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Masmoudi I, Dindane Z, Richter S, Ebert M. Ventricular arrhythmias in the context of chronic kidney disease and electrolyte imbalance. Herzschrittmacherther Elektrophysiol 2024; 35:211-218. [PMID: 39008102 DOI: 10.1007/s00399-024-01029-7] [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] [Accepted: 05/28/2024] [Indexed: 07/16/2024]
Abstract
Patients with chronic kidney disease face a high risk of sudden cardiac death, particularly in more advanced stages of renal dysfunction. Ventricular arrhythmias are prevalent and contribute to the heightened cardiovascular mortality. This review aims to explore the intricate interplay of disease-specific risk factors, arrhythmic triggers, and electrolyte disorders that amplify susceptibility to ventricular arrhythmias and sudden cardiac death in this population and influence the efficacy of available treatments.
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MESH Headings
- Humans
- Water-Electrolyte Imbalance/etiology
- Water-Electrolyte Imbalance/therapy
- Water-Electrolyte Imbalance/complications
- Water-Electrolyte Imbalance/physiopathology
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Renal Insufficiency, Chronic/complications
- Tachycardia, Ventricular/physiopathology
- Tachycardia, Ventricular/etiology
- Tachycardia, Ventricular/therapy
- Tachycardia, Ventricular/complications
- Arrhythmias, Cardiac/etiology
- Arrhythmias, Cardiac/physiopathology
- Arrhythmias, Cardiac/therapy
- Evidence-Based Medicine
- Risk Factors
- Comorbidity
- Ventricular Fibrillation/etiology
- Ventricular Fibrillation/physiopathology
- Ventricular Fibrillation/therapy
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Affiliation(s)
- Ines Masmoudi
- Division of Electrophysiology, Department for Internal Medicine and Cardiology, Heart Centre Dresden, Faculty of Medicine and University Hospital Carl Gustav Carus, TUD Dresden University of Technology, Dresden, Germany
| | - Zouhir Dindane
- Division of Electrophysiology, Department for Internal Medicine and Cardiology, Heart Centre Dresden, Faculty of Medicine and University Hospital Carl Gustav Carus, TUD Dresden University of Technology, Dresden, Germany
| | - Sergio Richter
- Division of Electrophysiology, Department for Internal Medicine and Cardiology, Heart Centre Dresden, Faculty of Medicine and University Hospital Carl Gustav Carus, TUD Dresden University of Technology, Dresden, Germany
| | - Micaela Ebert
- Division of Electrophysiology, Department for Internal Medicine and Cardiology, Heart Centre Dresden, Faculty of Medicine and University Hospital Carl Gustav Carus, TUD Dresden University of Technology, Dresden, Germany.
- Sektion Rhythmologie, Klinik für Innere Medizin und Kardiologie, Herzzentrum Dresden, Medizinische Fakultät und Universitätsklinikum Carl Gustav Carus, Technische Universität Dresden, Fetscherstr. 76, 01307, Dresden, Germany.
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Sanders D, Du-Fay-de-Lavallaz JM, Winterfield J, Santangeli P, Liang J, Rhodes P, Ravi V, Badertscher P, Mazur A, Larsen T, Sharma PS, Huang HD. Surpoint algorithm for improved guidance of ablation for ventricular tachycardia (SURFIRE-VT): A pilot study. J Cardiovasc Electrophysiol 2024; 35:625-638. [PMID: 38174841 DOI: 10.1111/jce.16165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/27/2023] [Accepted: 12/16/2023] [Indexed: 01/05/2024]
Abstract
INTRODUCTION The utility of ablation index (AI) to guide ventricular tachycardia (VT) ablation in patients with structural heart disease is unknown. The aim of this study was to assess procedural characteristics and clinical outcomes achieved using AI-guided strategy (target value 550) or conventional non-AI-guided parameters in patients undergoing scar-related VT ablation. METHODS Consecutive patients (n = 103) undergoing initial VT ablation at a single center from 2017 to 2022 were evaluated. Patient groups were 1:1 propensity-matched for baseline characteristics. Single lesion characteristics for all 4707 lesions in the matched cohort (n = 74) were analyzed. The impact of ablation characteristics was assessed by linear regression and clinical outcomes were evaluated by Cox proportional hazard model. RESULTS After propensity-matching, baseline characteristics were well-balanced between AI (n = 37) and non-AI (n = 37) groups. Lesion sets were similar (scar homogenization [41% vs. 27%; p = .34], scar dechanneling [19% vs. 8%; p = .18], core isolation [5% vs. 11%; p = .4], linear and elimination late potentials/local abnormal ventricular activities [35% vs. 44%; p = .48], epicardial mapping/ablation [11% vs. 14%; p = .73]). AI-guided strategy had 21% lower procedure duration (-47.27 min, 95% confidence interval [CI] [-81.613, -12.928]; p = .008), 49% lower radiofrequency time per lesion (-13.707 s, 95% CI [-17.86, -9.555]; p < .001), 21% lower volume of fluid administered (1664 cc [1127, 2209] vs. 2126 cc [1750, 2593]; p = .005). Total radiofrequency duration (-339 s [-24%], 95%CI [-776, 62]; p = .09) and steam pops (-155.6%, 95% CI [19.8%, -330.9%]; p = .08) were nonsignificantly lower in the AI group. Acute procedural success (95% vs. 89%; p = .7) and VT recurrence (0.97, 95% CI [0.42-2.2]; p = .93) were similar for both groups. Lesion analysis (n = 4707) demonstrated a plateau in the magnitude of impedance drops once reaching an AI of 550-600. CONCLUSION In this pilot study, an AI-guided ablation strategy for scar-related VT resulted in shorter procedure time and average radiofrequency time per lesion with similar acute procedural and intermediate-term clinical outcomes to a non-AI-guided approach utilizing traditional ablation parameters.
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Affiliation(s)
- David Sanders
- Department of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Jeffrey Winterfield
- Department of Cardiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Jackson Liang
- Department of Cardiology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Venkatesh Ravi
- Department of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Alexander Mazur
- Department of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Timothy Larsen
- Department of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Parikshit S Sharma
- Department of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Henry D Huang
- Department of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
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Freedman BL, Maher TR, Tracey M, Santangeli P, d'Avila A. Procedural Adaptations to Avoid Haemodynamic Instability During Catheter Ablation of Scar-related Ventricular Tachycardia. Arrhythm Electrophysiol Rev 2023; 12:e20. [PMID: 37465104 PMCID: PMC10350657 DOI: 10.15420/aer.2022.24] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/08/2022] [Indexed: 07/20/2023] Open
Abstract
Classically, catheter ablation for scar-related ventricular tachycardia (VT) relied upon activation and entrainment mapping of induced VT. Advances in post-MI therapies have led to VTs that are faster and haemodynamically less stable, because of more heterogeneous myocardial fibrosis patterns. The PAINESD score is one means of identifying patients at highest risk for haemodynamic decompensation during attempted VT induction, who may, therefore, benefit from alternative ablation strategies. One strategy is to use temporary mechanical circulatory support, although this warrants formal assessment of cost-effectiveness. A second strategy is to minimise or avoid VT induction altogether by employing a family of 'substrate'-based approaches aimed at identifying VT isthmuses during sinus or paced rhythm. Substrate mapping techniques are diverse, and focus on the timing, morphology and amplitude of local ventricular electrograms - sometimes aided by advanced non-invasive cardiac imaging modalities. In this review, the evolution of VT ablation over time is discussed, with an emphasis on procedural adaptations to the challenge of haemodynamic instability.
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Affiliation(s)
- Benjamin L Freedman
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, US
| | - Timothy R Maher
- Harvard-Thorndike Electrophysiology Institute and Arrhythmia Service, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, US
| | | | - Pasquale Santangeli
- Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, US
| | - Andre d'Avila
- Harvard-Thorndike Electrophysiology Institute and Arrhythmia Service, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, US
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Vlachos K, Letsas KP, Srinivasan NT, Frontera A, Efremidis M, Dragasis S, Martin CA, Martin R, Nakashima T, Bazoukis G, Kitamura T, Mililis P, Saplaouras A, Georgopoulos S, Sofoulis S, Kariki O, Koskina S, Takigawa M, Sacher F, Jais P, Santangeli P. The value of functional substrate mapping in ventricular tachycardia ablation. Heart Rhythm O2 2023; 4:134-146. [PMID: 36873315 PMCID: PMC9975018 DOI: 10.1016/j.hroo.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
In the setting of structural heart disease, ventricular tachycardia (VT) is typically associated with a re-entrant mechanism. In patients with hemodynamically tolerated VTs, activation and entrainment mapping remain the gold standard for the identification of the critical parts of the circuit. However, this is rarely accomplished, as most VTs are not hemodynamically tolerated to permit mapping during tachycardia. Other limitations include noninducibility of arrhythmia or nonsustained VT. This has led to the development of substrate mapping techniques during sinus rhythm, eliminating the need for prolonged periods of mapping during tachycardia. Recurrence rates following VT ablation are high; therefore, new mapping techniques for substrate characterization are required. Advances in catheter technology and especially multielectrode mapping of abnormal electrograms has increased the ability to identify the mechanism of scar-related VT. Several substrate-guided approaches have been developed to overcome this, including scar homogenization and late potential mapping. Dynamic substrate changes are mainly identified within regions of myocardial scar and can be identified as local abnormal ventricular activities. Furthermore, mapping strategies incorporating ventricular extrastimulation, including from different directions and coupling intervals, have been shown to increase the accuracy of substrate mapping. The implementation of extrastimulus substrate mapping and automated annotation require less extensive ablation and would make VT ablation procedures less cumbersome and accessible to more patients.
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Affiliation(s)
- Konstantinos Vlachos
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- Electrophysiology Department, Onassis Cardiac Surgery Center, Athens, Greece
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
- Address reprint requests and correspondence: Dr Konstantinos Vlachos, Onassis Cardiac Surgery Center, Electrophysiology Department, Syggrou Avenue 356, PC 176 74, Athens, Greece.
| | | | - Neil T. Srinivasan
- Department of Cardiac Electrophysiology, Essex Cardiothoracic Centre, Basildon, United Kingdom
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Antonio Frontera
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - Michael Efremidis
- Electrophysiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Stelios Dragasis
- Electrophysiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Claire A. Martin
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus
| | - Ruaridh Martin
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - Takashi Nakashima
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - George Bazoukis
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus
- Department of Cardiology, Larnaca General Hospital, Larnaca, Cyprus
| | - Takeshi Kitamura
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - Panagiotis Mililis
- Laboratory of Cardiac Electrophysiology, General Hospital of Athens Evangelismos, Athens, Greece
| | | | - Stamatios Georgopoulos
- Laboratory of Cardiac Electrophysiology, General Hospital of Athens Evangelismos, Athens, Greece
| | - Stamatios Sofoulis
- Electrophysiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Ourania Kariki
- Electrophysiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Stavroula Koskina
- Electrophysiology Department, Onassis Cardiac Surgery Center, Athens, Greece
| | - Masateru Takigawa
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - Frédéric Sacher
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - Pierre Jais
- Cardiac Pacing and Electrophysiology Department, Hôpital Cardiologique du Haut Lévêque, Pessac, France
- INSERM U1045, Institut hostpialo-universitaire–L’institut de rythmologie et modélisation cardiaque, Centre Hospitalier Universitaire de Bordeaux, Université de Bordeaux, Pessac, France
| | - Pasquale Santangeli
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Richardson TD, Stevenson WG. High Density Pace-Mapping for Scar-related Ventricular Tachycardia Ablation. J Cardiovasc Electrophysiol 2022; 33:1810-1812. [PMID: 35665563 DOI: 10.1111/jce.15585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 05/26/2022] [Indexed: 11/28/2022]
Abstract
Despite advances in medical and interventional therapies, ventricular tachycardia (VT) due to reentrant activity within complex regions of myocardial scar remains a common late complication of myocardial infarction This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Travis D Richardson
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - William G Stevenson
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Hiruma T, Sekiguchi Y, Nagase T, Nitta J, Isobe M. Short-time ventricular tachycardia ablation for cardiac sarcoidosis using coherent map. J Arrhythm 2022; 38:454-457. [PMID: 35785377 PMCID: PMC9237297 DOI: 10.1002/joa3.12706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 03/06/2022] [Accepted: 03/19/2022] [Indexed: 11/25/2022] Open
Abstract
A 69-year-old woman with isolated cardiac sarcoidosis was hospitalized for frequent appropriate implantable converter defibrillator therapies for ventricular tachycardia (VT) despite of favorably controlled condition with oral prednisolone. The patient underwent urgent catheter ablation with CARTO 3D mapping system. Although the voltage map, activation map, and propagation map during VT could not visualize the tachycardia circuit, the coherent map clarified entrance and exit sites of the tachycardia circuit with slow or nonconducting (SNO) zones, which seemed like a figure-of-eight circuit. Considering the risk of VT termination or acceleration to rapid unstable VT, neither entrainment nor pacing studies were performed. The VT was terminated near the exit site of the isthmus where tiny pre-systolic potential was detected. Any diastolic potentials could not be detected. This meant that the critical isthmus might be located at the epicardium or deep incite of the left-ventricular myocardium where the coherent map showed as SNO zones. We should recognize coherent map as artificial that may represent VT circuit as if complete endocardial reentry even if not. The procedural time from mapping to termination of VT was only 22 minutes. The patient has been free from any cardiovascular events after the procedure. Coherent map might be feasible for revealing the critical isthmus of hemodynamically stable VTs without using electrophysiological techniques, including entrainment, pacing study, and voltage map during own beats, and would enable us to achieve successful VT ablation in a short time.
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Affiliation(s)
- Takashi Hiruma
- Department of CardiologySakakibara Heart InstituteTokyoJapan
| | - Yukio Sekiguchi
- Department of CardiologySakakibara Heart InstituteTokyoJapan
| | - Takahiko Nagase
- Department of CardiologySakakibara Heart InstituteTokyoJapan
| | - Junichi Nitta
- Department of CardiologySakakibara Heart InstituteTokyoJapan
| | - Mitsuaki Isobe
- Department of CardiologySakakibara Heart InstituteTokyoJapan
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Kanagaratnam A, Virk SA, Pham T, Anderson RD, Turnbull S, Campbell T, Bennett R, Thomas SP, Lee G, Kumar S. Catheter Ablation for Ventricular Tachycardia in Ischaemic Versus Non-Ischaemic Cardiomyopathy: A Systematic Review and Meta-Analysis. Heart Lung Circ 2022; 31:1064-1074. [PMID: 35643798 DOI: 10.1016/j.hlc.2022.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/28/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND There are differences in substrate and ablation approaches for ventricular tachycardia (VT) in ischaemic (ICM) and non-ischaemic cardiomyopathy (NICM). OBJECTIVE To perform a systematic review and meta-analysis comparing clinical and procedural characteristics/outcomes of VT ablation in ICM versus NICM. METHODS Electronic databases were searched for comparative studies reporting outcomes of VT ablation in patients with ICM and NICM. Primary outcomes were acute procedural success, VT recurrence and long-term mortality. Meta-analyses were performed using random-effects modelling. RESULTS Thirty-one (31) studies (7,473 patients; 4,418 ICM and 3,055 NICM) were included. Patients with ICM were significantly older (67.0 vs 55.3 yrs), more commonly male (89% vs 79%), had lower left ventricular ejection fraction (29% vs 38%) were less likely to undergo epicardial access (11% vs 36%) and were more likely to require haemodynamic support during ablation (relative risk [RR] 1.30; 95% CI 1.01-1.69). Acute procedural success (i.e. non-inducibility of VT) was higher in the ICM cohort (RR 1.10, 95% CI 1.05-1.15). Recurrence of VT at follow-up was significantly lower in the ICM cohort (RR 0.77; 95% CI 0.70-0.84). Peri-procedural mortality, incidence of procedural complications and long-term mortality were not significantly different between the cohorts. CONCLUSIONS NICM and ICM patients undergoing VT ablation are fundamentally different in their clinical characteristics, ablation approaches, acute procedural outcomes and likelihood of VA recurrence. VT ablation in NICM has a lower likelihood of procedural success with increased risk of VA recurrence, consistent with known challenging arrhythmia substrate.
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Affiliation(s)
| | - Sohaib A Virk
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
| | - Timmy Pham
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia
| | - Robert D Anderson
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia; Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Vic, Australia
| | - Samual Turnbull
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia
| | - Timothy Campbell
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia
| | - Richard Bennett
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia
| | - Stuart P Thomas
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia; Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Vic, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia.
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Impact of substrate-based ablation for ventricular tachycardia in patients with frequent appropriate implantable cardioverter-defibrillator therapy and dilated cardiomyopathy: Long-term experience with high-density mapping. Rev Port Cardiol 2021; 40:865-873. [PMID: 34857160 DOI: 10.1016/j.repce.2021.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 12/15/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Recurrent ventricular tachycardia (VT) episodes have a negative impact on the clinical outcome of implantable cardioverter-defibrillator (ICD) patients. Modification of the arrhythmogenic substrate has been used as a promising approach for treating recurrent VTs. However, there are limited data on long-term follow-up. AIM To analyze long-term results of VT substrate-based ablation using high-density mapping in patients with severe left ventricular (LV) dysfunction and recurrent appropriate ICD therapy. METHODS We analyzed 20 patients (15 men, 55% with non-ischemic cardiomyopathy, age 58±15 years, LV ejection fraction 32±5%) and repeated appropriate shocks or arrhythmic storm (>2 shocks/24 h) despite antiarrhythmic drug therapy and optimal heart failure medication. All patients underwent ventricular programmed stimulation (600 ms/S3) to document VT. A sinus rhythm (SR) voltage map was created with a three-dimensional electroanatomic mapping system (CARTO, Biosense Webster, CA) using a PentaRay® high-density mapping catheter (Biosense Webster, CA) to delineate areas of scarred myocardium (ventricular bipolar voltage ≤0.5 mV - dense scar; 0.5-1.5 mV - border zone; ≥1.5 mV - healthy tissue) and to provide high-resolution electrophysiological mapping. Substrate modification included elimination of local abnormal ventricular activities (LAVAs) during SR (fractionated, split, low-amplitude/long-lasting, late potentials, pre-systolic), and linear ablation to obtain scar homogenization and dechanneling. Pace-mapping techniques were used when capture was possible. The LV approach was retrograde in nine cases, transseptal in five and epi-endocardial in four. In two patients ablation was performed inside the right ventricle. RESULTS LAVAs and scar areas were modified in all patients. Mean procedure duration was 149 min (105-220 min), with radiofrequency ranging from 18 to 70 min (mean 33 min) and mean fluoroscopy time of 15 min. Non-inducibility was achieved in 75% of cases (in four patients with hemodynamic deterioration and an LV assist device, VT inducibility was not performed). There were two cases of pericardial tamponade, drained successfully. During a follow-up of 50±24 months, 65% had no VT recurrences. Among the seven patients with recurrences, three underwent redo ablation and four, with fewer VT episodes, received appropriate ICD therapy. There were five hospital readmissions due to heart failure decompensation, one patient died in the first week after unsuccessful ablation of a VT storm and three died (stroke and pneumonia) >1 year after ablation. CONCLUSION Catheter ablation based on substrate modification is feasible and safe in patients with frequent VTs and severe LV dysfunction. This approach may be of clinical relevance, with potential long-term benefits in reducing VT burden.
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Oliveira M, Cunha P, Valente B, Portugal G, Lousinha A, Pereira M, Braz M, Delgado A, Ferreira RC. Impact of substrate-based ablation for ventricular tachycardia in patients with frequent appropriate implantable cardioverter-defibrillator therapy and dilated cardiomyopathy: Long-term experience with high-density mapping. Rev Port Cardiol 2021. [DOI: 10.1016/j.repc.2020.12.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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10
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Masjedi M, Jungen C, Kuklik P, Alken FA, Kahle AK, Klatt N, Scherschel K, Lorenz J, Meyer C. A novel algorithm for 3-D visualization of electrogram duration for substrate-mapping in patients with ischemic heart disease and ventricular tachycardia. PLoS One 2021; 16:e0254683. [PMID: 34260658 PMCID: PMC8279369 DOI: 10.1371/journal.pone.0254683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 06/30/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Myocardial slow conduction is a cornerstone of ventricular tachycardia (VT). Prolonged electrogram (EGM) duration is a useful surrogate parameter and manual annotation of EGM characteristics are widely used during catheter-based ablation of the arrhythmogenic substrate. However, this remains time-consuming and prone to inter-operator variability. We aimed to develop an algorithm for 3-D visualization of EGM duration relative to the 17-segment American Heart Association model. METHODS To calculate and visualize EGM duration, in sinus rhythm acquired high-density maps of patients with ischemic cardiomyopathy undergoing substrate-based VT ablation using a 64-mini polar basket-catheter with low noise of 0.01 mV were analyzed. Using a custom developed algorithm based on standard deviation and threshold, the relationship between EGM duration, endocardial voltage and ablation areas was studied by creating 17-segment 3-D models and 2-D polar plots. RESULTS 140,508 EGMs from 272 segments (n = 16 patients, 94% male, age: 66±2.4, ejection fraction: 31±2%) were studied and 3-D visualization of EGM duration was performed. Analysis of signal processing parameters revealed that a 40 ms sliding SD-window, 15% SD-threshold and >70 ms EGM duration cutoff was chosen based on diagnostic odds ratio of 12.77 to visualize rapidly prolonged EGM durations. EGMs > 70 ms matched to 99% of areas within dense scar (<0.2 mV), in 95% of zones within scar border zone (0.2-1.0 mV) and detected ablated areas having resulted in non-inducibility at the end of the procedure. Ablation targets were identified with a sensitivity of 65.6% and a specificity of 94.6% avoiding false positive labeling of prolonged EGMs in segments with healthy myocardium. CONCLUSION The novel algorithm allows rapid visualization of prolonged EGM durations. This may facilitate more objective characterization of arrhythmogenic substrate in patients with ischemic cardiomyopathy.
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Affiliation(s)
- Mustafa Masjedi
- Department of Cardiology, Angiology and Intensive Care, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Düsseldorf, Germany
- Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Christiane Jungen
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
- Department of Cardiology, University Heart & Vascular Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Pawel Kuklik
- Department of Cardiology, Asklepios Hospital St. Georg, Hamburg, Germany
| | - Fares-Alexander Alken
- Department of Cardiology, Angiology and Intensive Care, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Düsseldorf, Germany
- Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ann-Kathrin Kahle
- Department of Cardiology, Angiology and Intensive Care, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Düsseldorf, Germany
- Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Niklas Klatt
- Department of Cardiology, Schoen Hospital Neustadt, Neustadt in Holstein, Germany
| | - Katharina Scherschel
- Department of Cardiology, Angiology and Intensive Care, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Düsseldorf, Germany
- Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
| | - Jürgen Lorenz
- Faculty of Life Sciences, Department of Biomedical Engineering, Applied Science University Hamburg, Hamburg, Germany
| | - Christian Meyer
- Department of Cardiology, Angiology and Intensive Care, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Düsseldorf, Germany
- Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Germany
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11
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Della Bella P, Radinovic A, Limite LR, Baratto F. Mechanical circulatory support in the management of life-threatening arrhythmia. Europace 2020; 23:1166-1178. [PMID: 33382868 DOI: 10.1093/europace/euaa371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 11/30/2020] [Indexed: 11/12/2022] Open
Abstract
Life-threatening refractory unstable ventricular arrhythmias in presence of advanced heart failure (HF) may determine haemodynamic impairment. Haemodynamic mechanical support (HMS) in this setting has a relevant role to restore end-organ perfusion. Catheter ablation (CA) of ventricular tachycardia (VT) is effective at achieving rhythm stabilization, allowing patient's weaning from HMS, or bridging to permanent HF treatments. Acute heart decompensation during CA at anaesthesia induction in presence of advanced heart disease, in selected cases requires a preemptive HMS to prevent periprocedure adverse outcomes. Substrate ablation during sinus rhythm (SR) might be an effective strategy of ablation in presence of unstable VTs; however, in a minority of patients, it might have some limitations and might be unfeasible in some settings, including the case of the mechanical induction of several unstable VTs and the absence of ablation targets. In case of the persistent induction of unstable VTs after a previous failure of a substrate-based ablation in SR, a feasible alternative strategy of ablation might be VT activation/entrainment mapping supported by HMS. Multiple devices are available for HMS in the low-output states related to electrical storm and during CA of VT. The choice of the device is not standardized and it is based on the centres' expertise. The aim of this article is to provide an up-to-date review on HMS for the management of life-threatening arrhythmias, in the context of catheter ablation and discussing our approach to manage critical VT patients.
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Affiliation(s)
- Paolo Della Bella
- Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery, Ospedale San Raffaele, via Olgettina 60, Milan, Italy
| | - Andrea Radinovic
- Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery, Ospedale San Raffaele, via Olgettina 60, Milan, Italy
| | - Luca Rosario Limite
- Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery, Ospedale San Raffaele, via Olgettina 60, Milan, Italy
| | - Francesca Baratto
- Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery, Ospedale San Raffaele, via Olgettina 60, Milan, Italy
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12
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Chen Q, Pollet M, Mehta A, Wang S, Dean J, Parenti J, Rojas-Delgado F, Simpson L, Cheng J, Mathuria N. Delayed removal of a percutaneous left ventricular assist device for patients undergoing catheter ablation of ventricular tachycardia is associated with increased 90-day mortality. J Interv Card Electrophysiol 2020; 62:49-56. [PMID: 32949304 DOI: 10.1007/s10840-020-00875-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 09/10/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Assess if timing of removal of a percutaneous left ventricular assist device (pLVAD) after ventricular tachycardia (VT) ablation alters patient outcomes. METHODS Sixty-nine patients underwent pLVAD support. Patients were divided into early (< 24 h, n = 43) and delayed (≥ 24 h, n = 26) removal groups after ablation. Factors for delayed pLVAD removal and predictors of 90-day mortality were analyzed. RESULTS The delayed removal group had lower LVEF (27.1 ± 9.3% vs. 20.6 ± 5.4%, p = 0.002), greater percentage LVEF < 25% (58.1% vs. 84.6%, p = 0.02), and more VT storm (41.9% vs. 96.2%, p < 0.001). Ventricular fibrillation (VF) was induced in 9/69 (13%), with incidence higher in delayed removal group (27% vs. 5%, p = 0.002). VT storm (OR = 34.72, 95% CI, 4.30-280.33; p = 0.001), LVEF < 25% (OR = 3.95, 95% CI, 1.16-13.48; p = 0.03), and VF induced during ablation (OR = 9.25, 95% CI, 1.71-50.0; p = 0.01) were associated with delayed pLVAD removal in univariate analysis. Delayed pLVAD removal had a significantly higher 90-day mortality rate (2.3% vs 30.2%; p < 0.001). Univariate Cox proportional hazard regression analysis revealed delayed pLVAD removal was a significant predictor of 90-day mortality. CONCLUSIONS Prolonged pLVAD insertion (≥ 24 h) after VT ablation was associated with VT storm, LVEF < 25%, and VF induced during ablation. Delayed pLVAD removal was a significant predictor of 90-day mortality in patients undergoing VT ablation.
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Affiliation(s)
- Qi Chen
- Division of Cardiac Electrophysiology, Texas Heart Institute, MC 2-225, PO BOX 20345, Houston, TX, 77225-0345, USA
| | - Mark Pollet
- Division of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Adwait Mehta
- Division of Cardiac Electrophysiology, Texas Heart Institute, MC 2-225, PO BOX 20345, Houston, TX, 77225-0345, USA
| | - Shuyu Wang
- Texas A&M University, College Station, TX, USA
| | - Juliette Dean
- Division of Cardiac Electrophysiology, Texas Heart Institute, MC 2-225, PO BOX 20345, Houston, TX, 77225-0345, USA
| | - Jennifer Parenti
- Division of Cardiac Electrophysiology, Texas Heart Institute, MC 2-225, PO BOX 20345, Houston, TX, 77225-0345, USA
| | - Francia Rojas-Delgado
- Division of Cardiac Electrophysiology, Texas Heart Institute, MC 2-225, PO BOX 20345, Houston, TX, 77225-0345, USA
| | - Leo Simpson
- Division of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Jie Cheng
- Division of Cardiac Electrophysiology, Texas Heart Institute, MC 2-225, PO BOX 20345, Houston, TX, 77225-0345, USA
| | - Nilesh Mathuria
- Division of Cardiac Electrophysiology, Texas Heart Institute, MC 2-225, PO BOX 20345, Houston, TX, 77225-0345, USA.
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13
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Pisani CF, Romero J, Lara S, Hardy C, Chokr M, Sacilotto L, Wu TC, Darrieux F, Hachul D, Kalil-Filho R, Di Biase L, Scanavacca M. Efficacy and safety of combined endocardial/epicardial catheter ablation for ventricular tachycardia in Chagas disease: A randomized controlled study. Heart Rhythm 2020; 17:1510-1518. [DOI: 10.1016/j.hrthm.2020.02.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 02/11/2020] [Indexed: 10/25/2022]
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14
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Anderson RD, Lee G, Campbell T, Bennett RG, Kizana E, Watts T, Kalman J, Kumar S. Scar nonexcitability using simultaneous pacing for substrate ablation of ventricular tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:1219-1234. [PMID: 32720390 DOI: 10.1111/pace.14025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/21/2020] [Accepted: 07/26/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To describe an expedited strategy of simultaneous high-output pacing during radiofrequency ablation to achieve scar homogenization and electrical inexcitability as an approach for substrate ablation for scar-related ventricular tachycardia (VT). BACKGROUND Scar homogenization with additional testing for electrical inexcitability is known endpoints for catheter ablation, but achieving both can be time consuming. We describe a strategy of simultaneous pacing during radiofrequency ablation to expedite this approach. METHODS AND RESULTS Ten patients (age 74 ± 6 years; all men, (LV) ejection fraction of 33% ± 8%, ischemic cardiomyopathy, 9; VT storm, 7) underwent scar homogenization with electrical inexcitability to pacing (10 mA, 9 ms pulse width), as well as noninducibility of any VT as an acute procedural endpoint. Thirty-four VTs were inducible in 10 patients with a total of 1127 ablation lesions applied. Median ablation lesions per patient were 97 (interquartile range [IQR]25-75 71-151), and the total ablation time was 49 minutes (IQR25-75 45-56 minutes) with average duration per lesion of 32.2 seconds (IQR25-75 25.8-37.8 seconds). Average power was 33 W (IQR25-75 32-38 W), average contact force was 13 g (IQR25-75 11.9-14.6 g) with a median impedance drop of 9.6 Ω/lesion (IQR25-75 8.1-10.0 Ω). There were no ventricular fibrillation episodes using this strategy. The median procedure time was 246 minutes (IQR25-75 214-293 minutes). Acute procedural success was seen in nine patients with 97% of VTs noninducible. CONCLUSION Simultaneous ablation with high output pacing to achieve scar inexcitability, when combined with scar homogenization and noninducibility of any VT may be an expeditious, safe, and effective technique for catheter ablation.
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Affiliation(s)
- Robert D Anderson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia.,Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Timothy Campbell
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Richard G Bennett
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Eddy Kizana
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Troy Watts
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia.,Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
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15
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Aleong RG, Chang S. Can Ablation for Atrial Fibrillation Be Simpler?: Are Urethral Catheters Unnecessary in Atrial Fibrillation Ablations? JACC Clin Electrophysiol 2020; 6:191-192. [PMID: 32081222 DOI: 10.1016/j.jacep.2019.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/02/2019] [Accepted: 12/03/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Ryan G Aleong
- Section of Cardiac Electrophysiology, University of Colorado Hospital, Aurora, Colorado, USA.
| | - Shu Chang
- Section of Cardiac Electrophysiology, University of Colorado Hospital, Aurora, Colorado, USA
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16
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König S, Ueberham L, Müller-Röthing R, Wiedemann M, Ulbrich M, Sause A, Tebbenjohanns J, Schade A, Shin DI, Staudt A, Andrié R, Neuser H, Kuhlen R, Arya A, Hindricks G, Bollmann A. Catheter ablation of ventricular arrhythmias and in-hospital mortality: insights from the German-wide Helios hospital network of 5052 cases. Europace 2020; 22:100-108. [PMID: 31638643 DOI: 10.1093/europace/euz260] [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: 08/01/2019] [Accepted: 08/27/2019] [Indexed: 11/13/2022] Open
Abstract
AIMS Catheter ablation (CA) of ventricular arrhythmias is one of the most challenging electrophysiological interventions with an increasing use over the last years. Several benefits must be weighed against the risk of potentially life-threatening complications which necessitates a steady reevaluation of safety endpoints. Therefore, the aims of this study were (i) to investigate overall in-hospital mortality in patients undergoing such procedures and (ii) to identify variables associated with in-hospital mortality in a German-wide hospital network. METHODS AND RESULTS Between January 2010 and September 2018, administrative data provided by 85 Helios hospitals were screened for patients with main or secondary discharge diagnosis of ventricular tachycardia (VT) or premature ventricular contractions (PVCs) in combination with an arrhythmia-related CA using ICD- and OPS codes. In 5052 cases (mean age 60.9 ± 14.3 years, 30.1% female) of 30 different hospitals, in-hospital mortality was 1.27% with a higher mortality in patients ablated for VT (1.99%, n = 2, 955) compared to PVC (0.24%, n = 2, 097, P < 0.01). Mortality rates were 2.06% in patients with ischaemic heart disease (IHD, n = 2, 137), 1.47% in patients with non-ischaemic structural heart disease (NIHD, n = 1, 224), and 0.12% in patients without structural heart disease (NSHD, n = 1, 691). Considering different types of hospital admission, mortality rates were 0.35% after elective (n = 2, 825), 1.60% after emergency admission/hospital transfer <24 h (n = 1, 314) and 3.72% following delayed hospital transfer >24 h after initial admission (n = 861, P < 0.01 vs. elective admission and emergency admission/hospital transfer <24 h). In multivariable analysis, a delayed hospital transfer >24 h [odds ratio (OR) 2.28, 95% confidence interval (CI) 1.59-3.28, P < 0.01], the occurrence of procedure-related major adverse events (OR 6.81, 95% CI 2.90-16.0, P < 0.01), Charlson Comorbidity Index (CCI, OR 2.39, 95% CI 1.56-3.66, P < 0.01) and its components congestive heart failure (OR 8.04, 95% CI 1.71-37.8, P < 0.01), and diabetes mellitus (OR 1.59, 95% CI 1.13-2.22, P < 0.01) were significantly associated with in-hospital death. CONCLUSIONS We reported in-hospital mortality rates after CA of ventricular arrhythmias in the largest multicentre, administrative dataset in Germany which can be implemented in quality management programs. Aside from comorbidities, a delayed hospital transfer to a CA performing centre is associated with an increased in-hospital mortality. This deserves further studies to determine the optimal management strategy.
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Affiliation(s)
- Sebastian König
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Strümpellstraße 39, Leipzig, Germany.,Leipzig Heart Institute, Leipzig, Germany
| | - Laura Ueberham
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Strümpellstraße 39, Leipzig, Germany.,Leipzig Heart Institute, Leipzig, Germany
| | | | - Michael Wiedemann
- Department of Cardiology, Helios Hospital Berlin-Buch, Berlin, Germany
| | - Michael Ulbrich
- Department of Internal Medicine I, Helios Hospital München West, München, Germany
| | - Armin Sause
- Department of Cardiology, Helios University Hospital Wuppertal, Wuppertal, Germany
| | | | - Anja Schade
- Department of Cardiology, Helios Hospital Erfurt, Erfurt, Germany
| | - Dong-In Shin
- Department of Cardiology, Helios Hospital Krefeld, Krefeld, Germany
| | - Alexander Staudt
- Department of Cardiology and Angiology, Helios Hospital Schwerin, Schwerin, Germany
| | - René Andrié
- Department of Cardiology, Helios Hospital Siegburg, Siegburg, Germany
| | - Hans Neuser
- Department of Internal Medicine II, Helios Hospital Plauen, Plauen, Germany
| | | | - Arash Arya
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Strümpellstraße 39, Leipzig, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Strümpellstraße 39, Leipzig, Germany.,Leipzig Heart Institute, Leipzig, Germany
| | - Andreas Bollmann
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Strümpellstraße 39, Leipzig, Germany.,Leipzig Heart Institute, Leipzig, Germany
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17
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Chang S, Tzou WS. Advances in Technologies to Improve Ventricular Ablation Safety and Efficacy. CURRENT CARDIOVASCULAR RISK REPORTS 2019. [DOI: 10.1007/s12170-019-0628-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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18
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Aziz Z, Shatz D, Raiman M, Upadhyay GA, Beaser AD, Besser SA, Shatz NA, Fu Z, Jiang R, Nishimura T, Liao H, Nayak HM, Tung R. Targeted Ablation of Ventricular Tachycardia Guided by Wavefront Discontinuities During Sinus Rhythm. Circulation 2019; 140:1383-1397. [DOI: 10.1161/circulationaha.119.042423] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Accurate and expedited identification of scar regions most prone to reentry is needed to guide ventricular tachycardia (VT) ablation. We aimed to prospectively assess outcomes of VT ablation guided primarily by the targeting of deceleration zones (DZ) identified by propagational analysis of ventricular activation during sinus rhythm.
Methods:
Patients with scar-related VT were prospectively enrolled in the University of Chicago VT Ablation Registry between 2016 and 2018. Isochronal late activation maps annotated to the latest local electrogram deflection were created with high-density multielectrode mapping catheters. Targeted ablation of DZ (>3 isochrones within 1cm radius) was performed, prioritizing later activated regions with maximal isochronal crowding. When possible, activation mapping of VT was performed, and successful ablation sites were compared with DZ locations for mechanistic correlation. Patients were prospectively followed for VT recurrence and mortality.
Results:
One hundred twenty patients (median age 65 years [59-71], 15% female, 50% nonischemic, median ejection fraction 31%) underwent 144 ablation procedures for scar-related VT. 57% of patients had previous ablation and epicardial access was employed in 59% of cases. High-density mapping during baseline rhythm was performed (2518 points [1615-3752] endocardial, 5049±2580 points epicardial) and identified an average of 2±1 DZ, which colocalized to successful termination sites in 95% of cases. The median total radiofrequency application duration was 29 min (21-38 min) to target DZ, representing ablation of 18% of the low-voltage area. At 12±10 months, 70% freedom from VT recurrence (80% in ischemic cardiomyopathy and 63% in nonischemic cardiomyopathy) was achieved. The overall survival rate was 87%.
Conclusions:
A novel voltage-independent high-density mapping display can identify the functional substrate for VT during sinus rhythm and guide targeted ablation, obviating the need for extensive radiofrequency delivery. Regions with isochronal crowding during the baseline rhythm were predictive of VT termination sites, providing mechanistic evidence that deceleration zones are highly arrhythmogenic, functioning as niduses for reentry.
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Affiliation(s)
- Zaid Aziz
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
| | - Dalise Shatz
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
| | - Michael Raiman
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
- Abbott, Abbott Park, IL (M.R., N.A.S.)
| | - Gaurav A Upadhyay
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
| | - Andrew D. Beaser
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
| | - Stephanie A. Besser
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
| | | | - Zihuan Fu
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
| | - Ruhong Jiang
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
| | - Takuro Nishimura
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
| | - Hongtao Liao
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
| | - Hemal M. Nayak
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
| | - Roderick Tung
- Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Division of Cardiology, University of Chicago, IL (Z.A., D.S., M.R., G.A.U., A.B., S.A.B., Z.F., R.J., T.N., H.L, H.M.N., R.T.)
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19
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Launer H, Clark T, Dewland T, Henrikson CA, Nazer B. An automated fractionation mapping algorithm for mapping of scar-based ventricular tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:1133-1140. [PMID: 31257596 DOI: 10.1111/pace.13758] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 05/14/2019] [Accepted: 06/20/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Mapping and ablation of fractionated electrograms is a common treatment for scar-based ventricular tachycardia (VT). An automated algorithm has been developed for rapid "fractionation mapping." METHODS Electroanatomic maps from 21 ablation procedures (14 scar-based VT and seven control idiopathic VT/premature ventricular contractions with normal voltage) were retrospectively analyzed using the Ensite Precision fractionation map (fMap; Abbott Laboratories; Abbott Park, IL, USA) algorithm. For each study, voltage maps and 30 fMaps were generated using combinations of parameters: width (5, 10, 20 ms), refractory time (15, 30 ms), sensitivity (0.1, 0.2 mV), and fractionation threshold (2, 3, 5). Parameter sensitivity was assessed by overlap of fractionated areas (fArea) with successful VT ablation sites (defined by entrainment and/or pace mapping). Specificity was assessed by presence of fractionated areas in control patients. RESULTS Of the 30 fMap parameter sets tested, seven identified >50% of scar-based VT ablation sites, and 26 contained <5 cm2 fractionation on control fMaps. Three combinations of fMap width/refractory/sensitivity/threshold parameters met both of the above criteria, and 20/30/0.1/2 identified the most VT ablation sites (79%) and generated 42.3 ± 28.2 cm2 of fArea on scar-based VT maps compared with 4.9 ± 3.2 cm2 on control maps (P = .001). None of the control patients and 23% of the scar-based VT patients had VT recurrence at mean 15 month follow-up. CONCLUSION Careful selection of signal processing parameters optimizes sensitivity and specificity of automated fractionation mapping for scar-based VT. Real-time use of fMap algorithms may reduce VT ablation procedure time and improve substrate modification, which may improve outcomes.
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Affiliation(s)
- Hunter Launer
- Rosalind Franklin University of Medicine and Science, Chicago, Illinois
| | - Tom Clark
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - Thomas Dewland
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - Charles A Henrikson
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon
| | - Babak Nazer
- Rosalind Franklin University of Medicine and Science, Chicago, Illinois
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20
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Performance of Prognostic Heart Failure Models in Patients With Nonischemic Cardiomyopathy Undergoing Ventricular Tachycardia Ablation. JACC Clin Electrophysiol 2019; 5:801-813. [PMID: 31320008 DOI: 10.1016/j.jacep.2019.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/27/2019] [Accepted: 04/18/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVES This study sought to assess the performance of established risk models in predicting outcomes after catheter ablation (CA) in patients with nonischemic dilated cardiomyopathy (NIDCM) and ventricular tachycardia (VT). BACKGROUND A correct pre-procedural risk stratification of patients with NIDCM and VT undergoing CA is crucial. The performance of different pre-procedural risk stratification approaches to predict outcomes of CA of VT in patients with NIDCM is unknown. METHODS The study compared the performance of 8 prognostic scores (SHFM [Seattle Heart Failure Model], MAGGIC [Meta-analysis Global Group in Chronic Heart Failure], ADHERE [Acute Decompensated Heart Failure National Registry], EFFECT [Enhanced Feedback for Effective Cardiac Treatment-Heart Failure], OPTIMIZE-HF [Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure], CHARM [Candesartan in Heart Failure-Assessment of Reduction in Mortality], EuroSCORE [European System for Cardiac Operative Risk Evaluation], and PAINESD [Chronic Obstructive Pulmonary Disease, Age > 60 Years, Ischemic Cardiomyopathy, New York Heart Association Functional Class III or IV, Ejection Fraction <25%, Presentation With VT Storm, Diabetes Mellitus]) for the endpoints of death/cardiac transplantation and VT recurrence in 282 consecutive patients (age 59 ± 15 years, left ventricular ejection fraction: 36 ± 13%) with NIDCM undergoing CA of VT. Discrimination and calibration of each model were evaluated through area under the curve (AUC) of receiver-operating characteristic curve and goodness-of-fit test. RESULTS After a median follow-up of 48 (interquartile range: 19-67) months, 43 patients (15%) died, 24 (9%) underwent heart transplantation, and 58 (21%) experienced VT recurrence. The prognostic accuracy of SHFM (AUC = 0.89; goodness-of-fit p = 0.68 for death/transplant and AUC = 0.77; goodness-of-fit p = 0.16 for VT recurrence) and PAINESD (AUC = 0.83; goodness-of-fit p = 0.24 for death/transplant and AUC = 0.68; goodness-of-fit p = 0.58 for VT recurrence) were significantly superior to that of other scores. CONCLUSIONS In patients with NIDCM and VT undergoing CA, the SHFM and PAINESD risk scores are powerful predictors of recurrent VT and death/transplant during follow-up, with similar performance and significantly superior to other scores. A pre-procedural calculation of the SHFM and PAINESD can be useful to predict outcomes.
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Affiliation(s)
- Kalyanam Shivkumar
- From the University of California, Los Angeles (UCLA), Cardiac Arrhythmia Center and Electrophysiology Programs, David Geffen School of Medicine at UCLA, Los Angeles
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22
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Gunda S, Padala SK, Saini A, Kang L, Ellenbogen KA, Koneru JN. Risk score model for predicting complications in patients undergoing ventricular tachycardia ablation: insights from the National Inpatient Sample database. Europace 2019; 21:475-483. [PMID: 30304357 DOI: 10.1093/europace/euy213] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 09/01/2018] [Indexed: 11/14/2022] Open
Abstract
AIMS Outcome data on ventricular tachycardia (VT) ablation has been limited to few experienced centres. We sought to identify complication rates, predictors, and create a risk score model for predicting complications in patients from real-world data. METHODS AND RESULTS A total of 25 451 patients undergoing VT ablation from year 2006 to 2013 were identified from the National Inpatient Sample (NIS) database. The whole cohort was randomly divided into derivation cohort to derive the model and validation cohort to validate the model. Multivariate predictors of any complication were identified using regression model. Each predictor was assigned a risk score and each patient was assigned to one of the four groups (risk score in parenthesis) based on total combined risk score: Group 0 (0), Group 1 (1-5), Group 2 (6-10), and Group 3 (>11). The rate of 'any complication' and 'in-hospital mortality' in whole cohort was 14.7% and 2.8%, respectively. The predictors of any complication include chronic kidney disease, coagulopathy, chronic liver disease, stroke (cerebrovascular accident), emergency procedure, age ≥ 65 years, coronary artery disease, peripheral vascular disease, and female gender. There was a significant increase in complication rate in a linear fashion as the risk score increased. The incidence of any complications increased from 2.7% in Group 0 to 31% in Group 3. The risk score model performed well in predicting complications associated with VT ablation. CONCLUSION Patients with higher risk scores have significant increase in any complication and in-hospital mortality from VT ablation. The simple risk score model can help to risk stratify patients prior to VT ablation.
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Affiliation(s)
- Sampath Gunda
- Pauley Heart Center, Division of Cardiology, Virginia Commonwealth University, Gateway Building, 3rd Floor, 3-216, 1200 East Marshall St, Richmond, VA, USA
| | - Santosh K Padala
- Pauley Heart Center, Division of Cardiology, Virginia Commonwealth University, Gateway Building, 3rd Floor, 3-216, 1200 East Marshall St, Richmond, VA, USA
| | - Aditya Saini
- Pauley Heart Center, Division of Cardiology, Virginia Commonwealth University, Gateway Building, 3rd Floor, 3-216, 1200 East Marshall St, Richmond, VA, USA
| | - Le Kang
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA, USA
| | - Kenneth A Ellenbogen
- Pauley Heart Center, Division of Cardiology, Virginia Commonwealth University, Gateway Building, 3rd Floor, 3-216, 1200 East Marshall St, Richmond, VA, USA
| | - Jayanthi N Koneru
- Pauley Heart Center, Division of Cardiology, Virginia Commonwealth University, Gateway Building, 3rd Floor, 3-216, 1200 East Marshall St, Richmond, VA, USA
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23
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Feasibility of Performing Radiofrequency Catheter Ablation and Endomyocardial Biopsy in the Same Setting. Am J Cardiol 2018; 121:1373-1379. [PMID: 29580630 DOI: 10.1016/j.amjcard.2018.02.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 01/28/2018] [Accepted: 02/06/2018] [Indexed: 01/11/2023]
Abstract
In patients with unexplained cardiomyopathy, electroanatomical mapping can identify abnormal tissue to target during electrophysiology-guided endomyocardial biopsy (EP-guided EMB). The objective of this study is to determine whether catheter ablation performed in the same setting as EP-guided EMB increases procedural risk. Sixty-seven patients (mean age 54.4 ± 13.8, 57% male) undergoing EP-guided EMB were included. Radiofrequency catheter ablation was performed in 17 patients (25%) for ventricular arrhythmias and in 2 (3%) for typical atrial flutter. Femoral arterial access was obtained in 90% ablation patients and 40% biopsy-only patients; vascular access complications were more common in the ablation group than in the EMB-only group (p = 0.02). There were no significant differences in rate of tricuspid regurgitation, thromboembolism, or pericardial effusion, whether procedural anticoagulation was used. In conclusion, catheter ablation and procedural anticoagulation can be combined with EP-guided EMB with an increased risk of vascular access complications, but no significant increase in intracardiac complications.
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Porta-Sánchez A, Jackson N, Lukac P, Kristiansen SB, Nielsen JM, Gizurarson S, Massé S, Labos C, Viswanathan K, King B, Ha AC, Downar E, Nanthakumar K. Multicenter Study of Ischemic Ventricular Tachycardia Ablation With Decrement-Evoked Potential (DEEP) Mapping With Extra Stimulus. JACC Clin Electrophysiol 2018; 4:307-315. [DOI: 10.1016/j.jacep.2017.12.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 12/07/2017] [Accepted: 12/11/2017] [Indexed: 10/18/2022]
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25
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Saksena S, Slee A. Atrial fibrillation and its pernicious role in heart failure with preserved ejection fraction: a new frontier in interventional electrophysiology. J Interv Card Electrophysiol 2018; 51:89-90. [PMID: 29480345 DOI: 10.1007/s10840-018-0341-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Sanjeev Saksena
- Rutgers' - Robert Wood Johnson Medical School, Piscataway, NJ, USA.
- Electrophysiology Research Foundation, 161 Washington Valley Road, Suite 201, Warren, NJ, 07059J, USA.
| | - April Slee
- Electrophysiology Research Foundation, 161 Washington Valley Road, Suite 201, Warren, NJ, 07059J, USA
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26
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Tang PT, Do DH, Li A, Boyle NG. Team Management of the Ventricular Tachycardia Patient. Arrhythm Electrophysiol Rev 2018; 7:238-246. [PMID: 30588311 DOI: 10.15420/aer.2018.37.2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Accepted: 08/03/2018] [Indexed: 12/16/2022] Open
Abstract
Ventricular tachycardia is a common arrhythmia in patients with structural heart disease and heart failure, and is now seen more frequently as these patients survive longer with modern therapies. In addition, these patients often have multiple comorbidities. While anti-arrhythmic drug therapy, implantable cardioverter-defibrillator implantation and ventricular tachycardia ablation are the mainstay of therapy, well managed by the cardiac electrophysiologist, there are many other facets in the care of these patients, such as heart failure management, treatment of comorbidities and anaesthetic interventions, where the expertise of other specialists is essential for optimal patient care. A coordinated team approach is therefore essential to achieve the best possible outcomes for these complex patients.
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Affiliation(s)
- Pok Tin Tang
- Cardiology Department, John Radcliffe Hospital Oxford, UK
| | - Duc H Do
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA Los Angeles, California, USA
| | - Anthony Li
- Cardiology Department, St George's University Hospital London, UK
| | - Noel G Boyle
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA Los Angeles, California, USA
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27
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Muser D, Santangeli P, Castro SA, Pathak RK, Liang JJ, Hayashi T, Magnani S, Garcia FC, Hutchinson MD, Supple GG, Frankel DS, Riley MP, Lin D, Schaller RD, Dixit S, Zado ES, Callans DJ, Marchlinski FE. Long-Term Outcome After Catheter Ablation of Ventricular Tachycardia in Patients With Nonischemic Dilated Cardiomyopathy. Circ Arrhythm Electrophysiol 2017; 9:CIRCEP.116.004328. [PMID: 27733494 DOI: 10.1161/circep.116.004328] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 08/25/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Catheter ablation (CA) of ventricular tachycardia (VT) in patients with nonischemic dilated cardiomyopathy can be challenging because of the complexity of underlying substrates. We sought to determine the long-term outcomes of endocardial and adjuvant epicardial CA in nonischemic dilated cardiomyopathy. METHODS AND RESULTS We examined 282 consecutive patients (aged 59±15 years, 80% males) with nonischemic dilated cardiomyopathy who underwent CA. Ablation was guided by activation/entrainment mapping for tolerated VT and pacemapping/targeting of abnormal electrograms for unmappable VT. Adjuvant epicardial ablation was performed for recurrent VT or persistent inducibility after endocardial-only ablation. Epicardial ablation was performed in 90 (32%) patients. Before ablation, patients failed a median of 2 antiarrhythmic drugs), including amiodarone, in 166 (59%) patients. The median follow-up after the last procedure was 48 (19-67) months. Overall, VT-free survival was 69% at 60-month follow-up. Transplant-free survival was 76% and 68% at 60- and 120-month follow-up, respectively. Among the 58 (21%) patients with VT recurrence, CA still resulted in a significant reduction of VT burden, with 31 (53%) patients having only isolated (1-3) VT episodes in 12 (4-35) months after the procedure. At the last follow-up, 128 (45%) patients were only on β-blockers or no treatment, 41 (15%) were on sotalol or class I antiarrhythmic drugs, and 62 (22%) were on amiodarone. CONCLUSIONS In patients with nonischemic dilated cardiomyopathy and VT, endocardial and adjuvant epicardial CA is effective in achieving long-term VT freedom in 69% of cases, with a substantial improvement in VT burden in many of the remaining patients.
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Affiliation(s)
- Daniele Muser
- From the Cardiac Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia
| | - Pasquale Santangeli
- From the Cardiac Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia
| | - Simon A Castro
- From the Cardiac Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia
| | - Rajeev K Pathak
- From the Cardiac Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia
| | - Jackson J Liang
- From the Cardiac Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia
| | - Tatsuya Hayashi
- From the Cardiac Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia
| | - Silvia Magnani
- From the Cardiac Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia
| | - Fermin C Garcia
- From the Cardiac Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia
| | - Mathew D Hutchinson
- From the Cardiac Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia
| | - Gregory G Supple
- From the Cardiac Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia
| | - David S Frankel
- From the Cardiac Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia
| | - Michael P Riley
- From the Cardiac Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia
| | - David Lin
- From the Cardiac Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia
| | - Robert D Schaller
- From the Cardiac Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia
| | - Sanjay Dixit
- From the Cardiac Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia
| | - Erica S Zado
- From the Cardiac Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia
| | - David J Callans
- From the Cardiac Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia
| | - Francis E Marchlinski
- From the Cardiac Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia.
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28
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Santangeli P, Rame JE, Birati EY, Marchlinski FE. Management of Ventricular Arrhythmias in Patients With Advanced Heart Failure. J Am Coll Cardiol 2017; 69:1842-1860. [DOI: 10.1016/j.jacc.2017.01.047] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 01/19/2017] [Accepted: 01/23/2017] [Indexed: 02/08/2023]
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Baratto F, Pappalardo F, Oloriz T, Bisceglia C, Vergara P, Silberbauer J, Albanese N, Cireddu M, D’Angelo G, Di Prima AL, Monaco F, Paglino G, Radinovic A, Regazzoli D, Silvetti S, Trevisi N, Zangrillo A, Della Bella P. Extracorporeal Membrane Oxygenation for Hemodynamic Support of Ventricular Tachycardia Ablation. Circ Arrhythm Electrophysiol 2016; 9:CIRCEP.116.004492. [DOI: 10.1161/circep.116.004492] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Accepted: 11/11/2016] [Indexed: 12/11/2022]
Abstract
Background—
We report the experience in a cohort of consecutive patients receiving extracorporeal membrane oxygenation during catheter ablation of unstable ventricular tachycardia (VT) at our center.
Methods and Results—
From 2010 to 2015, extracorporeal membrane oxygenation was initiated in 64 patients (average age: 63±15 years; left ventricular ejection fraction in 27±9%; cardiogenic shock in 23%, and electrical storm in 62% of patients) undergoing 74 unstable VT catheter ablation procedures. At least one VT was terminated in 81% of procedures with baseline inducible VT, and VT noninducibility was achieved in 69%. Acute heart failure occurred in 5 patients: 3 underwent emergency heart transplantation, 1 had left ventricular assist device (LVAD) implantation, and 1 patient eventually died because of subsequent mesenteric ischemia. All other patients were discharged alive. After a median follow-up of 21 months (13–28 months), VT recurrence was 33%; overall survival was 56 out of 64 patients (88%). Extracorporeal membrane oxygenation–supported ablation was the bridge to LVAD in 6.9% and to heart transplantation in 3.5% of patients. VT recurrence was related to ablation success (after 180 days of follow up: 19% when VT was noninducible, 42% if nonclinical VT was inducible, 75% when clinical VT was inducible, and 75% in untested patients,
P
<0.001). Incidence of all-cause death, heart transplantation, and LVAD was independently related to ablation outcome (at 180 days of follow-up: 9% when noninducibility was achieved, 50% in case of inducible VT, and 75% in untested patients,
P
<0.001). At multivariable analyses, noninducibility (hazard ratio 0.198;
P
=0.001) and left ventricular ejection fraction (hazard ratio 0.916;
P
=0.008) correlated with all-cause death, LVAD, and heart transplantation.
Conclusions—
Ablation of unstable VTs can be safely supported by extracorporeal membrane oxygenation, which allows rhythm stabilization with low procedure mortality, bridging decompensated patients to permanent LVAD or heart transplantation. Successful ablation is associated with better outcomes than unsuccessful ablation.
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Affiliation(s)
- Francesca Baratto
- From the Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery (F.B., T.O., C.B., P.V., J.S., N.A., M.C., G.D., G.P., A.R., D.R., N.T., P.D.B.) and Anesthesia and Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery (F.P., A.L.D.P., F.M., S.S., A.Z.), Ospedale San Raffaele, Milan, Italy
| | - Federico Pappalardo
- From the Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery (F.B., T.O., C.B., P.V., J.S., N.A., M.C., G.D., G.P., A.R., D.R., N.T., P.D.B.) and Anesthesia and Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery (F.P., A.L.D.P., F.M., S.S., A.Z.), Ospedale San Raffaele, Milan, Italy
| | - Teresa Oloriz
- From the Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery (F.B., T.O., C.B., P.V., J.S., N.A., M.C., G.D., G.P., A.R., D.R., N.T., P.D.B.) and Anesthesia and Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery (F.P., A.L.D.P., F.M., S.S., A.Z.), Ospedale San Raffaele, Milan, Italy
| | - Caterina Bisceglia
- From the Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery (F.B., T.O., C.B., P.V., J.S., N.A., M.C., G.D., G.P., A.R., D.R., N.T., P.D.B.) and Anesthesia and Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery (F.P., A.L.D.P., F.M., S.S., A.Z.), Ospedale San Raffaele, Milan, Italy
| | - Pasquale Vergara
- From the Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery (F.B., T.O., C.B., P.V., J.S., N.A., M.C., G.D., G.P., A.R., D.R., N.T., P.D.B.) and Anesthesia and Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery (F.P., A.L.D.P., F.M., S.S., A.Z.), Ospedale San Raffaele, Milan, Italy
| | - John Silberbauer
- From the Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery (F.B., T.O., C.B., P.V., J.S., N.A., M.C., G.D., G.P., A.R., D.R., N.T., P.D.B.) and Anesthesia and Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery (F.P., A.L.D.P., F.M., S.S., A.Z.), Ospedale San Raffaele, Milan, Italy
| | - Nicolò Albanese
- From the Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery (F.B., T.O., C.B., P.V., J.S., N.A., M.C., G.D., G.P., A.R., D.R., N.T., P.D.B.) and Anesthesia and Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery (F.P., A.L.D.P., F.M., S.S., A.Z.), Ospedale San Raffaele, Milan, Italy
| | - Manuela Cireddu
- From the Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery (F.B., T.O., C.B., P.V., J.S., N.A., M.C., G.D., G.P., A.R., D.R., N.T., P.D.B.) and Anesthesia and Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery (F.P., A.L.D.P., F.M., S.S., A.Z.), Ospedale San Raffaele, Milan, Italy
| | - Giuseppe D’Angelo
- From the Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery (F.B., T.O., C.B., P.V., J.S., N.A., M.C., G.D., G.P., A.R., D.R., N.T., P.D.B.) and Anesthesia and Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery (F.P., A.L.D.P., F.M., S.S., A.Z.), Ospedale San Raffaele, Milan, Italy
| | - Ambra Licia Di Prima
- From the Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery (F.B., T.O., C.B., P.V., J.S., N.A., M.C., G.D., G.P., A.R., D.R., N.T., P.D.B.) and Anesthesia and Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery (F.P., A.L.D.P., F.M., S.S., A.Z.), Ospedale San Raffaele, Milan, Italy
| | - Fabrizio Monaco
- From the Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery (F.B., T.O., C.B., P.V., J.S., N.A., M.C., G.D., G.P., A.R., D.R., N.T., P.D.B.) and Anesthesia and Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery (F.P., A.L.D.P., F.M., S.S., A.Z.), Ospedale San Raffaele, Milan, Italy
| | - Gabriele Paglino
- From the Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery (F.B., T.O., C.B., P.V., J.S., N.A., M.C., G.D., G.P., A.R., D.R., N.T., P.D.B.) and Anesthesia and Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery (F.P., A.L.D.P., F.M., S.S., A.Z.), Ospedale San Raffaele, Milan, Italy
| | - Andrea Radinovic
- From the Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery (F.B., T.O., C.B., P.V., J.S., N.A., M.C., G.D., G.P., A.R., D.R., N.T., P.D.B.) and Anesthesia and Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery (F.P., A.L.D.P., F.M., S.S., A.Z.), Ospedale San Raffaele, Milan, Italy
| | - Damiano Regazzoli
- From the Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery (F.B., T.O., C.B., P.V., J.S., N.A., M.C., G.D., G.P., A.R., D.R., N.T., P.D.B.) and Anesthesia and Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery (F.P., A.L.D.P., F.M., S.S., A.Z.), Ospedale San Raffaele, Milan, Italy
| | - Simona Silvetti
- From the Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery (F.B., T.O., C.B., P.V., J.S., N.A., M.C., G.D., G.P., A.R., D.R., N.T., P.D.B.) and Anesthesia and Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery (F.P., A.L.D.P., F.M., S.S., A.Z.), Ospedale San Raffaele, Milan, Italy
| | - Nicola Trevisi
- From the Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery (F.B., T.O., C.B., P.V., J.S., N.A., M.C., G.D., G.P., A.R., D.R., N.T., P.D.B.) and Anesthesia and Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery (F.P., A.L.D.P., F.M., S.S., A.Z.), Ospedale San Raffaele, Milan, Italy
| | - Alberto Zangrillo
- From the Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery (F.B., T.O., C.B., P.V., J.S., N.A., M.C., G.D., G.P., A.R., D.R., N.T., P.D.B.) and Anesthesia and Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery (F.P., A.L.D.P., F.M., S.S., A.Z.), Ospedale San Raffaele, Milan, Italy
| | - Paolo Della Bella
- From the Arrhythmia Unit and Electrophysiology Laboratories, Department of Cardiology and Cardiothoracic Surgery (F.B., T.O., C.B., P.V., J.S., N.A., M.C., G.D., G.P., A.R., D.R., N.T., P.D.B.) and Anesthesia and Intensive Care Unit, Department of Cardiology and Cardiothoracic Surgery (F.P., A.L.D.P., F.M., S.S., A.Z.), Ospedale San Raffaele, Milan, Italy
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Mathuria N, Wu G, Rojas-Delgado F, Shuraih M, Razavi M, Civitello A, Simpson L, Silva G, Wang S, Elayda M, Kantharia B, Singh S, Frazier OH, Cheng J. Outcomes of pre-emptive and rescue use of percutaneous left ventricular assist device in patients with structural heart disease undergoing catheter ablation of ventricular tachycardia. J Interv Card Electrophysiol 2016; 48:27-34. [PMID: 27497847 DOI: 10.1007/s10840-016-0168-8] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 07/25/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE Patient selection and timing of percutaneous left ventricular assist device (pLVAD) insertion for maximal benefit during ventricular tachycardia (VT) ablation is not well defined. We aimed to assess the outcomes of pre-emptive and rescue use of pLVAD during VT ablation in patients with ischemic and non-ischemic cardiomyopathy. METHODS Between January 2009 and October 2011, 93 patients underwent VT ablation. Three groups were compared: (1) Rescue group (n = 12)-patients who required emergent pLVAD insertion due to hemodynamic collapse during VT ablation, (2) Pre-emptive group (n = 24)-patients who had pre-ablation pLVAD insertion, and (3) Non-pLVAD group (n = 57)-patients who did not undergo pLVAD insertion. Procedural outcomes including 30-day mortality were compared. RESULTS Thirty-day mortality was higher in the Rescue group compared to the Pre-emptive group (58 vs. 4 %, p = 0.003) and non-pLVAD (58 vs. 3 %, p = 0.001) group. There was no significant difference in 30-day mortality or long-term freedom of VT between the pre-emptive and non-pLVAD groups. CONCLUSIONS Despite rescue pLVAD insertion, hemodynamic collapse during VT ablation is associated with a persistently high 30-day mortality. Further studies are warranted to predict hemodynamic collapse and to refine the role of pLVAD in this setting.
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Affiliation(s)
- Nilesh Mathuria
- Division of Cardiology, Baylor St. Luke's Medical Center/Texas Heart Institute, PO Box 20345, Houston, TX, 77225-0345, USA.
| | - Geru Wu
- Division of Cardiology, Baylor St. Luke's Medical Center/Texas Heart Institute, PO Box 20345, Houston, TX, 77225-0345, USA
| | - Francia Rojas-Delgado
- Division of Cardiology, Baylor St. Luke's Medical Center/Texas Heart Institute, PO Box 20345, Houston, TX, 77225-0345, USA
| | - Mossaab Shuraih
- Division of Cardiology, Baylor St. Luke's Medical Center/Texas Heart Institute, PO Box 20345, Houston, TX, 77225-0345, USA
| | - Mehdi Razavi
- Division of Cardiology, Baylor St. Luke's Medical Center/Texas Heart Institute, PO Box 20345, Houston, TX, 77225-0345, USA
| | - Andrew Civitello
- Division of Cardiology, Baylor St. Luke's Medical Center/Texas Heart Institute, PO Box 20345, Houston, TX, 77225-0345, USA
| | - Leo Simpson
- Division of Cardiology, Baylor St. Luke's Medical Center/Texas Heart Institute, PO Box 20345, Houston, TX, 77225-0345, USA
| | - Guilherme Silva
- Division of Cardiology, Baylor St. Luke's Medical Center/Texas Heart Institute, PO Box 20345, Houston, TX, 77225-0345, USA
| | - Suwei Wang
- Division of Biostatistics, Baylor St. Luke's Medical Center/Texas Heart Institute, Houston, TX, USA
| | - MacArthur Elayda
- Division of Biostatistics, Baylor St. Luke's Medical Center/Texas Heart Institute, Houston, TX, USA
| | - Bharat Kantharia
- University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Steve Singh
- Division of Cardiovascular Surgery, Baylor College of Medicine/Texas Heart Institute, Houston, TX, USA
| | - O H Frazier
- Division of Cardiovascular Surgery, Baylor College of Medicine/Texas Heart Institute, Houston, TX, USA
| | - Jie Cheng
- Division of Cardiology, Baylor St. Luke's Medical Center/Texas Heart Institute, PO Box 20345, Houston, TX, 77225-0345, USA
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Substrate modification or ventricular tachycardia induction, mapping, and ablation as the first step? A randomized study. Heart Rhythm 2016; 13:1589-95. [DOI: 10.1016/j.hrthm.2016.05.013] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Indexed: 11/22/2022]
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