, Ferró E, Sánchez-Somonte P, Guichard JB, Falzone PV, Guasch E, Porta-Sánchez A, Tolosana JM, Borras R, Arbelo E, Ortiz-Pérez JT, Prats S, Perea RJ, Brugada J, Mont L, Roca-Luque I. Personalized voltage maps guided by cardiac magnetic resonance in the era of high-density mapping. Heart Rhythm 2024:S1547-5271(24)02501-3. [PMID: 38670249 DOI: 10.1016/j.hrthm.2024.04.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Voltage mapping could identify the conducting channels potentially responsible for ventricular tachycardia (VT). Standard thresholds (0.5-1.5 mV) were established using bipolar catheters. No thresholds have been analyzed with high-density mapping catheters. In addition, channels identified by cardiac magnetic resonance (CMR) has been proven to be related with VT. OBJECTIVE The purpose of this study was to analyze the diagnostic yield of a personalized voltage map using CMR to guide the adjustment of voltage thresholds. METHODS All consecutive patients with scar-related VT undergoing ablation after CMR (from October 2018 to December 2020) were included. First, personalized CMR-guided voltage thresholds were defined systematically according to the distribution of the scar and channels. Second, to validate these new thresholds, a comparison with standard thresholds (0.5-1.5 mV) was performed. Tissue characteristics of areas identified as deceleration zones (DZs) were recorded for each pair of thresholds. In addition, the relation of VT circuits with voltage channels was analyzed for both maps. RESULTS Thirty-two patients were included [mean age 66.6 ± 11.2 years; 25 (78.1%) ischemic cardiomyopathy]. Overall, 52 DZs were observed: 44.2% were identified as border zone tissue with standard cutoffs vs 75.0% using personalized voltage thresholds (P = .003). Of the 31 VT isthmuses detected, only 35.5% correlated with a voltage channel with standard thresholds vs 74.2% using adjusted thresholds (P = .005). Adjusted cutoff bipolar voltages that better matched CMR images were 0.51 ± 0.32 and 1.79 ± 0.71 mV with high interindividual variability (from 0.14-1.68 to 0.7-3.21 mV). CONCLUSION Personalized voltage CMR-guided personalized voltage maps enable a better identification of the substrate with a higher correlation with both DZs and VT isthmuses than do conventional voltage maps using fixed thresholds.
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Affiliation(s)
- Sara Vázquez-Calvo
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Paz Garre
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Elisenda Ferró
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Paula Sánchez-Somonte
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Jean-Baptiste Guichard
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Pasquale Valerio Falzone
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Eduard Guasch
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Andreu Porta-Sánchez
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - José Maria Tolosana
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Roger Borras
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Salud Mental, CIBERSAM, Instituto de Salud Carlos III, Madrid, Spain
| | - Elena Arbelo
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - José T Ortiz-Pérez
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Susana Prats
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Rosario J Perea
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Josep Brugada
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Lluís Mont
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Ivo Roca-Luque
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
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Ciaccio EJ, Coromilas J, Wan EY, Yarmohammadi H, Saluja DS, Peters NS, Garan H, Biviano AB. Correlation relationships of the reentrant ventricular tachycardia circuit. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 241:107764. [PMID: 37597351 DOI: 10.1016/j.cmpb.2023.107764] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 07/01/2023] [Accepted: 08/12/2023] [Indexed: 08/21/2023]
Abstract
INTRODUCTION A quantitative analysis of the components of reentrant ventricular tachycardia (VT) circuitry could improve understanding of its onset and perpetuation. METHOD In 19 canine experiments, the left anterior descending coronary artery was ligated to generate a subepicardial infarct. The border zone resided at the epicardial surface of the anterior left ventricle and was mapped 3-5 days postinfarction with a 196-312 bipolar multielectrode array. Monomorphic VT was inducible by extrastimulation. Activation maps revealed an epicardial double-loop reentrant circuit and isthmus, causing VT. Several circuit parameters were analyzed: the coupling interval for VT induction, VT cycle length, the lateral isthmus boundary (LIB) lengths, and isthmus width and angle. RESULTS The extrastimulus interval for VT induction and the VT cycle length were strongly correlated (p < 0.001). Both the extrastimulus interval and VT cycle length were correlated to the shortest LIB (p < 0.005). A derivation was developed to suggest that when conduction block at the shorter LIB is functional, the VT cycle length may depend on the local refractory period and the delay from wavefront pivot around the LIB. Isthmus width and angle were uncorrelated to other parameters. CONCLUSIONS The shorter LIB is correlated to VT cycle length, hence its circuit loop may drive reentrant VT. The extrastimulation interval, VT cycle length, and shorter LIB are intertwined, and may depend upon the local refractory period. Isthmus width and angle are less correlated, perhaps being more related to electrical discontinuity caused by alterations in infarct shape at depth.
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Affiliation(s)
- Edward J Ciaccio
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY, USA; ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.
| | - James Coromilas
- Department of Medicine - Division of Cardiovascular Disease and Hypertension, Rutgers University, New Brunswick, NJ, USA
| | - Elaine Y Wan
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Hirad Yarmohammadi
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Deepak S Saluja
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Nicholas S Peters
- ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Hasan Garan
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Angelo B Biviano
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY, USA
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3
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Ascione C, Kowalewski C, Bergonti M, Yokoyama M, Monaco C, Bouyer B, Chauvel R, Arnaud M, Buliard S, Tixier R, Vlachos K, Krisai P, Kamakura T, Takagi T, Duchateau J, Pambrun T, Derval N, Hocini M, Haïssaguerre M, Jaïs P, Sacher F. Omnipolar versus bipolar mapping to guide ventricular tachycardia ablation. Heart Rhythm 2023; 20:1370-1377. [PMID: 37414109 DOI: 10.1016/j.hrthm.2023.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/25/2023] [Accepted: 06/29/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Omnipolar technology (OT) was recently proposed to generate electroanatomic voltage maps with orientation-independent electrograms. We describe the first cohort of patients undergoing ventricular tachycardia (VT) ablation guided by OT. OBJECTIVE The purpose of this study was to compare omnipolar and bipolar high-density maps with regard to voltage amplitude, late potential (LP) annotation, and isochronal late activation mapping distribution. METHODS A total of 24 patients (16 [66%] ischemic cardiomyopathy and 12 [50%] redo cases) underwent VT ablation under OT guidance. Twenty-seven sinus rhythm substrate maps and 10 VT activation maps were analyzed. Omnipolar and bipolar (HD Wave Solution algorithm, Abbott, Abbott Park, IL) voltages were compared. Areas of LPs were correlated with the VT isthmus areas, and late electrogram misannotation was evaluated. Deceleration zones based on isochronal late activation maps were analyzed by 2 blinded operators and compared to the VT isthmuses. RESULTS OT maps had higher point density (13.8 points/cm2 vs 8.0 points/cm2). Omnipolar points had 7.1% higher voltages than bipolar points within areas of dense scar and border zone. The number of misannotated points was significantly lower for OT maps (6.8% vs 21.9%; P = .01), showing comparable sensitivity (53% vs 59%) but higher specificity (79% vs 63%). The sensitivity and specificity of detection of the VT isthmus in the deceleration zones were, respectively, 75% and 65% for OT and 35% and 55% for bipolar mapping. At 8.4 months, 71% freedom from VT recurrence was achieved. CONCLUSION OT is a valuable tool for guiding VT ablation, providing more accurate identification of LPs and isochronal crowding due to slightly higher voltages.
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Affiliation(s)
- Ciro Ascione
- Univ. Bordeaux, INSERM, CRCTB, U 1045, IHU Liryc, Bordeaux, France; CHU de Bordeaux, Cardiac arrhythmia department, INSERM, U 1045, Bordeaux, France.
| | - Christopher Kowalewski
- Univ. Bordeaux, INSERM, CRCTB, U 1045, IHU Liryc, Bordeaux, France; CHU de Bordeaux, Cardiac arrhythmia department, INSERM, U 1045, Bordeaux, France
| | - Marco Bergonti
- Division of Cardiology, Cardiocentro Ticino Institute, Lugano, Switzerland
| | - Masaaki Yokoyama
- Univ. Bordeaux, INSERM, CRCTB, U 1045, IHU Liryc, Bordeaux, France; CHU de Bordeaux, Cardiac arrhythmia department, INSERM, U 1045, Bordeaux, France
| | - Cinzia Monaco
- Univ. Bordeaux, INSERM, CRCTB, U 1045, IHU Liryc, Bordeaux, France; CHU de Bordeaux, Cardiac arrhythmia department, INSERM, U 1045, Bordeaux, France
| | - Benjamin Bouyer
- Univ. Bordeaux, INSERM, CRCTB, U 1045, IHU Liryc, Bordeaux, France; CHU de Bordeaux, Cardiac arrhythmia department, INSERM, U 1045, Bordeaux, France
| | - Rémi Chauvel
- Univ. Bordeaux, INSERM, CRCTB, U 1045, IHU Liryc, Bordeaux, France; CHU de Bordeaux, Cardiac arrhythmia department, INSERM, U 1045, Bordeaux, France
| | - Marine Arnaud
- Univ. Bordeaux, INSERM, CRCTB, U 1045, IHU Liryc, Bordeaux, France; CHU de Bordeaux, Cardiac arrhythmia department, INSERM, U 1045, Bordeaux, France
| | - Samuel Buliard
- Univ. Bordeaux, INSERM, CRCTB, U 1045, IHU Liryc, Bordeaux, France; CHU de Bordeaux, Cardiac arrhythmia department, INSERM, U 1045, Bordeaux, France
| | - Romain Tixier
- Univ. Bordeaux, INSERM, CRCTB, U 1045, IHU Liryc, Bordeaux, France; CHU de Bordeaux, Cardiac arrhythmia department, INSERM, U 1045, Bordeaux, France
| | - Konstantinos Vlachos
- Univ. Bordeaux, INSERM, CRCTB, U 1045, IHU Liryc, Bordeaux, France; CHU de Bordeaux, Cardiac arrhythmia department, INSERM, U 1045, Bordeaux, France
| | - Philipp Krisai
- Univ. Bordeaux, INSERM, CRCTB, U 1045, IHU Liryc, Bordeaux, France; CHU de Bordeaux, Cardiac arrhythmia department, INSERM, U 1045, Bordeaux, France
| | - Tsukasa Kamakura
- Univ. Bordeaux, INSERM, CRCTB, U 1045, IHU Liryc, Bordeaux, France; CHU de Bordeaux, Cardiac arrhythmia department, INSERM, U 1045, Bordeaux, France
| | - Takamitsu Takagi
- Univ. Bordeaux, INSERM, CRCTB, U 1045, IHU Liryc, Bordeaux, France; CHU de Bordeaux, Cardiac arrhythmia department, INSERM, U 1045, Bordeaux, France
| | - Josselin Duchateau
- Univ. Bordeaux, INSERM, CRCTB, U 1045, IHU Liryc, Bordeaux, France; CHU de Bordeaux, Cardiac arrhythmia department, INSERM, U 1045, Bordeaux, France
| | - Thomas Pambrun
- Univ. Bordeaux, INSERM, CRCTB, U 1045, IHU Liryc, Bordeaux, France; CHU de Bordeaux, Cardiac arrhythmia department, INSERM, U 1045, Bordeaux, France
| | - Nicolas Derval
- Univ. Bordeaux, INSERM, CRCTB, U 1045, IHU Liryc, Bordeaux, France; CHU de Bordeaux, Cardiac arrhythmia department, INSERM, U 1045, Bordeaux, France
| | - Mélèze Hocini
- Univ. Bordeaux, INSERM, CRCTB, U 1045, IHU Liryc, Bordeaux, France; CHU de Bordeaux, Cardiac arrhythmia department, INSERM, U 1045, Bordeaux, France
| | - Michel Haïssaguerre
- Univ. Bordeaux, INSERM, CRCTB, U 1045, IHU Liryc, Bordeaux, France; CHU de Bordeaux, Cardiac arrhythmia department, INSERM, U 1045, Bordeaux, France
| | - Pierre Jaïs
- Univ. Bordeaux, INSERM, CRCTB, U 1045, IHU Liryc, Bordeaux, France; CHU de Bordeaux, Cardiac arrhythmia department, INSERM, U 1045, Bordeaux, France
| | - Frederic Sacher
- Univ. Bordeaux, INSERM, CRCTB, U 1045, IHU Liryc, Bordeaux, France; CHU de Bordeaux, Cardiac arrhythmia department, INSERM, U 1045, Bordeaux, France
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4
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Subramanian M, Atreya AR, Saggu DK, Yalagudri S, Calambur N. Catheter ablation of ventricular tachycardia: strategies to improve outcomes. Front Cardiovasc Med 2023; 10:966634. [PMID: 37645526 PMCID: PMC10461400 DOI: 10.3389/fcvm.2023.966634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 04/24/2023] [Indexed: 08/31/2023] Open
Abstract
Catheter ablation of ventricular arrhythmias has evolved considerably since it was first described more than 3 decades ago. Advancements in understanding the underlying substrate, utilizing pre-procedural imaging, and evolving ablation techniques have improved the outcomes of catheter ablation. Ensuring safety and efficacy during catheter ablation requires adequate planning, including analysis of the 12 lead ECG and appropriate pre-procedural imaging. Defining the underlying arrhythmogenic substrate and disease eitology allow for the developed of tailored ablation strategies, especially for patients with non-ischemic cardiomyopathies. During ablation, the type of anesthesia can affect VT induction, the quality of the electro-anatomic map, and the stability of the catheter during ablation. For high risk patients, appropriate selection of hemodynamic support can increase the success of VT ablation. For patients in whom VT is hemodynamically unstable or difficult to induce, substrate modification strategies can aid in safe and successful ablation. Recently, there has been an several advancements in substrate mapping strategies that can be used to identify and differentiate local late potentials. The incorporation of high-definition mapping and contact-sense technologies have both had incremental benefits on the success of ablation procedures. It is crucial to harness newer technology and ablation strategies with the highest level of peri-procedural safety to achieve optimal long-term outcomes in patients undergoing VT ablation.
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Affiliation(s)
- Muthiah Subramanian
- Department of Cardiology, AIG Institute of Cardiac Sciences, Gachibowli, India
| | - Auras R. Atreya
- Department of Cardiology, University of Arkansas Medical Sciences, Little Rock, AR, United States
| | - Daljeet Kaur Saggu
- Department of Cardiology, AIG Institute of Cardiac Sciences, Gachibowli, India
| | - Sachin Yalagudri
- Department of Cardiology, AIG Institute of Cardiac Sciences, Gachibowli, India
| | - Narasimhan Calambur
- Department of Cardiology, AIG Institute of Cardiac Sciences, Gachibowli, India
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5
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Atreya AR, Yalagudri SD, Subramanian M, Rangaswamy VV, Saggu DK, Narasimhan C. Best Practices for the Catheter Ablation of Ventricular Arrhythmias. Card Electrophysiol Clin 2022; 14:571-607. [PMID: 36396179 DOI: 10.1016/j.ccep.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Techniques for catheter ablation have evolved to effectively treat a range of ventricular arrhythmias. Pre-operative electrocardiographic and cardiac imaging data are very useful in understanding the arrhythmogenic substrate and can guide mapping and ablation. In this review, we focus on best practices for catheter ablation, with emphasis on tailoring ablation strategies, based on the presence or absence of structural heart disease, underlying clinical status, and hemodynamic stability of the ventricular arrhythmia. We discuss steps to make ablation safe and prevent complications, and techniques to improve the efficacy of ablation, including optimal use of electroanatomical mapping algorithms, energy delivery, intracardiac echocardiography, and selective use of mechanical circulatory support.
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Affiliation(s)
- Auras R Atreya
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India; Division of Cardiovascular Medicine, Electrophysiology Section, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sachin D Yalagudri
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India
| | - Muthiah Subramanian
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India
| | | | - Daljeet Kaur Saggu
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India
| | - Calambur Narasimhan
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India.
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6
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Packer DL, Wilber DJ, Kapa S, Dyrda K, Nault I, Killu AM, Kanagasundram A, Richardson T, Stevenson W, Verma A, Curley M. Ablation of Refractory Ventricular Tachycardia Using Intramyocardial Needle Delivered Heated Saline-Enhanced Radiofrequency Energy: A First-in-Man Feasibility Trial. Circ Arrhythm Electrophysiol 2022; 15:e010347. [PMID: 35776711 PMCID: PMC9388560 DOI: 10.1161/circep.121.010347] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/23/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ablation of ventricular tachycardia (VT) is limited by the inability to create penetrating lesions to reach intramyocardial origins. Intramural needle ablation using in-catheter, heated saline-enhanced radio frequency (SERF) energy uses convective heating to increase heat transfer and produce deeper, controllable lesions at intramural targets. This first-in-human trial was designed to evaluate the safety and efficacy of SERF needle ablation in patients with refractory VT. METHODS Thirty-two subjects from 6 centers underwent needle electrode ablation. Each had recurrent drug-refractory monomorphic VT after implantable cardioverter defibrillator implantation and prior standard ablation. During the SERF study procedure, one or more VTs were induced and mapped. The SERF needle catheter was used to create intramural lesions at targeted VT site(s). Acute procedural success was defined as noninducibility of the clinical VT after the procedure. Patients underwent follow-up at 30 days, and 3 and 6 months, with implantable cardioverter defibrillator interrogation at follow-up to determine VT recurrence. RESULTS These refractory VT patients (91% male, 66±10 years, ejection fraction 35±11%; 56% ischemic, and 44% nonischemic) had a median of 45 device therapies (shock/antitachycardia pacing) for VT in the 3 to 6 months pre-SERF ablation. The study catheter was used to deliver an average of 10±5 lesions per case, with an average of 430±295 seconds of radiofrequency time, 122±65 minute of catheter use time, and a procedural duration of 4.3±1.3 hours. Acute procedural success was 97% for eliminating the clinical VT. At average follow-up of 5 months (n=32), device therapies were reduced by 89%. Complications included 2 periprocedural deaths: an embolic mesenteric infarct and cardiogenic shock, 2 mild strokes, and a pericardial effusion treated with pericardiocentesis (n=1). CONCLUSIONS Intramural heated saline needle ablation showed complete acute and satisfactory mid-term control of difficult VTs failing 1 to 5 prior ablations and drug therapy. Further study is warranted to define safety and longer-term efficacy. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique Identifier: NCT03628534 and NCT02994446.
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Affiliation(s)
| | | | | | | | - Isabelle Nault
- Canada Quebec Heart and Lung Institute, Quebec City, QC, Canada
| | | | | | | | | | - Atul Verma
- Southlake Regional Health Centre, Newmarket Ontario, Canada
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7
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Matsunaga-Lee Y, Egami Y, Matsumoto S, Masunaga N, Ukita K, Kawamura A, Nakamura H, Matsuhiro Y, Yasumoto K, Tsuda M, Okamoto N, Yano M, Takano Y, Sakata Y, Nishino M, Tanouchi J. Electrophysiological characteristics of non-pulmonary vein triggers excluding origins from the superior vena cava and left atrial posterior wall: Lessons from the self-reference mapping technique. PLoS One 2022; 17:e0263938. [PMID: 35385530 PMCID: PMC8985937 DOI: 10.1371/journal.pone.0263938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/30/2022] [Indexed: 11/18/2022] Open
Abstract
Background
The detailed electrophysiological characteristics of atrial fibrillation (AF) initiating non-pulmonary vein (PV) triggers excluding origins from the superior vena cava (SVC) and left atrial posterior wall (LAPW) (Non-PV-SVC-LAPW triggers) remain unclear. This study aimed to clarify the detailed electrophysiological characteristics of non-PV-SVC-LAPW triggers.
Methods
Among 446 AF ablation procedures at 2 institutions, patients with reproducible AF initiating non-PV-SVC-LAPW triggers were retrospectively enrolled. The trigger origin was mapped using the self-reference mapping technique. The following electrophysiological parameters were evaluated: the voltage during sinus rhythm and at the onset of AF at the earliest activation site, coupling interval of the trigger between the prior sinus rhythm and AF trigger, and voltage change ratio defined as the trigger voltage at the onset of AF divided by the sinus voltage.
Results
Detailed electrophysiological data were obtained at 28 triggers in 21 patients. The median trigger voltage at the onset of AF was 0.16mV and median trigger coupling interval 182msec. Normal sinus voltages (≧0.5mV) were observed at 16 triggers and low voltages (<0.5mV) at 12 triggers. The voltage change ratio was significantly lower for the normal sinus voltage than low sinus voltage (0.20 vs. 0.60, p = 0.002). The trigger coupling intervals were comparable between the normal sinus voltage and low sinus voltage (170ms vs. 185ms, p = 0.353).
Conclusions
The trigger voltage at the onset of AF was low, regardless of whether the sinus voltage of the trigger was preserved or low.
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Affiliation(s)
| | - Yasuyuki Egami
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
| | - Sen Matsumoto
- Department of Cardiology, JCHO Hoshigaoka Medical Center, Osaka, Japan
| | - Nobutaka Masunaga
- Department of Cardiology, JCHO Hoshigaoka Medical Center, Osaka, Japan
| | - Kohei Ukita
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
| | - Akito Kawamura
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
| | | | | | - Koji Yasumoto
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
| | - Masaki Tsuda
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
| | | | - Masamichi Yano
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
| | - Yuzuru Takano
- Department of Cardiology, Higashiosaka Citizen Hospital, Osaka, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masami Nishino
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
- * E-mail:
| | - Jun Tanouchi
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
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8
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Ciaccio EJ, Anter E, Coromilas J, Wan EY, Yarmohammadi H, Wit AL, Peters NS, Garan H. Structure and function of the ventricular tachycardia isthmus. Heart Rhythm 2022; 19:137-153. [PMID: 34371192 DOI: 10.1016/j.hrthm.2021.08.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/22/2021] [Accepted: 08/01/2021] [Indexed: 12/24/2022]
Abstract
Catheter ablation of postinfarction reentrant ventricular tachycardia (VT) has received renewed interest owing to the increased availability of high-resolution electroanatomic mapping systems that can describe the VT circuits in greater detail, and the emergence and need to target noninvasive external beam radioablation. These recent advancements provide optimism for improving the clinical outcome of VT ablation in patients with postinfarction and potentially other scar-related VTs. The combination of analyses gleaned from studies in swine and canine models of postinfarction reentrant VT, and in human studies, suggests the existence of common electroanatomic properties for reentrant VT circuits. Characterizing these properties may be useful for increasing the specificity of substrate mapping techniques and for noninvasive identification to guide ablation. Herein, we describe properties of reentrant VT circuits that may assist in elucidating the mechanisms of onset and maintenance, as well as a means to localize and delineate optimal catheter ablation targets.
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Affiliation(s)
- Edward J Ciaccio
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York; ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom.
| | - Elad Anter
- Department of Cardiovascular Medicine, Cardiac Electrophysiology, Cleveland Clinic, Cleveland, Ohio
| | - James Coromilas
- Department of Medicine, Division of Cardiovascular Disease and Hypertension, Rutgers University, New Brunswick, New Jersey
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Hirad Yarmohammadi
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Andrew L Wit
- Department of Pharmacology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Nicholas S Peters
- ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom
| | - Hasan Garan
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York
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9
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Frøysa V, Berg GJ, Eftestøl T, Woie L, Ørn S. Texture-based probability mapping for automatic scar assessment in late gadolinium-enhanced cardiovascular magnetic resonance images. Eur J Radiol Open 2021; 8:100387. [PMID: 34926726 PMCID: PMC8649215 DOI: 10.1016/j.ejro.2021.100387] [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: 09/02/2021] [Revised: 11/16/2021] [Accepted: 11/22/2021] [Indexed: 01/18/2023] Open
Abstract
Purpose To evaluate a novel texture-based probability mapping (TPM) method for scar size estimation in LGE-CMRI. Methods This retrospective proof-of-concept study included chronic myocardial scars from 52 patients. The TPM was compared with three signal intensity-based methods: manual segmentation, full-width-half-maximum (FWHM), and 5-standard deviation (5-SD). TPM is generated using machine learning techniques, expressing the probability of scarring in pixels. The probability is derived by comparing the texture of the 3 × 3 pixel matrix surrounding each pixel with reference dictionaries from patients with established myocardial scars. The Sørensen-Dice coefficient was used to find the optimal TPM range. A non-parametric test was used to test the correlation between infarct size and remodeling parameters. Bland-Altman plots were performed to assess agreement among the methods. Results The study included 52 patients (76.9% male; median age 64.5 years (54, 72.5)). A TPM range of 0.328–1.0 was found to be the optimal probability interval to predict scar size compared to manual segmentation, median dice (25th and 75th percentiles)): 0.69(0.42–0.81). There was no significant difference in the scar size between TPM and 5-SD. However, both 5-SD and TPM yielded larger scar sizes compared with FWHM (p < 0.001 and p = 0.002). There were strong correlations between scar size measured by TPM, and left ventricular ejection fraction (LVEF, r = −0.76, p < 0.001), left ventricular end-diastolic volume index (r = 0.73, p < 0.001), and left ventricular end-systolic volume index (r = 0.75, p < 0.001). Conclusion The TPM method is comparable with current SI-based methods, both for the scar size assessment and the relationship with left ventricular remodeling when applied on LGE-CMRI. Texture based probability mapping can be used to evaluate myocardial scar size. The method can assess myocardial fibrosis independent of signal intensity. The TPM method shows strong correlations between scar size and left ventricular ejection fraction.
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Affiliation(s)
- Vidar Frøysa
- Department of Cardiology, Stavanger University Hospital, Armauer Hansens vei 20, 4011, Stavanger, Norway
| | - Gøran J Berg
- Department of Electrical and Computer Science, University of Stavanger, P.O. box 8600, 4036 Stavanger, Norway
| | - Trygve Eftestøl
- Department of Electrical and Computer Science, University of Stavanger, P.O. box 8600, 4036 Stavanger, Norway
| | - Leik Woie
- Department of Electrical and Computer Science, University of Stavanger, P.O. box 8600, 4036 Stavanger, Norway
| | - Stein Ørn
- Department of Cardiology, Stavanger University Hospital, Armauer Hansens vei 20, 4011, Stavanger, Norway.,Department of Electrical and Computer Science, University of Stavanger, P.O. box 8600, 4036 Stavanger, Norway
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10
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de Oliveira Dietrich C, de Oliveira Hollanda L, Cirenza C, de Paola AAV. Epicardial and Endocardial Ablation Based on Channel Mapping in Patients With Ventricular Tachycardia and Chronic Chagasic Cardiomyopathy: Importance of Late Potential Mapping During Sinus Rhythm to Recognize the Critical Substrate. J Am Heart Assoc 2021; 11:e021889. [PMID: 34927451 PMCID: PMC9075208 DOI: 10.1161/jaha.121.021889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Ventricular tachycardia (VT) in patients with chronic chagasic cardiomyopathy (CCC) is associated with considerable morbidity and mortality. Catheter ablation of VT in patients with CCC is very complex and challenging. The main goal of this work was to assess the efficacy of VT catheter ablation guided by late potentials (LPs) in patients with CCC. Methods and Results Seventeen consecutive patients with refractory VT and CCC were prospectively included in the study. Combined endo‐epicardial voltage and late activation mapping were obtained during baseline rhythm to define scarred and LP areas, respectively. The end point of the ablation procedure was the elimination of all identified LPs. Epicardial and endocardial dense scars (<0.5 mV) were detected in 17/17 and 15/17 patients, respectively. LPs were detected in the epicardial scars of 16/17 patients and in the endocardial scars of 14/15 patients. A total of 63 VTs were induced in 17 patients; 22/63 (33%) were stable and entrained, presenting LPs recorded in the isthmus sites. The end point of ablation was achieved in 15 of 17 patients. Ablation was not completed in 2 patients because of cardiac tamponade or vicinity of the phrenic nerve and circumflex artery. Three patients (2 with unsuccessful ablation) had VT recurrence during follow‐up (39 months). Conclusions Endo‐epicardial LP mapping allows us to identify the putative isthmuses of different VTs and effectively perform catheter ablation in patients with CCC and drug‐refractory VTs.
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Affiliation(s)
- Cristiano de Oliveira Dietrich
- Clinical Cardiac Electrophysiology Cardiology Division Department of Medicine Hospital São Paulo Escola Paulista de Medicina - Universidade Federal of São Paulo São Paulo Brazil
| | - Lucas de Oliveira Hollanda
- Clinical Cardiac Electrophysiology Cardiology Division Department of Medicine Hospital São Paulo Escola Paulista de Medicina - Universidade Federal of São Paulo São Paulo Brazil
| | - Claudio Cirenza
- Clinical Cardiac Electrophysiology Cardiology Division Department of Medicine Hospital São Paulo Escola Paulista de Medicina - Universidade Federal of São Paulo São Paulo Brazil
| | - Angelo Amato Vincenzo de Paola
- Clinical Cardiac Electrophysiology Cardiology Division Department of Medicine Hospital São Paulo Escola Paulista de Medicina - Universidade Federal of São Paulo São Paulo Brazil
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11
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Advances in Mapping of Ventricular Tachycardia. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00951-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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12
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Katritsis G, Luther V, Jamil-Copley S, Koa-Wing M, Qureshi N, Whinnett Z, Lim PB, Ng FS, Malcolme-Lawes L, Peters NS, Fudge M, Lim E, Linton NWF, Kanagaratnam P. Postinfarct ventricular tachycardia substrate: Characterization and ablation of conduction channels using ripple mapping. Heart Rhythm 2021; 18:1682-1690. [PMID: 34004345 DOI: 10.1016/j.hrthm.2021.05.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/27/2021] [Accepted: 05/11/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Conduction channels have been demonstrated within the postinfarct scar and seem to be co-located with the isthmus of ventricular tachycardia (VT). Mapping the local scar potentials (SPs) that define the conduction channels is often hindered by large far-field electrograms generated by healthy myocardium. OBJECTIVE The purpose of this study was to map conduction channel using ripple mapping to categorize SPs temporally and anatomically. We tested the hypothesis that ablation of early SPs would eliminate the latest SPs without direct ablation. METHODS Ripple maps of postinfarct scar were collected using the PentaRay (Biosense Webster) during normal rhythm. Maps were reviewed in reverse, and clusters of SPs were color-coded on the geometry, by timing, into early, intermediate, late, and terminal. Ablation was delivered sequentially from clusters of early SPs, checking for loss of terminal SPs as the endpoint. RESULTS The protocol was performed in 11 patients. Mean mapping time was 65 ± 23 minutes, and a mean 3050 ± 1839 points was collected. SP timing ranged from 98.1 ± 60.5 ms to 214.8 ± 89.8 ms post QRS peak. Earliest SPs were present at the border, occupying 16.4% of scar, whereas latest SPs occupied 4.8% at the opposing border or core. Analysis took 15 ± 10 minutes to locate channels and identify ablation targets. It was possible to eliminate latest SPs in all patients without direct ablation (mean ablation time 16.3 ± 11.1 minutes). No VT recurrence was recorded (mean follow-up 10.1 ± 7.4 months). CONCLUSION Conduction channels can be located using ripple mapping to analyze SPs. Ablation at channel entrances can eliminate the latest SPs and is associated with good medium-term results.
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Affiliation(s)
| | - Vishal Luther
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | | | - Norman Qureshi
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | - Phang Boon Lim
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Fu Siong Ng
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | | | - Michael Fudge
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Elaine Lim
- Imperial College Healthcare NHS Trust, London, United Kingdom
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13
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto S, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 guideline on non-pharmacotherapy of cardiac arrhythmias. J Arrhythm 2021; 37:709-870. [PMID: 34386109 PMCID: PMC8339126 DOI: 10.1002/joa3.12491] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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14
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto SI, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 Guideline on Non-Pharmacotherapy of Cardiac Arrhythmias. Circ J 2021; 85:1104-1244. [PMID: 34078838 DOI: 10.1253/circj.cj-20-0637] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Haruhiko Abe
- Department of Heart Rhythm Management, University of Occupational and Environmental Health, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital
| | - Toshiyuki Ishikawa
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University
| | - Katsuhiko Imai
- Department of Cardiovascular Surgery, Kure Medical Center and Chugoku Cancer Center
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kaoru Okishige
- Department of Cardiology, Yokohama City Minato Red Cross Hospital
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Morio Shoda
- Department of Cardiology, Tokyo Women's Medical University
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Yoshihiro Seo
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui
| | | | - Yuji Nakazato
- Department of Cardiovascular Medicine, Juntendo University Urayasu Hospital
| | - Takashi Nishimura
- Department of Cardiac Surgery, Tokyo Metropolitan Geriatric Hospital
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | | | - Yuji Murakawa
- Fourth Department of Internal Medicine, Teikyo University Hospital Mizonokuchi
| | - Teiichi Yamane
- Department of Cardiology, Jikei University School of Medicine
| | - Takeshi Aiba
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Koichi Inoue
- Division of Arrhythmia, Cardiovascular Center, Sakurabashi Watanabe Hospital
| | - Yuki Iwasaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kikuya Uno
- Arrhythmia Center, Chiba Nishi General Hospital
| | - Michio Ogano
- Department of Cardiovascular Medicine, Shizuoka Medical Center
| | - Masaomi Kimura
- Advanced Management of Cardiac Arrhythmias, Hirosaki University Graduate School of Medicine
| | | | - Shingo Sasaki
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine
| | | | - Tsuyoshi Shiga
- Department of Cardiology, Tokyo Women's Medical University
| | - Tsugutoshi Suzuki
- Departments of Pediatric Electrophysiology, Osaka City General Hospital
| | - Yukio Sekiguchi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Kyoko Soejima
- Arrhythmia Center, Second Department of Internal Medicine, Kyorin University Hospital
| | - Masahiko Takagi
- Division of Cardiac Arrhythmia, Department of Internal Medicine II, Kansai Medical University
| | - Masaomi Chinushi
- School of Health Sciences, Faculty of Medicine, Niigata University
| | - Nobuhiro Nishi
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hitoshi Hachiya
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | | | | | - Yasushi Miyauchi
- Department of Cardiovascular Medicine, Nippon Medical School Chiba-Hokusoh Hospital
| | - Aya Miyazaki
- Department of Pediatric Cardiology, Congenital Heart Disease Center, Tenri Hospital
| | - Tomoshige Morimoto
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Hiro Yamasaki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | | | - Takeshi Kimura
- Department of Cardiology, Graduate School of Medicine and Faculty of Medicine, Kyoto University
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
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15
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Nishimura T, Upadhyay GA, Aziz ZA, Beaser AD, Shatz DY, Nayak HM, Tung R. Double loop ventricular tachycardia activation patterns with single loop mechanisms: Asymmetric entrainment responses during "pseudo-figure-of-eight" reentry. Heart Rhythm 2021; 18:1548-1556. [PMID: 33965607 DOI: 10.1016/j.hrthm.2021.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/19/2021] [Accepted: 05/03/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The classical paradigm of scar-related reentrant ventricular tachycardia (VT) features a circuit with a double loop figure-of-eight (F8) activation pattern. OBJECTIVE The purpose of this study was to interrogate VT circuits with F8 activation patterns by entrainment mapping to differentiate an active loop from a passive loop. METHODS Sixty VT circuits with >90% of tachycardia cycle length delineated in high resolution were retrospectively analyzed in 55 patients (nonischemic 49%). A pseudo-F8 VT circuit was defined as a double loop activation pattern driven by a single loop mechanism with a passive loop that yields a long postpacing interval (postpacing interval - tachycardia cycle length ≥ 30 ms). RESULTS Single loop activation patterns were observed in 33% (n = 20). Of 40 circuits with F8 patterns by activation mapping, 20 were studied with entrainment mapping, where a passive loop was identified by a long postpacing interval in 50%. In 6 circuits where entrainment mapping was performed from both outer loop regions, all demonstrated asymmetric responses to entrainment, confirming a single loop mechanism. Entrainment from both lateral margins of the common pathway (n = 7) demonstrated an asymmetric response in 29%. In all pseudo-F8 circuits (n = 10), the shorter loop functioned as the active loop and ablation targeting the active loop side of the isthmus resulted in VT termination with a single radiofrequency application. CONCLUSION In a selected cohort, single loop mechanisms are more prevalent than double loop reentry in reentrant human VT. Half of VT circuits with double loop activation patterns can be demonstrated to be sustained by a single active loop mechanism by entrainment mapping. Ablation targeting the shorter active loop resulted in rapid termination during radiofrequency application.
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Affiliation(s)
- Takuro Nishimura
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Gaurav A Upadhyay
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Zaid A Aziz
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Andrew D Beaser
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Dalise Y Shatz
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Hemal M Nayak
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Roderick Tung
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois.
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16
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Conte E, Mushtaq S, Carbucicchio C, Piperno G, Catto V, Mancini ME, Formenti A, Annoni A, Guglielmo M, Baggiano A, Muscogiuri G, Belmonte M, Cattani F, Pontone G, Jereczek-Fossa BA, Orecchia R, Tondo C, Andreini D. State of the art paper: Cardiovascular CT for planning ventricular tachycardia ablation procedures. J Cardiovasc Comput Tomogr 2021; 15:394-402. [PMID: 33563533 DOI: 10.1016/j.jcct.2021.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/22/2020] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
In the last 20 years coronary computed tomography angiography (CCTA) gained a pivotal role in the evaluation of patients with suspected coronary artery disease (CAD) as finally recognized by the ESC guidelines on stable CAD. Technological advances have progressively improved the temporal resolution of CT scanners, contemporary reducing acquisition time, radiation dose and contrast volume needed for the whole heart volume acquisition, further expanding the role of cardiac CT beyond coronary anatomy evaluation. Aim of the present review is to discuss use and benefit of cardiac CT for the planning and preparation of VT ablation.
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Affiliation(s)
| | | | | | - Gaia Piperno
- Division of Radiotherapy IEO, European Institute of Oncology, IRCCS, Milan, Italy
| | | | | | | | | | | | | | | | | | - Federica Cattani
- Unit of Medical Physics, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | | | - Barbara Alicja Jereczek-Fossa
- Unit of Medical Physics, IEO European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Roberto Orecchia
- Scientific Directorate, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Claudio Tondo
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | - Daniele Andreini
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy.
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17
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Gimelli A, Menichetti F, Soldati E, Liga R, Scelza N, Zucchelli G, Di Cori A, Segreti L, Vannozzi A, Bongiorni MG, Marzullo P. Predictors of ventricular ablation's success: Viability, innervation, or mismatch? J Nucl Cardiol 2021; 28:175-183. [PMID: 30603891 DOI: 10.1007/s12350-018-01575-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/07/2018] [Indexed: 10/27/2022]
Abstract
AIMS Sympathetic dys-innervation may play an important role in the development of post-ischemic ventricular arrhythmias (VA). Aim of this study was to prove that perfusion/innervation mismatch (PIM) evaluated by SPECT can identify areas of local abnormal ventricular activities (LAVA) on electroanatomic mapping (EAM). METHODS Sixteen patients referred to post-ischemic VA catheter ablation underwent pre-procedural and 1-month post-ablation 123I-MIBG/99mTc-tetrofosmin rest SPECT myocardial imaging. PIM was defined according to the segmental distributions of 99mTc-tetrofosmin and 123I-MIBG. A 17-segment LV analysis was used for either SPECT or LV EAM voltage map. All patients were followed up clinically for at least 1 year. RESULTS Before ablation, the mean voltage in the PIM segments was higher than in the scarred ones but lower than in the normal regions. The presence of PIM in a specific LV zone was an independent predictor of LAVA. After ablation, PIM value was significantly reduced, mainly due to an increase in perfusion summed rest score, in particular in patients that were responders to ablation. CONCLUSIONS PIM may associate with VA substrate expressed by LAVA and might provide a novel guide for substrate ablation. A significant reduction of PIM could predict a positive clinical response to ablation.
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Affiliation(s)
- Alessia Gimelli
- Fondazione Toscana G. Monasterio, Via Moruzzi, 1, 56124, Pisa, Italy.
| | - Francesca Menichetti
- Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
- Sant'Anna, School of Advanced Studies, Pisa, Italy
| | - Ezio Soldati
- Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Riccardo Liga
- Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Nicola Scelza
- Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Giulio Zucchelli
- Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Andrea Di Cori
- Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Luca Segreti
- Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Andrea Vannozzi
- Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | | | - Paolo Marzullo
- Fondazione Toscana G. Monasterio, Via Moruzzi, 1, 56124, Pisa, Italy
- CNR, Institute of Clinical Physiology, Pisa, Italy
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18
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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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Ciaccio EJ, Coromilas J, Wan EY, Yarmohammadi H, Saluja DS, Biviano AB, Wit AL, Peters NS, Garan H. Slow uniform electrical activation during sinus rhythm is an indicator of reentrant VT isthmus location and orientation in an experimental model of myocardial infarction. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2020; 196:105666. [PMID: 32717622 DOI: 10.1016/j.cmpb.2020.105666] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/12/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND To validate the predictability of reentrant circuit isthmus locations without ventricular tachycardia (VT) induction during high-definition mapping, we used computer methods to analyse sinus rhythm activation in experiments where isthmus location was subsequently verified by mapping reentrant VT circuits. METHOD In 21 experiments using a canine postinfarction model, bipolar electrograms were obtained from 196-312 recordings with 4mm spacing in the epicardial border zone during sinus rhythm and during VT. From computerized electrical activation maps of the reentrant circuit, areas of conduction block were determined and the isthmus was localized. A linear regression was computed at three different locations about the reentry isthmus using sinus rhythm electrogram activation data. From the regression analysis, the uniformity, a measure of the constancy at which the wavefront propagates, and the activation gradient, a measure that may approximate wavefront speed, were computed. The purpose was to test the hypothesis that the isthmus locates in a region of slow uniform activation bounded by areas of electrical discontinuity. RESULTS Based on the regression parameters, sinus rhythm activation along the isthmus near its exit proceeded uniformly (mean r2= 0.95±0.05) and with a low magnitude gradient (mean 0.37±0.10mm/ms). Perpendicular to the isthmus long-axis across its boundaries, the activation wavefront propagated much less uniformly (mean r2= 0.76±0.24) although of similar gradient (mean 0.38±0.23mm/ms). In the opposite direction from the exit, at the isthmus entrance, there was also less uniformity (mean r2= 0.80±0.22) but a larger magnitude gradient (mean 0.50±0.25mm/ms). A theoretical ablation line drawn perpendicular to the last sinus rhythm activation site along the isthmus long-axis was predicted to prevent VT reinduction. Anatomical conduction block occurred in 7/21 experiments, but comprised only small portions of the isthmus lateral boundaries; thus detection of sinus rhythm conduction block alone was insufficient to entirely define the VT isthmus. CONCLUSIONS Uniform activation with a low magnitude gradient during sinus rhythm is present at the VT isthmus exit location but there is less uniformity across the isthmus lateral boundaries and at isthmus entrance locations. These factors may be useful to verify any proposed VT isthmus location, reducing the need for VT induction to ablate the isthmus. Measured computerized values similar to those determined herein could therefore be assistive to sharpen specificity when applying sinus rhythm mapping to localize EP catheter ablation sites.
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Affiliation(s)
- Edward J Ciaccio
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA; ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK.
| | - James Coromilas
- Department of Medicine - Division of Cardiovascular Disease and Hypertension, Rutgers University, New Brunswick, NJ, USA
| | - Elaine Y Wan
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Hirad Yarmohammadi
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Deepak S Saluja
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Angelo B Biviano
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Andrew L Wit
- Department of Pharmacology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Nicholas S Peters
- ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, UK
| | - Hasan Garan
- Department of Medicine - Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
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20
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Outer loop and isthmus in ventricular tachycardia circuits: Characteristics and implications. Heart Rhythm 2020; 17:1719-1728. [DOI: 10.1016/j.hrthm.2020.05.034] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 05/06/2020] [Accepted: 05/27/2020] [Indexed: 11/21/2022]
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21
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, 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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22
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Frontera A, Melillo F, Baldetti L, Radinovic A, Bisceglia C, D'Angelo G, Foppoli L, Gigli L, Peretto G, Cireddu M, Sala S, Mazzone P, Della Bella P. High-Density Characterization of the Ventricular Electrical Substrate During Sinus Rhythm in Post-Myocardial Infarction Patients. JACC Clin Electrophysiol 2020; 6:799-811. [PMID: 32703562 DOI: 10.1016/j.jacep.2020.04.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 03/26/2020] [Accepted: 04/01/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aim of this study was to characterize, during sinus rhythm, the electric activation abnormalities in post-myocardial infarction patients undergoing ablation of ventricular tachycardia (VT) in order to identify specific signatures of those abnormal electrograms (EGMs). BACKGROUND In the setting of VT ablation, substrate characterization hinges on the identification of local abnormal ventricular activity (LAVA) and late potentials (LPs) that are considered to be related to the VT circuit. METHODS Patients scheduled for VT ablation underwent high-density ventricular substrate mapping. The substrate map during sinus rhythm was then compared with the activation maps of the clinical VT. Abnormal EGMs (LAVA and LPs) during sinus rhythm were characterized according to their configuration, duration, and amplitude and distinguished as belonging to bystander region or to the re-entrant circuit. Underlying electrophysiological mechanisms (wave-front collision, slow conduction) were identified on the activation maps and assigned to corresponding EGMs. RESULTS Ten patients satisfied the criteria to be enrolled in the study. A mean of 5 ± 1 slow-conduction areas and 4 ± 2 wave-front collisions were identified. LAVA was due to slow conduction in 60.5%, followed by wave-front collision (17.5%). LPs were caused by slow conduction in 52% of cases and by wave-front collision in 43% of cases. During sinus rhythm, entrance and exit sites were characterized by LAVA, while at the VT isthmus, only LPs were identified. Cutoff values of duration <24.5 ms (95% sensitivity and 99% specificity) and amplitude <0.14 mV (90% sensitivity and 48.1% specificity) discriminated those LPs belonging to the circuit from those playing a bystander role. CONCLUSIONS In the setting of post-myocardial infarction cardiomyopathy, specific EGM signatures are expressions of distinct electrophysiological phenomena. LAVA and LPs may play a bystander or an active role in the VT circuit, but only LPs with low amplitude and short duration predicted the VT isthmus.
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Affiliation(s)
- Antonio Frontera
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy.
| | - Francesco Melillo
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Luca Baldetti
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Andrea Radinovic
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Giuseppe D'Angelo
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Luca Foppoli
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Lorenzo Gigli
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Giovanni Peretto
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Manuela Cireddu
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Simone Sala
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Patrizio Mazzone
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Paolo Della Bella
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
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23
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Kim Y, Chen S, Ernst S, Guzman CE, Han S, Kalarus Z, Labadet C, Lin Y, Lo L, Nogami A, Saad EB, Sapp J, Sticherling C, Tilz R, Tung R, Kim YG, Stiles MK. 2019 APHRS expert consensus statement on three-dimensional mapping systems for tachycardia developed in collaboration with HRS, EHRA, and LAHRS. J Arrhythm 2020; 36:215-270. [PMID: 32256872 PMCID: PMC7132207 DOI: 10.1002/joa3.12308] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 01/20/2020] [Indexed: 12/24/2022] Open
Affiliation(s)
- Young‐Hoon Kim
- Department of Internal MedicineArrhythmia CenterKorea University Medicine Anam HospitalSeoulRepublic of Korea
| | - Shih‐Ann Chen
- Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalTaipeiROC
| | - Sabine Ernst
- Department of CardiologyRoyal Brompton and Harefield HospitalImperial College LondonLondonUK
| | | | - Seongwook Han
- Division of CardiologyDepartment of Internal MedicineKeimyung University School of MedicineDaeguRepublic of Korea
| | - Zbigniew Kalarus
- Department of CardiologyMedical University of SilesiaKatowicePoland
| | - Carlos Labadet
- Cardiology DepartmentArrhythmias and Electrophysiology ServiceClinica y Maternidad Suizo ArgentinaBuenos AiresArgentina
| | - Yenn‐Jian Lin
- Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalTaipeiROC
| | - Li‐Wei Lo
- Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalTaipeiROC
| | - Akihiko Nogami
- Department of CardiologyFaculty of MedicineUniversity of TsukubaTsukubaJapan
| | - Eduardo B. Saad
- Center for Atrial FibrillationHospital Pro‐CardiacoRio de JaneiroBrazil
| | - John Sapp
- Division of CardiologyDepartment of MedicineQEII Health Sciences CentreDalhousie UniversityHalifaxNSCanada
| | | | - Roland Tilz
- Medical Clinic II (Department of Cardiology, Angiology and Intensive Care Medicine)University Hospital Schleswig‐Holstein (UKSH) – Campus LuebeckLuebeckGermany
| | - Roderick Tung
- Center for Arrhythmia CarePritzker School of MedicineUniversity of Chicago MedicineChicagoILUSA
| | - Yun Gi Kim
- Department of Internal MedicineArrhythmia CenterKorea University Medicine Anam HospitalSeoulRepublic of Korea
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24
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Lee A, Walters TE, Alhede C, Vittinghoff E, Sievers R, Gerstenfeld EP. Standard peak-to-peak bipolar voltage amplitude criteria underestimate myocardial scar during substrate mapping with a novel microelectrode catheter. Heart Rhythm 2019; 17:476-484. [PMID: 31606463 DOI: 10.1016/j.hrthm.2019.10.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ventricular bipolar voltage values <0.5 and <1.0/1.5 mV (epi- and endocardium) correlating with dense scar and border zone, respectively, were established using a 3.5-mm tip catheter. Novel microelectrode catheters promise improved mapping resolution; however, whether standard voltage criteria apply to catheters with smaller electrode size and interelectrode distance remains unclear. OBJECTIVE The purpose of this study was to determine whether traditional bipolar voltage criteria for scar apply during substrate mapping with a microelectrode catheter. METHODS Paired bipolar and microbipolar voltage values were acquired from control swine (n = 2) using the microelectrode catheter and assessed for systemic differences. In a postinfarction swine model (n = 6), scar characteristics were compared between the bipolar maps and microbipolar maps using both standard and adjusted voltage criteria derived from the control animals. RESULTS In control swine, although 5th percentile values for bipolar and microbipolar voltage were similar (1.12 vs 1.22 mV [left ventricular (LV) endo]; 0.88 mV vs 0.98 mV [epi]), median values were significantly greater when acquired by microbipolar electrodes (3.60 vs 6.76 mV, P = .002 [LV endo]; 2.61 vs 2.72 mV, P = .02 [epi]). Microbipolar values were systematically larger by 2.0× and 1.4× in the LV endocardium and epicardium, respectively. Application of standard voltage values to microbipolar maps in postinfarct swine underestimated scar area by approximately 41% in the LV endocardium (13.7 vs 33.4 cm2, P = .004). CONCLUSION Bipolar voltage values acquired from microelectrodes are systemically larger than those acquired from standard catheters. New reference values should be established for these novel catheters.
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Affiliation(s)
- Adam Lee
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Tomos E Walters
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Christina Alhede
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Eric Vittinghoff
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Richard Sievers
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Edward P Gerstenfeld
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, University of California San Francisco, San Francisco, California.
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25
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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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26
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Xie S, Kubala M, Liang JJ, Yang J, Desjardins B, Santangeli P, van der Geest RJ, Schaller R, Riley M, Supple G, Frankel DS, Callans D, Pac EZ, Marchlinski F, Nazarian S. Utility of ripple mapping for identification of slow conduction channels during ventricular tachycardia ablation in the setting of arrhythmogenic right ventricular cardiomyopathy. J Cardiovasc Electrophysiol 2019; 30:366-373. [PMID: 30575168 DOI: 10.1111/jce.13819] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 11/01/2018] [Accepted: 11/21/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Ripple mapping displays every deflection of a bipolar electrogram and enables the visualization of conduction channels (RMCC) within postinfarction ventricular scar to guide ventricular tachycardia (VT) ablation. The utility of RMCC identification for facilitation of VT ablation in the setting of arrhythmogenic right ventricular cardiomyopathy (ARVC) has not been described. OBJECTIVE We sought to (a) identify the slow conduction channels in the endocardial/epicardial scar by ripple mapping and (b) retrospectively analyze whether the elimination of RMCC is associated with improved VT-free survival, in ARVC patients. METHODS High-density right ventricular endocardial and epicardial electrograms were collected using the CARTO 3 system in sinus rhythm or ventricular pacing and reviewed for RMCC. Low-voltage zones and abnormal myocardium in the epicardium were identified by using standardized late-gadolinium-enhanced (LGE) magnetic resonance imaging (MRI) signal intensity (SI) z-scores. RESULTS A cohort of 20 ARVC patients that had undergone simultaneous high-density right ventricular endocardial and epicardial electrogram mapping was identified (age 44 ± 13 years). Epicardial scar, defined as bipolar voltage less than 1.0 mV, occupied 47.6% (interquartile range [IQR], 30.9-63.7) of the total epicardial surface area and was larger than endocardial scar, defined as bipolar voltage less than 1.5 mV, which occupied 11.2% (IQR, 4.2 ± 17.8) of the endocardium (P < 0.01). A median 1.5 RMCC, defined as continuous corridors of sequential late activation within scar, were identified per patient (IQR, 1-3), most of which were epicardial. The median ratio of RMCC ablated was 1 (IQR, 0.6-1). During a median follow-up of 44 months (IQR, 11-49), the ratio of RMCC ablated was associated with freedom from recurrent VT (hazard ratio, 0.01; P = 0.049). Among nine patients with adequate MRI, 73% of RMCC were localized in LGE regions, 24% were adjacent to an area with LGE, and 3% were in regions without LGE. CONCLUSION Slow conduction channels within endocardial or epicardial ARVC scar were delineated clearly by ripple mapping and corresponded to critical isthmus sites during entrainment. Complete elimination of RMCC was associated with freedom from VT.
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Affiliation(s)
- Shuanglun Xie
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Cardiology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Maciej Kubala
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jackson J Liang
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jiandu Yang
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benoit Desjardins
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Radiology, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pasquale Santangeli
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rob J van der Geest
- Division of Image Processing, Leiden University Medical Centre, Leiden, The Netherlands
| | - Robert Schaller
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Riley
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory Supple
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David S Frankel
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David Callans
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Erica Zado Pac
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis Marchlinski
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Saman Nazarian
- Department of Medicine, Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Prakosa A, Arevalo HJ, Deng D, Boyle PM, Nikolov PP, Ashikaga H, Blauer JJE, Ghafoori E, Park CJ, Blake RC, Han FT, MacLeod RS, Halperin HR, Callans DJ, Ranjan R, Chrispin J, Nazarian S, Trayanova NA. Personalized virtual-heart technology for guiding the ablation of infarct-related ventricular tachycardia. Nat Biomed Eng 2018; 2:732-740. [PMID: 30847259 PMCID: PMC6400313 DOI: 10.1038/s41551-018-0282-2] [Citation(s) in RCA: 160] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 07/27/2018] [Indexed: 11/08/2022]
Abstract
Ventricular tachycardia (VT), which can lead to sudden cardiac death, occurs frequently in patients with myocardial infarction. Catheter-based radiofrequency ablation of cardiac tissue has achieved only modest efficacy, owing to the inaccurate identification of ablation targets by current electrical mapping techniques, which can lead to extensive lesions and to a prolonged, poorly tolerated procedure. Here we show that personalized virtual-heart technology based on cardiac imaging and computational modelling can identify optimal infarct-related VT ablation targets in retrospective animal (5 swine) and human studies (21 patients) and in a prospective feasibility study (5 patients). We first assessed in retrospective studies (one of which included a proportion of clinical images with artifacts) the capability of the technology to determine the minimum-size ablation targets for eradicating all VTs. In the prospective study, VT sites predicted by the technology were targeted directly, without relying on prior electrical mapping. The approach could improve infarct-related VT ablation guidance, where accurate identification of patient-specific optimal targets could be achieved on a personalized virtual heart prior to the clinical procedure.
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Affiliation(s)
- Adityo Prakosa
- Institute for Computational Medicine and Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Hermenegild J Arevalo
- Institute for Computational Medicine and Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
- Cardiac Modelling Department, Simula Research Laboratory, Fornebu, Norway
| | - Dongdong Deng
- Institute for Computational Medicine and Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Patrick M Boyle
- Institute for Computational Medicine and Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Plamen P Nikolov
- Institute for Computational Medicine and Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Hiroshi Ashikaga
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joshua J E Blauer
- Department of Bioengineering, University of Utah, Salt Lake City, UT, USA
| | - Elyar Ghafoori
- Department of Bioengineering, University of Utah, Salt Lake City, UT, USA
| | - Carolyn J Park
- Institute for Computational Medicine and Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Robert C Blake
- Institute for Computational Medicine and Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Frederick T Han
- University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Rob S MacLeod
- Department of Bioengineering, University of Utah, Salt Lake City, UT, USA
| | - Henry R Halperin
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David J Callans
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ravi Ranjan
- Department of Bioengineering, University of Utah, Salt Lake City, UT, USA
| | - Jonathan Chrispin
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Saman Nazarian
- Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Natalia A Trayanova
- Institute for Computational Medicine and Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA.
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Tzou WS, Rothstein PA, Cowherd M, Zipse MM, Tompkins C, Marzec L, Aleong RG, Schuller JL, Varosy PD, Borne RT, Mathew J, Tumolo A, Sandhu A, Nguyen DT, Sauer WH. Repeat ablation of refractory ventricular arrhythmias in patients with nonischemic cardiomyopathy: Impact of midmyocardial substrate and role of adjunctive ablation techniques. J Cardiovasc Electrophysiol 2018; 29:1403-1412. [PMID: 30033528 DOI: 10.1111/jce.13663] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 05/18/2018] [Accepted: 06/06/2018] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Multiple ablations are often necessary to manage ventricular arrhythmias (VAs) in nonischemic cardiomyopathy (NICM) patients. We assessed characteristics and outcomes and role of adjunctive, nonstandard ablation in repeat VA ablation (RAbl) in NICM. METHODS AND RESULTS Consecutive NICM patients undergoing RAbl were analyzed, with characteristics of the last VA ablations compared between those undergoing 1 versus multiple-repeat ablations (1-RAbl vs. >1RAbl), and between those with or without midmyocardial substrate (MMS). VA-free survival was compared. Eighty-eight patients underwent 124 RAbl, 26 with > 1RAbl, and 26 with MMS. 1-RAbl and > 1-RAbl groups were similar in age (57 ± 16 vs. 57 ± 17 years; P = 0.92), males (76% vs. 69%; P = 0.60), LVEF (40 ± 17% vs. 40 ± 18%; P = 0.96), and amiodarone use (31% vs. 46%, P = 0.22). One-year VA freedom between 1-RAbl vs. > 1RAbl was similar (82% vs. 80%; P = 0.81); adjunctive ablation was utilized more in >1RAbl (31% vs. 11%, P = 0.02), and complication rates were higher (27% vs. 7%, P = 0.01), most due to septal substrate and anticipated heart block. >1-RAbl patients had more MMS (62% vs. 16%, P < 0.01). Although MMS was associated with worse VA-free survival after 1-RAbl (43% vs. 69%, P = 0.01), when >1RAbl was performed, more often with nonstandard ablation, VA-free survival was comparable to non-MMS patients (85% vs. 81%; P = 0.69). More RAbls were required in MMS versus non-MMS patients (2.00 ± 0.98 vs. 1.16 ± 0.37; P < 0.001). CONCLUSION For NICM patients with recurrent, refractory VAs despite previous ablation, effective arrhythmia control can safely be achieved with subsequent ablation, although >1 repeat procedure with adjunctive ablation is often required, especially with MMS.
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Affiliation(s)
- Wendy S Tzou
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Peter A Rothstein
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Michael Cowherd
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Matthew M Zipse
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Christine Tompkins
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Lucas Marzec
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Ryan G Aleong
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Joseph L Schuller
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Paul D Varosy
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Ryan T Borne
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Jehu Mathew
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Alexis Tumolo
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Amneet Sandhu
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Duy T Nguyen
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - William H Sauer
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
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29
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Killu AM, Kella D, Kapa S. Fast and the Furious. Circ Arrhythm Electrophysiol 2018; 11:e006391. [DOI: 10.1161/circep.118.006391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ammar M. Killu
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN
| | - Danesh Kella
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN
| | - Suraj Kapa
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN
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Hutchinson MD, Garza HHK. Contemporary Tools and Techniques for Substrate Ablation of Ventricular Tachycardia in Structural Heart Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:16. [PMID: 29478118 DOI: 10.1007/s11936-018-0610-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
As we have witnessed in other arenas of catheter-based therapeutics, ventricular tachycardia (VT) ablation has become increasingly anatomical in its execution. Multi-modality imaging provides anatomical detail in substrate characterization, which is often complex in nonischemic cardiomyopathy patients. Patients with intramural, intraseptal, and epicardial substrates provide challenges in delivering effective ablation to the critical arrhythmia substrate due to the depth of origin or the presence of adjacent critical structures. Novel ablation techniques such as simultaneous unipolar or bipolar ablation can be useful to achieve greater lesion depth, though at the expense of increasing collateral damage. Disruptive technologies like stereotactic radioablation may provide a tailored approach to these complex patients while minimizing procedural risk. Substrate ablation is a cornerstone of the contemporary VT ablation procedure, and recent data suggest that it is as effective and more efficient that conventional activation guided ablation. A number of specific targets and techniques for substrate ablation have been described, and all have shown a fairly high success in achieving their acute procedural endpoint. Substrate ablation also provides a novel and reproducible procedural endpoint, which may add predictive value for VT recurrence beyond conventional programmed stimulation. Extrapolation of outcome data to nonischemic phenotypes requires caution given both the variability in substrate nonischemic distribution and the underrepresentation of these patients in previous trials.
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Affiliation(s)
- Mathew D Hutchinson
- Division of Cardiovascular Medicine, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ, USA. .,Sarver Heart Center, University of Arizona, 1501 N. Campbell Avenue, 4142B, Tucson, AZ, 85724, USA.
| | - Hyon-He K Garza
- Division of Cardiovascular Medicine, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
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Maagh P, Christoph A, Dopp H, Mueller MS, Plehn G, Meissner A. High-Density Mapping in Ventricular Tachycardia Ablation: A PentaRay ® Study. Cardiol Res 2017; 8:293-303. [PMID: 29317972 PMCID: PMC5755661 DOI: 10.14740/cr636w] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 11/28/2017] [Indexed: 11/11/2022] Open
Abstract
Background High-density mapping of ventricular tachycardia (VT) with PentaRay® (Biosense-Webster) provides high resolution with discrimination of local abnormal electrograms and slow conducting channels. We evaluate the feasibility of PentaRay® to characterize the anatomical substrate and assume an influence of the outcome despite limitations. Methods Over a 24-month period, 26 endocardial and four epicardial maps were obtained of 26 VT patients (18 ischemic cardiomyopathy (ICM, 69.2%) and 8 non-ischemic cardiomyopathy (NICM, 30.8%), age 65 ± 9 years). Catheter ablation (CA) was performed with the aim of transecting the isthmus. The endpoint was non-inducibility of any VT. Manual review of the maps was performed and focused on evaluating scarring, bipolar electrograms, and procedure times. Results In 55.6 ± 34.4 min, 1,085.9 ± 726.2 points were created. The mean ablation time was 50.8 ± 30.1 min. The endpoint was achieved in 12 patients (46.2%). The mean dense scar area and the mean patchy scar area were 49.4 ± 51.8 cm2 (range 0 - 190 cm2) and 14.7 ± 14.9 cm2 (range 0 - 110 cm2), respectively. Analyzing the learning curve, we found a tendency in decreasing procedure times. During the course of follow-up treatment averaging a 14-month period, device interrogation showed that 17 patients (65.4%) had remained free of any arrhythmia recurrence. Conclusion The high-density maps with PentaRay® were safely created in a short period of time. Our manual review of the maps reveals limitations of current annotation criteria; nevertheless, medium-term outcomes were encouraging. Further prospective studies are required to validate our findings in a larger cohort of patients.
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Affiliation(s)
- Petra Maagh
- Department of Cardiology, Electrophysiology and Intensive Care, Klinikum Merheim, University Witten/Herdecke/Germany, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Arnd Christoph
- Department of Cardiology, Electrophysiology and Intensive Care, Klinikum Merheim, University Witten/Herdecke/Germany, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Henning Dopp
- Department of Cardiology, Electrophysiology and Intensive Care, Klinikum Merheim, University Witten/Herdecke/Germany, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Markus Sebastian Mueller
- Department of Cardiology, Electrophysiology and Intensive Care, Klinikum Merheim, University Witten/Herdecke/Germany, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Gunnar Plehn
- Department of Cardiology and Angiology, Malteser-Krankenhaus St. Anna, Albertus-Magnus-Str. 33, 47259 Duisburg, Germany.,Ruhr-University of Bochum, Universitatsstrasse 150, 44801 Bochum, Germany
| | - Axel Meissner
- Department of Cardiology, Electrophysiology and Intensive Care, Klinikum Merheim, University Witten/Herdecke/Germany, Ostmerheimer Str. 200, 51109 Cologne, Germany.,Ruhr-University of Bochum, Universitatsstrasse 150, 44801 Bochum, Germany
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Nayyar S, Wilson L, Ganesan A, Sullivan T, Kuklik P, Young G, Sanders P, Roberts-Thomson KC. Electrophysiologic features of protected channels in late postinfarction patients with and without spontaneous ventricular tachycardia. J Interv Card Electrophysiol 2017; 51:13-24. [PMID: 29236200 DOI: 10.1007/s10840-017-0299-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 11/16/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Protected channels of surviving myocytes in late postinfarction ventricular scar predispose to ventricular tachycardia (VT). However, only a few patients develop VT spontaneously. We studied differences in electric remodeling and protected channels in late postinfarction patients with and without spontaneous VT. METHODS Patients with ischemic cardiomyopathy (ICM) with recurrent sustained monomorphic VT (n = 22) were compared with stable ICM patients without spontaneous VT (control group; n = 5). Left ventricular mapping was performed with a 20-pole catheter. Detailed pace mapping was used to identify channels of protected conduction, and confirmed, when feasible, by entrainment. Anatomical and electrophysiological properties of VT channels and non-VT channels in VT patients and channels in controls were evaluated. RESULTS Seventy-three (median 3) VTs were inducible in VT patients compared to two (median 0) in controls. The VT channels in VT patients (n = 57, 3 ± 1 per patient) were lengthier (mean ± SEM 53 ± 5 vs. 33 ± 4 vs. 24 ± 8 mm), had longer S-QRS (73 ± 4 vs. 63 ± 3 vs. 44 ± 8 ms), longer conduction time (103 ± 13 vs. 33 ± 4 vs. 24 ± 8 ms), and slower conduction velocity (CV) (0.85 ± 0.21 vs. 1.39 ± 0.20 vs. 1.31 ± 0.41 m/s) than non-VT channels in VT patients (n = 183, 8 ± 6 per patient) (p ≤ 0.01) and channels in controls (n = 46, 9 ± 8 per patient) (p ≤ 0.01). Additionally, non-VT channels in VT patients had longer S-QRS (p = 0.02); however, they were similar in length, conduction time, and CV compared to channels in controls. CONCLUSIONS Channels supporting VT are lengthier, with longer conduction times and slower CV compared to channels in patients without spontaneous VT. These observations may explain why some ICM patients have spontaneous VT and others do not.
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Affiliation(s)
- Sachin Nayyar
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Level 5, McEwin Building, North Terrace, Adelaide, SA, 5000, Australia
| | - Lauren Wilson
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Level 5, McEwin Building, North Terrace, Adelaide, SA, 5000, Australia
| | - Anand Ganesan
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Level 5, McEwin Building, North Terrace, Adelaide, SA, 5000, Australia
| | - Thomas Sullivan
- School of Public Health, University of Adelaide, Adelaide, Australia
| | - Pawel Kuklik
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Level 5, McEwin Building, North Terrace, Adelaide, SA, 5000, Australia
| | - Glenn Young
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Level 5, McEwin Building, North Terrace, Adelaide, SA, 5000, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Level 5, McEwin Building, North Terrace, Adelaide, SA, 5000, Australia
| | - Kurt C Roberts-Thomson
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Level 5, McEwin Building, North Terrace, Adelaide, SA, 5000, Australia.
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Abstract
Ventricular arrhythmias are a significant cause of morbidity and mortality in patients with ischemic structural heart disease. Endocardial and epicardial mapping strategies include scar characterization channel identification, and recording and ablation of late potentials and local abnormal ventricular activities. Catheter ablation along with new technology and techniques of bipolar ablation, needle catheter, and autonomic modulation may increase efficacy in difficult to ablate ventricular arrhythmias. Catheter ablation of ventricular arrhythmias seem to confer mortality and morbidity benefits in patients with ischemic heart disease.
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Affiliation(s)
- Ronald Lo
- Electrophysiology and Arrhythmia Service, Veterans Administration Medical Center, Loma Linda University, Mail Code 111C, 11201 Benton Street, Loma Linda, CA 92357, USA
| | - Karin K M Chia
- Department of Cardiology, Royal North Shore Hospital, The University of Sydney, Level 5, Acute Service Building, St Leonards, Sydney, North South Wales 2065, Australia
| | - Henry H Hsia
- Arrhythmia Service, Veterans Administration Medical Center-San Francisco, MC 111C-6, 4150 Clement Street, San Francisco, CA 94121, USA.
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Nayyar S, Kuklik P, Ganesan AN, Sullivan TR, Wilson L, Young GD, Sanders P, Roberts-Thomson KC. Development of Time- and Voltage-Domain Mapping (V-T-Mapping) to Localize Ventricular Tachycardia Channels During Sinus Rhythm. Circ Arrhythm Electrophysiol 2017; 9:CIRCEP.116.004050. [PMID: 27913399 DOI: 10.1161/circep.116.004050] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 09/28/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND In ventricular scar, impulse spread is slow because it traverses split and zigzag channels of surviving muscle. We aimed to evaluate scar electrograms to determine their local delay (activation time) and inequality in voltage splitting (entropy), and their relationship to channels. We reasoned that unlike innocuous channels, which are often short with multiple side branches, ventricular tachycardia (VT) supporting channels have very slow impulse spread and possess low entropy because of their longer protected length and relative lack of side-branching. METHODS AND RESULTS Patients with ischemic cardiomyopathy and multiple VT were studied. In initial mapping stage (16 patients and 58 VTs), left ventricular endocardial mapping was performed in sinus rhythm. Detailed pace mapping was used to identify VT channels and confirmed, when feasible, by entrainment. Scar electrograms were analyzed in time and voltage domains to determine mean activation time, dispersion in activation time, and entropy. Predictive performances of these properties to detect VT channels were tested. In the application stage (7 patients and 20 VTs), these properties were prospectively tested to guide catheter ablation. A mean number of 763±203 sampling points were taken. From 1770 pace maps, 47 channels corresponded to VTs. A combination of scar electrograms with the latest mean activation time and minimum entropy, in a high activation dispersion region, accurately recognized regions containing VT channels (κ=0.89, sensitivity=86%, specificity=100%, positive predictive value=93%, and negative predictive value=100%). Finally, focused ablation within 5-mm rim of the prospective channel regions eliminated 18 of 20 inducible VTs. CONCLUSIONS Activation time and entropy mapping in the scar accurately identify VT channels during sinus rhythm. The method integrates principles of reentry formation to recognize VT channels without pace mapping or mapping during VT.
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Affiliation(s)
- Sachin Nayyar
- From the Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia (S.N., P.K., A.N.G., L.W., G.D.Y., P.S., K.C.R.-T.); and School of Public Health, University of Adelaide, Australia (T.R.S.)
| | - Pawel Kuklik
- From the Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia (S.N., P.K., A.N.G., L.W., G.D.Y., P.S., K.C.R.-T.); and School of Public Health, University of Adelaide, Australia (T.R.S.)
| | - Anand N Ganesan
- From the Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia (S.N., P.K., A.N.G., L.W., G.D.Y., P.S., K.C.R.-T.); and School of Public Health, University of Adelaide, Australia (T.R.S.)
| | - Thomas R Sullivan
- From the Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia (S.N., P.K., A.N.G., L.W., G.D.Y., P.S., K.C.R.-T.); and School of Public Health, University of Adelaide, Australia (T.R.S.)
| | - Lauren Wilson
- From the Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia (S.N., P.K., A.N.G., L.W., G.D.Y., P.S., K.C.R.-T.); and School of Public Health, University of Adelaide, Australia (T.R.S.)
| | - Glenn D Young
- From the Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia (S.N., P.K., A.N.G., L.W., G.D.Y., P.S., K.C.R.-T.); and School of Public Health, University of Adelaide, Australia (T.R.S.)
| | - Prashanthan Sanders
- From the Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia (S.N., P.K., A.N.G., L.W., G.D.Y., P.S., K.C.R.-T.); and School of Public Health, University of Adelaide, Australia (T.R.S.)
| | - Kurt C Roberts-Thomson
- From the Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia (S.N., P.K., A.N.G., L.W., G.D.Y., P.S., K.C.R.-T.); and School of Public Health, University of Adelaide, Australia (T.R.S.).
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de Chillou C, Sellal JM, Magnin-Poull I. Pace Mapping to Localize the Critical Isthmus of Ventricular Tachycardia. Card Electrophysiol Clin 2017; 9:71-80. [PMID: 28167087 DOI: 10.1016/j.ccep.2016.10.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Most postinfarct ventricular tachycardias (VT) are sustained by a reentrant mechanism. The "protected isthmus" of the reentrant circuit is critical for the maintenance of VTs and the target for catheter ablation. In this article, the authors describe the technique of pace-mapping during sinus rhythm to unmask postinfarct VT isthmuses. A pace-mapping map should be considered as the surrogate of an activation map during VT, in both patients with a normal heart and patients with a structural heart disease. Pace mapping is useful to unmask VT isthmuses in patients with postinfarct reentrant VTs.
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Affiliation(s)
- Christian de Chillou
- Department of Cardiology, University Hospital Nancy, rue du Morvan, 54511 Vandœuvre lès-Nancy F-54500, France; INSERM-IADI, U947, rue du Morvan, 54511 Vandœuvre lès-Nancy F-54500, France.
| | - Jean-Marc Sellal
- Department of Cardiology, University Hospital Nancy, rue du Morvan, 54511 Vandœuvre lès-Nancy F-54500, France; INSERM-IADI, U947, rue du Morvan, 54511 Vandœuvre lès-Nancy F-54500, France
| | - Isabelle Magnin-Poull
- Department of Cardiology, University Hospital Nancy, rue du Morvan, 54511 Vandœuvre lès-Nancy F-54500, France; INSERM-IADI, U947, rue du Morvan, 54511 Vandœuvre lès-Nancy F-54500, France
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Pathak RK, Garcia FC. Ablation of Ventricular Tachycardia in Arrhythmogenic Right Ventricular Dysplasia. Card Electrophysiol Clin 2017; 9:99-106. [PMID: 28167090 DOI: 10.1016/j.ccep.2016.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Endocardial and epicardial electroanatomical mapping and ablation is a safe and effective therapy in the treatment of right ventricle arrhythmias occurring in the setting of arrhythmogenic right ventricular cardiomyopathy (ARVD). Careful mapping and ablation plans must be tailored for each patient based on comorbidities and ventricular tachycardia morphologies. This review focuses on the catheter ablation for ventricular arrhythmias in patients with ARVD.
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Affiliation(s)
- Rajeev K Pathak
- Clinical Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, 9 Founders Pavilion - Cardiology, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Fermin C Garcia
- Clinical Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, 9 Founders Pavilion - Cardiology, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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37
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Acosta J, Penela D, Andreu D, Cabrera M, Carlosena A, Vassanelli F, Alarcón F, Soto-Iglesias D, Korshunov V, Borras R, Linhart M, Martínez M, Fernández-Armenta J, Mont L, Berruezo A. Multielectrode vs. point-by-point mapping for ventricular tachycardia substrate ablation: a randomized study. Europace 2017; 20:512-519. [DOI: 10.1093/europace/euw406] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 11/21/2016] [Indexed: 01/05/2023] Open
Affiliation(s)
- Juan Acosta
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d’Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain
| | - Diego Penela
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d’Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain
| | - David Andreu
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d’Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain
| | - Mario Cabrera
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d’Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain
| | - Alicia Carlosena
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d’Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain
| | - Francesca Vassanelli
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d’Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain
| | - Francisco Alarcón
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d’Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain
| | - David Soto-Iglesias
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d’Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain
| | - Viatcheslav Korshunov
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d’Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain
| | - Roger Borras
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d’Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain
| | - Markus Linhart
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d’Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain
| | - Mikel Martínez
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d’Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain
| | - Juan Fernández-Armenta
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d’Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain
| | - Lluis Mont
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d’Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain
| | - Antonio Berruezo
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic and IDIBAPS (Institut d’Investigació Agustí Pi i Sunyer), Barcelona, Catalonia, Spain
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Fukunaga M, Goya M, Hiroshima K, Hayashi K, Ohe M, Makihara Y, Nagashima M, An Y, Shirai S, Ando K, Yokoi H, Iwabuchi M. Impact of catheter ablation of ventricular tachycardia in patients with prior myocardial infarctions. J Arrhythm 2016; 32:462-467. [PMID: 27920830 PMCID: PMC5129118 DOI: 10.1016/j.joa.2016.03.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 02/22/2016] [Accepted: 03/01/2016] [Indexed: 11/29/2022] Open
Abstract
Background Catheter ablation can reduce episodes of ventricular tachycardia (VT) after myocardial infarction (MI). However, the optimal endpoint of the ablation procedure remains unclear. Methods Fifty-one consecutive patients who received catheter ablation for VT after MI were included. The procedures targeted the isthmus of all the induced, sustained VTs. When the patients with induced VTs were hemodynamically stable, radiofrequency energy was delivered at the mid-diastolic potential recording site during VT. When the patients with VTs were hemodynamically unstable, the critical channel was identified at the delayed potential recording site, showing a good pace map, with a long stimulus-QRS interval. We delivered radiofrequency energy along the identified isthmus and across the exit of the circuit. Results At the end of the procedure, all VTs became non-inducible in 30 patients (59%) and some VTs were inducible in 21 patients (41%). During a mean of 40±29 months of follow-up, no VT or ventricular fibrillation recurred in 24 patients (80%) in the non-inducible group and in 12 patients (57%) in the inducible group, respectively (P=0.03). The identification of the channel during VT mapping tended to associate with no recurrence, although the difference was not statistically significant (P=0.2). Fourteen patients (27%) died during the follow-up period, mostly due to non-cardiac causes. Conclusions The catheter ablation targeting the isthmus of prior-MIVT and non-inducibility at the end of the procedure can provide a satisfactory follow-up result.
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Affiliation(s)
| | - Masahiko Goya
- Department of Cardiology, Kokura Memorial Hospital, Japan
| | | | | | - Masatsugu Ohe
- Department of Cardiology, Kokura Memorial Hospital, Japan
| | - Yu Makihara
- Department of Cardiology, Kokura Memorial Hospital, Japan
| | | | - Yoshimori An
- Department of Cardiology, Kokura Memorial Hospital, Japan
| | | | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital, Japan
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39
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Abstract
PURPOSE OF REVIEW This article summarizes current understanding of the arrhythmia substrate and effect of catheter ablation for infarct-related ventricular tachycardia, focusing on recent findings. RECENT FINDINGS Clinical studies support the use of catheter ablation earlier in the course of ischemic disease with moderate success in reducing arrhythmia recurrence and shocks from implantable defibrillators, although mortality remains unchanged. Ablation can be lifesaving for patients presenting with electrical storm. Advanced mapping systems with image integration facilitate identification of potential substrate, and several different approaches to manage hemodynamically unstable ventricular tachycardia have emerged. Novel ablation techniques that allow deeper lesion formation are in development. SUMMARY Catheter ablation is an important therapeutic option for preventing or reducing episodes of ventricular tachycardia in patients with ischemic cardiomyopathy. Present technologies allow successful ablation in the majority of patients, even when the arrhythmia is hemodynamically unstable. Failure of the procedure is often because of anatomic challenges that will hopefully be addressed with technological progress.
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40
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Relationships between cardiac innervation/perfusion imbalance and ventricular arrhythmias: impact on invasive electrophysiological parameters and ablation procedures. Eur J Nucl Med Mol Imaging 2016; 43:2383-2391. [DOI: 10.1007/s00259-016-3461-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 07/05/2016] [Indexed: 11/26/2022]
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41
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Proietti R, Roux JF, Verma A, Alturki A, Bernier ML, Essebag V. A Historical Perspective on the Role of Functional Lines of Block in the Re-entrant Circuit of Ventricular Tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:490-6. [PMID: 26852719 DOI: 10.1111/pace.12827] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 01/13/2016] [Accepted: 01/25/2016] [Indexed: 12/29/2022]
Abstract
The ablation strategy for ventricular tachycardia (VT) rapidly evolved from an entrainment mapping approach for identification of the critical isthmus of the re-entrant circuit during monomorphic VT, toward a substrate-based approach aiming to ablate surrogate markers of the circuit during sinus rhythm in hemodynamically nontolerated and polymorphic VT. The latter approach implies an assumption that the circuits responsible for the arrhythmia are anatomical or fixed, and present during sinus rhythm. Accordingly, the lines of block delimiting the channels of the circuits are often considered fixed, although there is evidence that they are functional or more frequently a combination of fixed and functional. The electroanatomical substrate-based approach to VT ablation performed during sinus rhythm is increasingly adopted in clinical practice and often described as scar homogenization, scar dechanneling, or core isolation. However, whether the surrogate markers of the VT circuit during sinus rhythm match the circuit during arrhythmias remains to be fully demonstrated. The myocardial scar is a heterogeneous electrophysiological milieu with complex arrhythmogenic mechanisms that potentially coexist simultaneously. Moreover, the scar consists of different areas of diverse refractoriness and conduction. It can be misleading to limit the arrhythmogenic perspective of the myocardial scar to fixed or anatomical barriers held responsible for the re-entry circuit. Greater understanding of the role of functional lines of block in VT and the validity of the surrogate targets being ablated is necessary to further improve the technique and outcome of VT ablation.
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Affiliation(s)
- Riccardo Proietti
- McGill University Health Center, Montreal, Quebec, Canada.,Cardiology Department, Luigi Sacco Hospital, Milan, Italy
| | - Jean-Francois Roux
- McGill University Health Center, Montreal, Quebec, Canada.,Centre Hospitalier Universite de Sherbrooke, Quebec, Canada
| | - Atul Verma
- McGill University Health Center, Montreal, Quebec, Canada.,Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Ahmed Alturki
- McGill University Health Center, Montreal, Quebec, Canada
| | | | - Vidal Essebag
- McGill University Health Center, Montreal, Quebec, Canada.,Hôpital Sacré-Coeur de Montréal, Montreal, Quebec, Canada
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42
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Wokhlu A. Changing the Way We “See” Scar: How Multimodality Imaging Fits in the Electrophysiology Laboratory. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2016. [DOI: 10.15212/cvia.2016.0004] [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] Open
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43
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John RM, Stevenson W. Current Management of Ventricular Tachycardia: Approaches and Timing. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2016. [DOI: 10.15212/cvia.2015.0015] [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] Open
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44
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Fernández-Armenta J, Penela D, Acosta J, Andreu D, Berruezo A. Approach to ablation of unmappable ventricular arrhythmias. Card Electrophysiol Clin 2015; 7:527-537. [PMID: 26304532 DOI: 10.1016/j.ccep.2015.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Most patients with structural heart disease referred for ventricular tachycardia ablation have unstable tachycardias not suitable for conventional mapping (ie, entrainment mapping). Substrate-guided mapping and ablation during sinus rhythm are intended to overcome the limitations of conventional mapping and ablation. Substrate ablation permits elimination of multiple ventricular tachycardias irrespective of their inducibility during the procedure or their hemodynamic tolerability. Moreover, the elimination/isolation of the arrhythmogenic substrate identified during sinus rhythm has been associated with better outcomes. There is currently no standardized approach for substrate-guided ablation. This article discusses the main aspects of the proposed techniques and substrate ablation targets.
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Affiliation(s)
- Juan Fernández-Armenta
- Arrhythmia Section, Cardiology Department, Puerta del Mar University Hospital, Cádiz, Spain
| | - Diego Penela
- Arrhythmia Section, Cardiology Department, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), Barcelona, Spain
| | - Juan Acosta
- Arrhythmia Section, Cardiology Department, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), Barcelona, Spain
| | - David Andreu
- Arrhythmia Section, Cardiology Department, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), Barcelona, Spain
| | - Antonio Berruezo
- Arrhythmia Section, Cardiology Department, Hospital Clínic and IDIBAPS (Institut d'Investigació Agustí Pi i Sunyer), Barcelona, Spain.
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45
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Yalin K, Golcuk E, Aksu T. Cardiac Magnetic Resonance for Ventricular Arrhythmia Therapies in Patients with Coronary Artery Disease. J Atr Fibrillation 2015; 8:1242. [PMID: 27957178 DOI: 10.4022/jafib.1242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 05/20/2015] [Accepted: 05/20/2015] [Indexed: 11/10/2022]
Abstract
Cardiac magnetic resonance (CMR) imaging is currently gold standard for myocardial tissue characterization and scar assessment. CMR serves potential prognostic information in patients with coronary artery disease (CAD) for both ventricular arrhythmia risk, as well as it may also be used for guiding VT ablation procedures. This review is focused on the usefulness of CMR for ventricular arrhythmia therapies in patients with CAD.
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Affiliation(s)
| | - Ebru Golcuk
- Derince Education and Research Hospital, Turkey
| | - Tolga Aksu
- Bursa State Hospital, Cardiology Clinic, Turkey
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46
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Vergara P, Roque C, Oloriz T, Mazzone P, Della Bella P. Substrate mapping strategies for successful ablation of ventricular tachycardia: a review. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2015; 83:104-11. [PMID: 23668956 DOI: 10.1016/j.acmx.2013.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 02/13/2013] [Accepted: 02/14/2013] [Indexed: 11/27/2022] Open
Abstract
Catheter ablation of ventricular tachycardia (VT) currently has an important role in the treatment of incessant ventricular tachycardia and reduction of the number of episodes of recurrent ventricular tachycardia. Conventional mapping techniques require ongoing tachycardia and haemodynamic stability during the procedure. However, in many patients with scar-related ventricular tachycardia, non-inducibility of clinical tachycardia, poor induction reproducibility, haemodynamic instability, and multiple ventricular tachycardias with frequent spontaneous changes of morphology, preclude tachycardia mapping. To overcome these limitations, new strategies for mapping and ablation in sinus rhythm (SR) - substrate mapping strategies - have been developed and are currently used by many centres. This review summarizes the progresses recently achieved in the ablative treatment of ventricular tachycardia using a substrate mapping approach in patients with structural heart disease.
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Affiliation(s)
- Pasquale Vergara
- Arrhythmia Unit and Electrophysiology Laboratories, San Raffaele Hospital, Milano, Italy.
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47
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Koutalas E, Rolf S, Dinov B, Richter S, Arya A, Bollmann A, Hindricks G, Sommer P. Contemporary Mapping Techniques of Complex Cardiac Arrhythmias - Identifying and Modifying the Arrhythmogenic Substrate. Arrhythm Electrophysiol Rev 2015; 4:19-27. [PMID: 26835095 PMCID: PMC4711490 DOI: 10.15420/aer.2015.4.1.19] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Accepted: 01/12/2015] [Indexed: 12/16/2022] Open
Abstract
Cardiac electrophysiology has moved a long way forward during recent decades in the comprehension and treatment of complex cardiac arrhythmias. Contemporary electroanatomical mapping systems, along with state-of-the-art technology in the manufacture of electrophysiology catheters and cardiac imaging modalities, have significantly enriched our armamentarium, enabling the implementation of various mapping strategies and techniques in electrophysiology procedures. Beyond conventional mapping strategies, ablation of complex fractionated electrograms and rotor ablation in atrial fibrillation ablation procedures, the identification and modification of the underlying arrhythmogenic substrate has emerged as a strategy that leads to improved outcomes. Arrhythmogenic substrate modification also has a major role in ventricular tachycardia ablation procedures. Optimisation of contact between tissue and catheter and image integration are a further step forward to augment our precision and effectiveness. Hybridisation of existing technologies with a reasonable cost should be our goal over the next few years.
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Affiliation(s)
- Emmanuel Koutalas
- Department of Electrophysiology, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Sascha Rolf
- Department of Electrophysiology, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Borislav Dinov
- Department of Electrophysiology, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Sergio Richter
- Department of Electrophysiology, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Arash Arya
- Department of Electrophysiology, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Andreas Bollmann
- Department of Electrophysiology, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
| | - Philipp Sommer
- Department of Electrophysiology, Leipzig Heart Center, University of Leipzig, Leipzig, Germany
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48
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Affiliation(s)
- Samuel J. Asirvatham
- From the Division of Cardiovascular Diseases, Department of Medicine–Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN (S.J.A.); and Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (W.G.S.)
| | - William G. Stevenson
- From the Division of Cardiovascular Diseases, Department of Medicine–Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, MN (S.J.A.); and Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (W.G.S.)
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49
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Tzou WS, Frankel DS, Hegeman T, Supple GE, Garcia FC, Santangeli P, Katz DF, Sauer WH, Marchlinski FE. Core Isolation of Critical Arrhythmia Elements for Treatment of Multiple Scar-Based Ventricular Tachycardias. Circ Arrhythm Electrophysiol 2015; 8:353-61. [DOI: 10.1161/circep.114.002310] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 01/29/2015] [Indexed: 12/21/2022]
Abstract
Background—
Radiofrequency ablation of multiple or unmappable ventricular tachycardias (VTs) remains a challenge with unclear end points. We present our experience with a new strategy isolating core elements of VT circuits.
Methods and Results—
Patients with structural heart disease presenting for VT radiofrequency ablation at 2 centers were included. Strategy involved entrainment/activation mapping if VT was hemodynamically stable, and voltage mapping with electrogram analysis and pacemapping. Core isolation (CI) was performed incorporating putative isthmus and early exit site(s) based on standard criteria. If VT was noninducible, the dense scar (<0.5 mV) region was isolated. Successful CI was defined by exit block (20 mA at 2 ms) within the isolated region. VT inducibility was also assessed. Forty-four patients were included (mean age, 63; 95% male; 73% ischemic cardiomyopathy; mean left ventricular ejection fraction, 31%; 68% with multiple unstable VTs [mean, 3+2]). CI area was 11+12 versus 55+40 cm
2
total scar area. Additional substrate modification was performed in 27 (61%), and epicardial radiofrequency ablation was performed in 4 (9%) patients. CI was achieved in 37 (84%) and led to better VT-free survival (log rank
P
=0.013).
Conclusions—
CI is a novel strategy with a discrete and measurable end point beyond VT inducibility to treat patients with multiple or unmappable VTs. The CI region can be selected based on standard characterization of suspected VT isthmus surrogates thus limiting ablation target size. Exit block within the isolated area is achievable in most and may further improve long-term success.
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Affiliation(s)
- Wendy S. Tzou
- From the Division of Cardiology, Section of Electrophysiology, University of Colorado Health System and School of Medicine, Aurora (W.S.T., T.H., D.F.K., W.H.S.); and Division of Cardiology, Section of Electrophysiology, University of Pennsylvania Health System and School of Medicine, Philadelphia (D.S.F., G.E.S., F.C.G., P.S., F.E.M.)
| | - David S. Frankel
- From the Division of Cardiology, Section of Electrophysiology, University of Colorado Health System and School of Medicine, Aurora (W.S.T., T.H., D.F.K., W.H.S.); and Division of Cardiology, Section of Electrophysiology, University of Pennsylvania Health System and School of Medicine, Philadelphia (D.S.F., G.E.S., F.C.G., P.S., F.E.M.)
| | - Timothy Hegeman
- From the Division of Cardiology, Section of Electrophysiology, University of Colorado Health System and School of Medicine, Aurora (W.S.T., T.H., D.F.K., W.H.S.); and Division of Cardiology, Section of Electrophysiology, University of Pennsylvania Health System and School of Medicine, Philadelphia (D.S.F., G.E.S., F.C.G., P.S., F.E.M.)
| | - Gregory E. Supple
- From the Division of Cardiology, Section of Electrophysiology, University of Colorado Health System and School of Medicine, Aurora (W.S.T., T.H., D.F.K., W.H.S.); and Division of Cardiology, Section of Electrophysiology, University of Pennsylvania Health System and School of Medicine, Philadelphia (D.S.F., G.E.S., F.C.G., P.S., F.E.M.)
| | - Fermin C. Garcia
- From the Division of Cardiology, Section of Electrophysiology, University of Colorado Health System and School of Medicine, Aurora (W.S.T., T.H., D.F.K., W.H.S.); and Division of Cardiology, Section of Electrophysiology, University of Pennsylvania Health System and School of Medicine, Philadelphia (D.S.F., G.E.S., F.C.G., P.S., F.E.M.)
| | - Pasquale Santangeli
- From the Division of Cardiology, Section of Electrophysiology, University of Colorado Health System and School of Medicine, Aurora (W.S.T., T.H., D.F.K., W.H.S.); and Division of Cardiology, Section of Electrophysiology, University of Pennsylvania Health System and School of Medicine, Philadelphia (D.S.F., G.E.S., F.C.G., P.S., F.E.M.)
| | - David F. Katz
- From the Division of Cardiology, Section of Electrophysiology, University of Colorado Health System and School of Medicine, Aurora (W.S.T., T.H., D.F.K., W.H.S.); and Division of Cardiology, Section of Electrophysiology, University of Pennsylvania Health System and School of Medicine, Philadelphia (D.S.F., G.E.S., F.C.G., P.S., F.E.M.)
| | - William H. Sauer
- From the Division of Cardiology, Section of Electrophysiology, University of Colorado Health System and School of Medicine, Aurora (W.S.T., T.H., D.F.K., W.H.S.); and Division of Cardiology, Section of Electrophysiology, University of Pennsylvania Health System and School of Medicine, Philadelphia (D.S.F., G.E.S., F.C.G., P.S., F.E.M.)
| | - Francis E. Marchlinski
- From the Division of Cardiology, Section of Electrophysiology, University of Colorado Health System and School of Medicine, Aurora (W.S.T., T.H., D.F.K., W.H.S.); and Division of Cardiology, Section of Electrophysiology, University of Pennsylvania Health System and School of Medicine, Philadelphia (D.S.F., G.E.S., F.C.G., P.S., F.E.M.)
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Yalin K, Golcuk E, Bilge AK, Aksu T, Buyukbayrak H, Tiryakioglu SK, Emet S, Adalet K. Combined analysis of unipolar and bipolar voltage mapping identifies recurrences after unmappable scar-related ventricular tachycardia ablation. Europace 2015; 17:1580-6. [PMID: 25750215 DOI: 10.1093/europace/euv013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Accepted: 01/19/2015] [Indexed: 11/14/2022] Open
Abstract
AIMS Scars causing ventricular tachycardia can extend deep to and beyond bipolar low-voltage areas (LVAs) and they may be a reason for endocardial ablation failure. Analysis of endocardial unipolar voltage maps has been used to detect scar transmurality and epicardial scar. We hypothesized that endocardial unipolar LVA around the overlying bipolar LVA may predict endocardial ablation recurrence in patients with structural heart disease undergoing substrate modification. METHODS AND RESULTS Twenty consecutive patients with structural heart disease (11 ischaemic and 9 non-ischaemic cardiomyopathy) and undergoing substrate modification due to unmappable ventricular tachycardia (VT) (18 males, 51 ± 11 age, LVEF: 36 ± 7%) were retrospectively reviewed. Bipolar LVA defined as <1.5 mV and unipolar LVA defined as <8.3 mV, respectively, on electro-anatomic mapping system. Peripheral unipolar LVA (pUni-LVA) surrounding bipolar LVA was measured and compared patients with and without VT recurrence at 6-month follow-up period. : Mean unipolar voltage and mean bipolar voltage was 6.26 ± 4.99 and 1.90 ± 2.30 mV, respectively. Bipolar voltage and unipolar voltage in corresponding points were correlated (r = 0.652, P = 0.0001). In all patients, unipolar LVAs were larger than the bipolar LVAs. Bipolar LVA (91.1 ± 93.5 vs. 87.5 ± 47.5 cm(2), P = 0.91) and unipolar LVA (148.1 ± 96.3 vs. 104.7 ± 44.2 cm(2), P = 0.21) were similar in patients with and without VT recurrence, respectively. Peripheral unipolar LVA was significantly larger in patients with VT recurrence than without (57.0 ± 40.4 vs. 17.2 ± 12.9 cm(2), P = 0.01). CONCLUSION In patients with structural heart disease and unmappable VT, pUni-LVA surrounding bipolar scar predicts recurrence of VT ablation. The results of this pilot study highlight the importance of intramural/epicardial substrate on endocardial VT ablation outcome.
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Affiliation(s)
- Kivanc Yalin
- Department of Cardiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul Tıp Fakültesi-Fatih, Fatih, Istanbul 34104, Turkey Cardiology Clinic, Bursa State Hospital, Kliniği Osmangazi, Alaaddin Mh., Bursa 16040, Turkey
| | - Ebru Golcuk
- Department of Cardiology, School of Medicine, Koc University, Davutpaşa Cd. No:4 Topkapı, İstanbul, Turkey
| | - Ahmet Kaya Bilge
- Department of Cardiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul Tıp Fakültesi-Fatih, Fatih, Istanbul 34104, Turkey
| | - Tolga Aksu
- Department of Cardiology, Kocaeli Derice Research and Training Hospital, İbnisina Mh. Lojman Sk. Derince, Kocaeli, Turkey
| | | | - Selma Kenar Tiryakioglu
- Cardiology Clinic, Bursa State Hospital, Kliniği Osmangazi, Alaaddin Mh., Bursa 16040, Turkey
| | - Samim Emet
- Department of Cardiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul Tıp Fakültesi-Fatih, Fatih, Istanbul 34104, Turkey
| | - Kamil Adalet
- Department of Cardiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul Tıp Fakültesi-Fatih, Fatih, Istanbul 34104, Turkey
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