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Gardziejczyk P, Piotrowski R, Kryński T, Sikorska A, Kułakowski P, Baran J. Bipolar catheter ablation with dedicated radiofrequency system for highly refractory ventricular arrhythmia-Does the rate of success depend on arrhythmia origin? J Cardiovasc Electrophysiol 2024; 35:667-674. [PMID: 38293729 DOI: 10.1111/jce.16186] [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: 07/04/2023] [Revised: 11/28/2023] [Accepted: 01/06/2024] [Indexed: 02/01/2024]
Abstract
INTRODUCTION Despite rapid technological progress, some arrhythmias are still resistant to standard unipolar ablation. These include arrhythmias arising from the base of the heart, cardiac crux, or epicardium. Bipolar radiofrequency ablation (B-RFA) may be useful in some cases, however, data on the efficacy of this approach in various arrhythmia localizations are scarce. The aim of this study was to assess the efficacy of B-RFA in patients with ventricular arrhythmias originating from various locations, occurring refractory to standard unipolar ablation approaches. METHODS An observational, single center study was conducted over a 30-month period. B-RFA were performed using dedicated radio frequency (RF) generator and electroanatomic mapping system. RESULTS Twenty-four procedures, in 23 patients with a median (range) of 1 (1-2) previously failed unipolar ablation procedures, were included in the final analysis. There were 12 ablations of ventricular arrhythmias originating from interventricular septum with an acute success rate of 75%, and 12 from left ventricular (LV) summit with an acute success rate of 58%. The midterm success rate (median interquartile range follow-up of 205 days [188-338]) was 66% and 50%, respectively. CONCLUSIONS B-RFA is a promising method of catheter ablation for refractory cardiac arrhythmias. A higher success rate was observed in ablation for difficult ventricular arrhythmias originating from interventricular septal region than LV summit.
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Affiliation(s)
- Piotr Gardziejczyk
- Division of Clinical Electrophysiology, Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland
| | - Roman Piotrowski
- Division of Clinical Electrophysiology, Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland
| | - Tomasz Kryński
- Division of Clinical Electrophysiology, Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland
| | - Agnieszka Sikorska
- Division of Clinical Electrophysiology, Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland
| | - Piotr Kułakowski
- Division of Clinical Electrophysiology, Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland
| | - Jakub Baran
- Division of Clinical Electrophysiology, Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland
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2
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Lenarczyk R, Zeppenfeld K, Tfelt-Hansen J, Heinzel FR, Deneke T, Ene E, Meyer C, Wilde A, Arbelo E, Jędrzejczyk-Patej E, Sabbag A, Stühlinger M, di Biase L, Vaseghi M, Ziv O, Bautista-Vargas WF, Kumar S, Namboodiri N, Henz BD, Montero-Cabezas J, Dagres N. Management of patients with an electrical storm or clustered ventricular arrhythmias: a clinical consensus statement of the European Heart Rhythm Association of the ESC-endorsed by the Asia-Pacific Heart Rhythm Society, Heart Rhythm Society, and Latin-American Heart Rhythm Society. Europace 2024; 26:euae049. [PMID: 38584423 PMCID: PMC10999775 DOI: 10.1093/europace/euae049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 04/09/2024] Open
Abstract
Electrical storm (ES) is a state of electrical instability, manifesting as recurrent ventricular arrhythmias (VAs) over a short period of time (three or more episodes of sustained VA within 24 h, separated by at least 5 min, requiring termination by an intervention). The clinical presentation can vary, but ES is usually a cardiac emergency. Electrical storm mainly affects patients with structural or primary electrical heart disease, often with an implantable cardioverter-defibrillator (ICD). Management of ES requires a multi-faceted approach and the involvement of multi-disciplinary teams, but despite advanced treatment and often invasive procedures, it is associated with high morbidity and mortality. With an ageing population, longer survival of heart failure patients, and an increasing number of patients with ICD, the incidence of ES is expected to increase. This European Heart Rhythm Association clinical consensus statement focuses on pathophysiology, clinical presentation, diagnostic evaluation, and acute and long-term management of patients presenting with ES or clustered VA.
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Affiliation(s)
- Radosław Lenarczyk
- Medical University of Silesia, Division of Medical Sciences, Department of Cardiology and Electrotherapy, Silesian Center for Heart Diseases, Skłodowskiej-Curie 9, 41-800 Zabrze, Poland
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacob Tfelt-Hansen
- The Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- The Department of Forensic Medicine, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Frank R Heinzel
- Cardiology, Angiology, Intensive Care, Städtisches Klinikum Dresden Campus Friedrichstadt, Dresden, Germany
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
- Clinic for Electrophysiology, Klinikum Nuernberg, University Hospital of the Paracelsus Medical University, Nuernberg, Germany
| | - Elena Ene
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
| | - Christian Meyer
- Division of Cardiology/Angiology/Intensive Care, EVK Düsseldorf, Teaching Hospital University of Düsseldorf, Düsseldorf, Germany
| | - Arthur Wilde
- Department of Cardiology, Amsterdam UMC University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Cardiovascular Sciences, Heart Failure and arrhythmias, Amsterdam, the Netherlands
| | - Elena Arbelo
- Arrhythmia Section, Cardiology Department, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain; IDIBAPS, Institut d'Investigació August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Ewa Jędrzejczyk-Patej
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Avi Sabbag
- The Davidai Center for Rhythm Disturbances and Pacing, Chaim Sheba Medical Center, Tel Hashomer, Israel
- School of Medicine, Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Markus Stühlinger
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Luigi di Biase
- Albert Einstein College of Medicine at Montefiore Hospital, New York, NY, USA
| | - Marmar Vaseghi
- UCLA Cardiac Arrythmia Center, Division of Cardiology, Department of Medicine, University of California, Los Angeles, CA, USA
| | - Ohad Ziv
- Case Western Reserve University, Cleveland, OH, USA
- The MetroHealth System Campus, Cleveland, OH, USA
| | | | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Sydney, Australia
| | | | - Benhur Davi Henz
- Instituto Brasilia de Arritmias-Hospital do Coração do Brasil-Rede Dor São Luiz, Brasilia, Brazil
| | - Jose Montero-Cabezas
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
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Volkov D, Lopin D, Skoriy D, Gianni C, La Fazia VM, Gallinghouse GJ, Horton R, Burkhardt JD, Mohanty S, Natale A. Bailout Deep Septal LV Pacing to Treat Inadvertent Complete AV Block During Complex Ablation Procedure. JACC Case Rep 2024; 29:102227. [PMID: 38464799 PMCID: PMC10920119 DOI: 10.1016/j.jaccas.2024.102227] [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: 09/28/2023] [Revised: 11/29/2023] [Accepted: 01/03/2024] [Indexed: 03/12/2024]
Abstract
We present a case of persistent complete atrioventricular block that occurred during the diagnostic portion of a premature ventricular contractions' radiofrequency ablation in a complex heart failure patient. The case was managed by bailout deep left ventricular septal pacing after bipolar radiofrequency elimination of premature ventricular contractions.
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Affiliation(s)
- Dmytro Volkov
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, Texas, USA
- Institute of General and Urgent Surgery of NAMS, Kharkiv, Ukraine
| | - Dmytro Lopin
- Institute of General and Urgent Surgery of NAMS, Kharkiv, Ukraine
| | - Dmytro Skoriy
- Institute of General and Urgent Surgery of NAMS, Kharkiv, Ukraine
| | - Carola Gianni
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, Texas, USA
| | - Vincenzo Mirko La Fazia
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, Texas, USA
| | - G. Joseph Gallinghouse
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, Texas, USA
| | - Rodney Horton
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, Texas, USA
| | - John D. Burkhardt
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, Texas, USA
| | - Sanghamitra Mohanty
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, Texas, USA
| | - Andrea Natale
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, Texas, USA
- Interventional Electrophysiology, Scripps Clinic, San Diego, California, USA
- Department of Internal Medicine, Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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4
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Enriquez A, Hanson M, Nazer B, Gibson DN, Cano O, Tokioka S, Fukamizu S, Sanchez Millan P, Hoyos C, Matos C, Sauer WH, Tedrow U, Romero J, Neira V, Futyma M, Futyma P. Bipolar ablation involving coronary venous system for refractory left ventricular summit arrhythmias. Heart Rhythm O2 2024; 5:24-33. [PMID: 38312200 PMCID: PMC10837170 DOI: 10.1016/j.hroo.2023.11.015] [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] [Indexed: 02/06/2024] Open
Abstract
Background Catheter ablation of premature ventricular complexes (PVCs) and ventricular tachycardia (VT) from the left ventricular summit (LVS) may require advanced ablation techniques. Bipolar ablation from the coronary veins and adjacent endocardial structures can be effective for refractory LVS arrhythmias. Objective The aim of this study was to investigate the outcomes of bipolar ablation performed between the coronary venous system and adjacent endocardial left ventricular outflow tract (LVOT) or right ventricular outflow tract (RVOT). Methods This multicenter study included consecutive patients with LVS PVC/VT who underwent bipolar ablation between the anterior interventricular vein (AIV) or great cardiac vein (GCV) and the endocardial LVOT/RVOT after failed unipolar ablation. Ablation was started with powers of 10-20 W and uptitrated to achieve an impedance drop of at least 10%. Angiography was performed in all cases to confirm a safe distance (>5 mm) of the catheter from the major coronary arteries. Results Between 2013 and 2023, bipolar radiofrequency ablation between the AIV/GCV and the adjacent LVOT/RVOT was attempted in 20 patients (4 female; age 57 ± 16 years). Unipolar ablation from sites of early activation (AIV/GCV, LVOT, aortic cusps, RVOT) failed to effectively suppress the PVC/VT in all subjects. Bipolar ablation was delivered with a maximum power of 30 ± 8 W and total duration of 238 ± 217 s and led to acute PVC/VT elimination in all patients. No procedural-related complications occurred. Over a follow-up period of 30 ± 24 months, the freedom from arrhythmia recurrence was 85% (1 recurrence in the VT group and 2 in the PVC group). PVC burden was reduced from 22% ± 10% to 4% ± 8% (P <.001). Conclusion In cases of LVS PVC/VT refractory to unipolar ablation, bipolar ablation between the coronary venous system and adjacent endocardial LVOT/RVOT is safe and effective if careful titration of power and intraprocedural angiography are performed to ensure a safe distance from the coronary arteries.
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Affiliation(s)
- Andres Enriquez
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Matthew Hanson
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Babak Nazer
- Division of Cardiology, University of Washington, Seattle, Washington
| | | | - Oscar Cano
- Division of Cardiology, Hospital Universitari Politècnic La Fe, Valencia, Spain
| | - Sayuri Tokioka
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Seiji Fukamizu
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Pablo Sanchez Millan
- Servicio de Cardiología, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Carolina Hoyos
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Carlos Matos
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - William H Sauer
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Usha Tedrow
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jorge Romero
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Victor Neira
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Marian Futyma
- Medical College, University of Rzeszów and St. Joseph's Heart Rhythm Center, Rzeszów, Poland
| | - Piotr Futyma
- Medical College, University of Rzeszów and St. Joseph's Heart Rhythm Center, Rzeszów, Poland
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5
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Romero J, Gamero M, Alviz I, Grushko M, Diaz JC, Lorente M, Gabr M, Toquica CC, Krishnan S, Velasco A, Lin A, Natale A, Zou F, Di Biase L. Catheter Ablation of Left Ventricular Summit Arrhythmias from Adjacent Anatomic Vantage Points. Card Electrophysiol Clin 2023; 15:31-37. [PMID: 36774134 DOI: 10.1016/j.ccep.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Idiopathic ventricular arrhythmias (VA), particularly left ventricular outflow tract (LVOT) VA accounts for up to 10% of all VAs referred for ablative therapy. In addition to being infrequent, its intricate anatomy and its pathophysiology make catheter ablation (CA) of these arrhythmias a challenge even for experts. In this scenario, detailed right ventricular outflow tract as well as LVOT electroanatomic mapping including epicardial mapping are essential. In this article, we will emphasize our approach toward the CA technique used for LVOT VA, particularly IVS and/or LVS VA originating from intramural foci, along with its acute and long-term efficacy and safety.
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Affiliation(s)
- Jorge Romero
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Maria Gamero
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Isabella Alviz
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Michael Grushko
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Juan Carlos Diaz
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Marta Lorente
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mohamed Gabr
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Suraj Krishnan
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Alejandro Velasco
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Aung Lin
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Fengwei Zou
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
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6
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Romero J, Diaz JC, Gamero M, Alviz I, Lorente M, Gabr M, Toquica CC, Krishnan S, Velasco A, Lin A, Natale A, Zou F, Di Biase L. Fluoroless Catheter Ablation of Left Ventricular Summit Arrhythmias: A Step-by-Step Approach. Card Electrophysiol Clin 2023; 15:75-83. [PMID: 36774139 DOI: 10.1016/j.ccep.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Prolonged use of fluoroscopy during catheter ablation (CA) of arrhythmias is associated with a significant exposure to ionizing radiation and risk of orthopedic injuries given the need for heavy protective equipment. CA of ventricular arrhythmias (VAs) arising from the left ventricular (LV) summit is challenging, requiring a vast knowledge of the intricate cardiac anatomy of this area and careful imaging delineation of the different anatomical structures, which is frequently performed using fluoroscopic guidance. Certain techniques, including pericardial mapping and ablation, use of intracoronary wires, and mapping and ablation inside the coronary venous system have been proposed, further prolonging fluoroscopy time. Fluoroless CA procedures are feasible with currently available technology and appear to have similar safety and efficacy outcomes compared with conventional techniques. To successfully perform fluoroless CA of LV summit arrhythmias, it is important to be fully acquainted with intracardiac echocardiography (ICE) imaging and electroanatomic mapping (EAM). We will describe our approach to perform fluoroless CA in LV summit VAs.
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Affiliation(s)
- Jorge Romero
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Juan Carlos Diaz
- Arrhythmia and electrhophysiology service, Clinica Las Vegas, Grupo Quiron Salud; Universidad CES School of Medicine, Medellin, Colombia, USA
| | - Maria Gamero
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Isabella Alviz
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Marta Lorente
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mohamed Gabr
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Suraj Krishnan
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Alejandro Velasco
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Aung Lin
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Fengwei Zou
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
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7
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Liang JJ, Bogun F. Ablation of Focal Intramural Outflow Tract Ventricular Arrhythmias. Card Electrophysiol Clin 2023; 15:49-56. [PMID: 36774136 DOI: 10.1016/j.ccep.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Most idiopathic ventricular arrhythmias (VAs) originate from the outflow tract (OT) region and can be targeted with ablation either from the endocardial aspect of the right and left ventricular outflow tracts or from the aortic sinuses of Valsalva. It is important to exclude scar in patients with OT VAs. In some patients, the site of origin may be intramural. Ablation of intramural OT VAs can be challenging to map and ablate due to deep intramural sites of origin. The coronary venous branches may permit mapping and ablation of intramural OT VAs.
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Affiliation(s)
- Jackson J Liang
- Electrophysiology Section, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Frank Bogun
- Electrophysiology Section, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
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8
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Muser D, Santangeli P, Liang JJ. Mechanisms of Ventricular Arrhythmias and Implications for Catheter Ablation. Card Electrophysiol Clin 2022; 14:547-558. [PMID: 36396177 DOI: 10.1016/j.ccep.2022.07.006] [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
Ventricular arrhythmias present with a wide spectrum of clinical manifestations, from mildly symptomatic frequent premature ventricular contractions to life-threatening events. Pathophysiologically, idiopathic ventricular arrhythmias occur in the absence of structural heart disease or ion channelopathies. Ventricular arrhythmias in the context of structural heart disease are usually determined by scar-related reentry and are associated with increased mortality. Catheter ablation is safe and highly effective in treating ventricular arrhythmias. The proper characterization of the arrhythmogenic substrate is essential for accurate procedural planning. We provide an overview on the main mechanisms of ventricular arrhythmias and their implications for catheter ablation.
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Affiliation(s)
- Daniele Muser
- Cardiothoracic Department, Udine University Hospital, Udine 33100, Italy; Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Pasquale Santangeli
- Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Jackson J Liang
- Electrophysiology Section, Division of Cardiology, University of Michigan, Frankel Cardiovascular Center, 1425 E. Ann Street, Ann Arbor, MI 48109, USA.
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9
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Intracardiac electrogram characteristics of intramural outflow tract ventricular arrhythmias. J Interv Card Electrophysiol 2022; 66:621-627. [PMID: 36121541 DOI: 10.1007/s10840-022-01374-y] [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: 08/13/2022] [Accepted: 09/13/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Annotation of earliest depolarization which depends on maximum dV/dt of unipolar-electrograms and unipolar QS morphology identify site of origin for ventricular premature contractions (VPC). However, identification of unipolar QS morphology has limitations due to low spatial resolution. This study aims to compare electrogram characteristics at successful ablation site in patients with outflow tract (OT) VPC. METHODS Local activation time (LAT), duration, and voltage data of each bipolar- and unipolar-electrogram at the successful ablation sites from the right ventricle OT (RVOT) and the left ventricle OT (LVOT) cases were analyzed. RESULTS Forty-four of 60 (73%) of patients were ablated from RVOT and in 16/60 (27%) required ablation from both sides. All patients had acute VPC suppression. Bipolar-electrogram-QRS onset was earlier (36.4 ± 14.5 ms vs 26.3 ± 7.4 ms, p = 0.01), duration of bipolar-electrogram was shorter (56.9 ± 18.9 ms vs 78.9 ± 21.8 ms, p = 0.002), and bi-voltage amplitude was higher (3.2 ± 2.3 mV vs 1.4 ± 1.1 mV, p = 0.07) for patients with RVOT-only ablation. Mean bipolar-unipolar-electrogram difference was 4.4 ± 4.5 ms in the RVOT group vs 12.8 ± 4.9 ms in RVOT + LVOT group (p < 0.001). Unipolar QS morphology was recorded in 3.0 ± 3.9 vs 3.6 ± 1.8 cm2 in RVOT and RVOT + LVOT group, respectively (p = 0.41). Unipolar-electrogram revealed W pattern in 3/44 of RVOT vs 5/16 of RVOT + LVOT group, respectively (p = 0.01). In 18/60 (30%) of patients, unipolar QS was not identified at successful ablation site. CONCLUSION QS in unipolar-electrogram was not a perfect predictor for successful ablation sites. Analysis of bipolar voltage amplitude and duration with bipolar-unipolar-electrogram time difference may identify presence of a deeper source.
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10
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Romero J, Velasco A, Díaz JC, Alviz I, Briceno D, Grushko M, Palma E, Ferrick K, Parashar A, Bello J, Zhang X, Gabr M, Purkayastha S, Polanco D, Grupposo V, Della Rocca D, Lakkireddy D, Natale A, Di Biase L. Fluoroless Versus Conventional Mapping and Ablation of Ventricular Arrhythmias Arising From the Left Ventricular Summit and Interventricular Septum. Circ Arrhythm Electrophysiol 2022; 15:e010547. [PMID: 35759380 DOI: 10.1161/circep.121.010547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jorge Romero
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.R., A.V., I.A., D.B., M.G., E.P., K.F., A.P., J.B., X.Z., M.G., S.P., D.P., V.G., L.D.B.)
| | - Alejandro Velasco
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.R., A.V., I.A., D.B., M.G., E.P., K.F., A.P., J.B., X.Z., M.G., S.P., D.P., V.G., L.D.B.)
| | | | - Isabella Alviz
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.R., A.V., I.A., D.B., M.G., E.P., K.F., A.P., J.B., X.Z., M.G., S.P., D.P., V.G., L.D.B.)
| | - David Briceno
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.R., A.V., I.A., D.B., M.G., E.P., K.F., A.P., J.B., X.Z., M.G., S.P., D.P., V.G., L.D.B.)
| | - Michael Grushko
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.R., A.V., I.A., D.B., M.G., E.P., K.F., A.P., J.B., X.Z., M.G., S.P., D.P., V.G., L.D.B.)
| | - Eugen Palma
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.R., A.V., I.A., D.B., M.G., E.P., K.F., A.P., J.B., X.Z., M.G., S.P., D.P., V.G., L.D.B.)
| | - Kevin Ferrick
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.R., A.V., I.A., D.B., M.G., E.P., K.F., A.P., J.B., X.Z., M.G., S.P., D.P., V.G., L.D.B.)
| | - Akhil Parashar
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.R., A.V., I.A., D.B., M.G., E.P., K.F., A.P., J.B., X.Z., M.G., S.P., D.P., V.G., L.D.B.)
| | - Juan Bello
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.R., A.V., I.A., D.B., M.G., E.P., K.F., A.P., J.B., X.Z., M.G., S.P., D.P., V.G., L.D.B.)
| | - Xiaodong Zhang
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.R., A.V., I.A., D.B., M.G., E.P., K.F., A.P., J.B., X.Z., M.G., S.P., D.P., V.G., L.D.B.)
| | - Mohamed Gabr
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.R., A.V., I.A., D.B., M.G., E.P., K.F., A.P., J.B., X.Z., M.G., S.P., D.P., V.G., L.D.B.)
| | - Sutopa Purkayastha
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.R., A.V., I.A., D.B., M.G., E.P., K.F., A.P., J.B., X.Z., M.G., S.P., D.P., V.G., L.D.B.)
| | - Dalvert Polanco
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.R., A.V., I.A., D.B., M.G., E.P., K.F., A.P., J.B., X.Z., M.G., S.P., D.P., V.G., L.D.B.)
| | - Vito Grupposo
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.R., A.V., I.A., D.B., M.G., E.P., K.F., A.P., J.B., X.Z., M.G., S.P., D.P., V.G., L.D.B.)
| | - Domenico Della Rocca
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX (D.D.R., A.N.)
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX (D.D.R., A.N.)
| | - Luigi Di Biase
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (J.R., A.V., I.A., D.B., M.G., E.P., K.F., A.P., J.B., X.Z., M.G., S.P., D.P., V.G., L.D.B.)
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11
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Shirai Y, Goya M, Sasaki T, Nagasawa R, Toya C, Hayasaka K, Sugiyama K, Shimizu S, Yamamoto T, Nishimura T, Tao S, Takigawa M, Miyazaki S, Sasano T. Usefulness of the over-the-wire microelectrodes catheter in treatment of ventricular arrhythmia arising from the left ventricular summit. Pacing Clin Electrophysiol 2022; 45:1141-1150. [PMID: 35665518 DOI: 10.1111/pace.14542] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/23/2022] [Accepted: 05/27/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND This study was aimed to investigate efficacy of the over-the-wire (OTW) microelectrodes catheter in coronary venous system (CVS) mapping and treatment of outflow tract ventricular arrhythmia (OTVA) arising from the vicinity of the left ventricular summit (LVS). METHODS Consecutive 62 patients with idiopathic OTVA in whom the OTW microelectrodes catheter was routinely used for CVS mapping were analyzed. CVS mapping was performed for both main trunk (from great cardiac vein to anterior interventricular vein) and branches including annular branch or septal branch. RESULTS The earliest activation site (EAS) was within the CVS in 21 patients. Among them, the EAS was within the main trunk of the CVS in 7 (33%) and within the branch of the CVS in 14 (67%) patients. Radiofrequency catheter ablation was started at an anatomically adjacent site to the EAS, which eliminated OTVA in 16 (76%) patients (the endocardial LVOT in 10 and the aortic sinus of Valsalva in 6 patients). For the remaining 5 patients with unsuccessful catheter ablation at an anatomically adjacent site, targeted OTVA was eliminated by catheter ablation at the EAS within the CVS in 2 patients and by chemical ablation with ethanol injection in 1 patient, resulting in overall success rate of 90% (19/21). CONCLUSION The OTW microelectrodes-guided ablation of OTVA from the vicinity of the LVS was effective. In maximizing the efficacy of ablation, CVS branch mapping is important since the earliest activation was commonly recorded not in the main trunk but within the branch of the CVS. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Yasuhiro Shirai
- Department of Cardiology, National Disaster Medical Center, Tokyo, Japan
| | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takeshi Sasaki
- Department of Cardiology, National Disaster Medical Center, Tokyo, Japan
| | - Ryo Nagasawa
- Department of Cardiology, National Disaster Medical Center, Tokyo, Japan
| | - Chisashi Toya
- Department of Cardiology, National Disaster Medical Center, Tokyo, Japan
| | - Kazuto Hayasaka
- Department of Cardiology, National Disaster Medical Center, Tokyo, Japan
| | - Koji Sugiyama
- Department of Cardiology, National Disaster Medical Center, Tokyo, Japan
| | - Shigeo Shimizu
- Department of Cardiology, National Disaster Medical Center, Tokyo, Japan
| | - Tasuku Yamamoto
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takuro Nishimura
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Susumu Tao
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masateru Takigawa
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shinsuke Miyazaki
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
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12
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Guandalini GS, Santangeli P, Schaller R, Pothineni NVK, Briceño DF, Enriquez A, Razminia P, Tung R, Marchlinski FE, Garcia FC. Intramyocardial mapping of ventricular premature depolarizations via septal venous perforators: Differentiating the superior intraseptal region from left ventricular summit origins. Heart Rhythm 2022; 19:1475-1483. [DOI: 10.1016/j.hrthm.2022.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 02/25/2022] [Accepted: 03/04/2022] [Indexed: 11/04/2022]
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13
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Wei HQ, Guo XG, Zhou GB, Sun Q, Yang JD, Xie HY, Liang J, Zhang S, Wu S, Ma J. Predictors and Long-Term Outcome of Ablation of Discrete Pre-potentials in Patients With Idiopathic Ventricular Arrhythmias Originating From the Aortic Sinuses of Valsalva. Front Cardiovasc Med 2021; 8:767514. [PMID: 34950714 PMCID: PMC8688708 DOI: 10.3389/fcvm.2021.767514] [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: 08/30/2021] [Accepted: 11/09/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The predictability and long-term outcome of the discrete pre-potential (DPP) of idiopathic ventricular arrhythmias (VAs) arising from the aortic sinuses of Valsalva (ASV) have not been fully identified. Methods: Of 687 consecutive patients undergoing ablation of outflow tract VAs, there were 105 (15.3%) patients with VAs originating from the ASV region who were included. Detailed mapping was performed within the ASV in all patients. Electrocardiographic, electrophysiological parameters, and long-term success rate were compared between patients with and without the DPPs. Results: A DPP was recorded in 67 of 105 (63.8%) patients, including 38 left sinus of Valsalva (LSV)-VAs (38/105, 36.2%) and 29 right sinus of Valsalva (RSV)-VAs (29/105, 27.6%). The patients with DPPs had wider QRS duration (152 ± 17 vs. 145 ± 14 ms, p < 0.001). The average of earliest activation time was significantly earlier in patients with DPPs (−38.6 ± 8.5 vs. −27.7 ± 5.7 ms, p < 0.001). Mean time from the first lesion to elimination of VAs was shorter in patients with DPPs (2.3 ± 2.1 s vs. 4.9 ± 1.0 s, p < 0.001). A stepwise logistic multivariable analysis identified only younger age as a significant predictor of DPP (age ≤ 35.5 years predicted DPP with 92.9% positive predictive value). During a follow-up duration of 42.5 ± 22.3 months, 63 (94.0%) patients with DPPs and 30 (78.9%) patients without DPPs remained free of recurrent VAs (p = 0.027). Conclusion: Discrete pre-potentials were observed in 63.8% of patients with VAs arising from the ASV. Ablation in patients with DPPs was associated with higher long-term success. DPPs were seen more commonly in younger (age ≤ 35.5 years) patients.
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Affiliation(s)
- Hui-Qiang Wei
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.,State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiao-Gang Guo
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Gong-Bu Zhou
- Department of Cardiology, Peking University Third Hospital, Beijing, China
| | - Qi Sun
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian-Du Yang
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hai-Yang Xie
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jackson Liang
- Division of Cardiovascular Medicine, Electrophysiology Service, University of Michigan Health System, Ann Arbor, MI, United States
| | - Shu Zhang
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shulin Wu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jian Ma
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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14
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Chimenti C, Magnocavallo M, Ballatore F, Bernardini F, Alfarano M, Della Rocca DG, Severino P, Lavalle C, Francesco F, Frustaci A. Prevalence and Clinical Implications of COVID-19 Myocarditis. Card Electrophysiol Clin 2021; 14:53-62. [PMID: 35221085 PMCID: PMC8576114 DOI: 10.1016/j.ccep.2021.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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15
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Turner H, Beinhoff P, Sonnen AJ, Hang D, Lincoln AH, Sutter HA, Almassi GH, Pagel PS. Progressive Dyspnea and Exercise Intolerance Four Months After Left Ventricular Outflow Tract Radiofrequency Ablation for Frequent Premature Ventricular Contractions. J Cardiothorac Vasc Anesth 2021; 36:2789-2792. [PMID: 34758926 DOI: 10.1053/j.jvca.2021.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 10/11/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Halen Turner
- Department of Surgery, the Medical College of Wisconsin, Milwaukee, WI
| | - Paul Beinhoff
- Department of Surgery, the Medical College of Wisconsin, Milwaukee, WI
| | - Aly J Sonnen
- Department of Surgery, the Medical College of Wisconsin, Milwaukee, WI
| | - Dustin Hang
- Department of Anesthesiology, the Medical College of Wisconsin, Milwaukee, WI
| | - Anne H Lincoln
- Department of Anesthesiology, the Medical College of Wisconsin, Milwaukee, WI
| | - Heather A Sutter
- Cardiothoracic Surgery Services, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI; Department of Cardiothoracic Surgery, the Medical College of Wisconsin, Milwaukee, WI
| | - G Hossein Almassi
- Cardiothoracic Surgery Services, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI; Department of Cardiothoracic Surgery, the Medical College of Wisconsin, Milwaukee, WI
| | - Paul S Pagel
- Anesthesiology Services, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI.
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16
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17
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Flecainide in Ventricular Arrhythmias: From Old Myths to New Perspectives. J Clin Med 2021; 10:jcm10163696. [PMID: 34441994 PMCID: PMC8397118 DOI: 10.3390/jcm10163696] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 08/10/2021] [Accepted: 08/18/2021] [Indexed: 11/21/2022] Open
Abstract
Flecainide is an IC antiarrhythmic drug (AAD) that received in 1984 Food and Drug Administration approval for the treatment of sustained ventricular tachycardia (VT) and subsequently for rhythm control of atrial fibrillation (AF). Currently, flecainide is mainly employed for sinus rhythm maintenance in AF and the treatment of idiopathic ventricular arrhythmias (IVA) in absence of ischaemic and structural heart disease on the basis of CAST data. Recent studies enrolling patients with different structural heart diseases demonstrated good effectiveness and safety profile of flecainide. The purpose of this review is to assess current evidence for appropriate and safe use of flecainide, 30 years after CAST data, in the light of new diagnostic and therapeutic tools in the field of ischaemic and non-ischaemic heart disease.
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18
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Di C, Letsas KP, Gao P, Wang Q, Wu Y, Lin W. Electrocardiographic and electrophysiological characteristics of idiopathic ventricular arrhythmias with acute successful ablation at the superior portion of the mitral annulus. BMC Cardiovasc Disord 2021; 21:397. [PMID: 34407753 PMCID: PMC8371855 DOI: 10.1186/s12872-021-02205-0] [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: 11/13/2020] [Accepted: 08/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We sought to identify the electrocardiographic and electrophysiological characteristics of ventricular arrhythmias (VAs), including idiopathic ventricular tachycardia (VT) and premature ventricular contractions (PVCs), with acute successful radiofrequency catheter ablation (RFCA) at the superior portion of the mitral annulus (SP-MA). METHODS AND RESULTS Among 437 consecutive patients who presented with VAs for RFCA, twenty-six patients with acute successful RFCA at the SP-MA were included in this study. The ratio of the amplitude of the first positive peak (if present) versus the nadir in the unipolar electrogram (EGM) was 0.00-0.03 (0.00) at the acute successful RFCA site. The time interval between the QRS onset and the maximum descending slope (D-Max) in the unipolar EGM (QRS-Uni) was 18.8 ± 13.6 ms. With bipolar mapping, the ventricular QRS (V-QRS) interval was 3.75-17.3 (11) ms, 6 (23.1%) patients showed the earliest V-QRS interval of 0 ms, and the other 20 patients (76.9%) showed a V-QRS interval of 10-54 ms. The RFCA start-to-effect time was 14.1 ± 7.2 s in 23 patients (88.5%). In the remaining 3 patients (11.5%), the mean duration of successful RFCA was not well defined due to the infrequent nature of clinical VAs during RFCA. Early (within 3 days) and late (1-year) recurrence rates were 23.1% (6 patients) and 26.9% (7 patients), respectively. VAs disappeared 3 days later due to delayed RFCA efficacy in 2 patients (7.7%). No complications occurred during the RFCA procedure or the one-year follow-up. CONCLUSIONS SP-MA VAs are a rare but distinct subgroup of VAs. Bipolar and unipolar EGM features can help to determine the optimal RFCA site, and the QRS-Uni interval may serve as a marker that could be used to guide RFCA.
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Affiliation(s)
- Chengye Di
- Cardiac Electrophysiology Unit, First Department of Cardiology, TEDA International Cardiovascular Hospital, 3rd Street, Tianjin Economic-Technological Development Area, Tianjin, 300457, China.,College of Clinical Cardiology, Tianjin Medical University, Tianjin, China.,Cardiovascular Institute, Tianjin University, Tianjin, China
| | - Konstantinos P Letsas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, 10676, Athens, Greece
| | - Peng Gao
- Cardiac Electrophysiology Unit, First Department of Cardiology, TEDA International Cardiovascular Hospital, 3rd Street, Tianjin Economic-Technological Development Area, Tianjin, 300457, China.,College of Clinical Cardiology, Tianjin Medical University, Tianjin, China.,Cardiovascular Institute, Tianjin University, Tianjin, China
| | - Qun Wang
- Cardiac Electrophysiology Unit, First Department of Cardiology, TEDA International Cardiovascular Hospital, 3rd Street, Tianjin Economic-Technological Development Area, Tianjin, 300457, China.,College of Clinical Cardiology, Tianjin Medical University, Tianjin, China.,Cardiovascular Institute, Tianjin University, Tianjin, China
| | - Yanxi Wu
- Cardiac Electrophysiology Unit, First Department of Cardiology, TEDA International Cardiovascular Hospital, 3rd Street, Tianjin Economic-Technological Development Area, Tianjin, 300457, China.,College of Clinical Cardiology, Tianjin Medical University, Tianjin, China.,Cardiovascular Institute, Tianjin University, Tianjin, China
| | - Wenhua Lin
- Cardiac Electrophysiology Unit, First Department of Cardiology, TEDA International Cardiovascular Hospital, 3rd Street, Tianjin Economic-Technological Development Area, Tianjin, 300457, China. .,College of Clinical Cardiology, Tianjin Medical University, Tianjin, China. .,Cardiovascular Institute, Tianjin University, Tianjin, China.
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19
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Plachinski SJ, Salman SS, Carey J, Flanagan CM, Novalija J, Pagel PS, Almassi GH. Iatrogenic Aortic Insufficiency After Radiofrequency Ablation of the Left Ventricular Outflow Tract. J Cardiothorac Vasc Anesth 2021; 36:1726-1729. [PMID: 34103217 DOI: 10.1053/j.jvca.2021.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 04/24/2021] [Accepted: 05/03/2021] [Indexed: 01/20/2023]
Affiliation(s)
- Sarah J Plachinski
- Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Sumaiya S Salman
- Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - James Carey
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | | | - Jutta Novalija
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI; Department of Anesthesiology, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
| | - Paul S Pagel
- Department of Anesthesiology, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI.
| | - G Hossein Almassi
- Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI; Department of Cardiothoracic Surgery, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
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20
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Liang JJ, Bogun F. Coronary Venous Mapping and Catheter Ablation for Ventricular Arrhythmias. Methodist Debakey Cardiovasc J 2021; 17:13-18. [PMID: 34104315 DOI: 10.14797/huzr1007] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Catheter ablation is an effective treatment method for ventricular arrhythmias (VAs). These arrhythmias can often be mapped and targeted with ablation from the left and right ventricular endocardium. However, in some situations the VA site of origin or substrate may be intramural or epicardial in nature. In these cases, the coronary venous system (CVS) provides an effective vantage point for mapping and ablation. This review highlights situations in which CVS mapping may be helpful and discusses techniques for CVS mapping and ablation.
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21
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Catheter Ablation of Life-Threatening Ventricular Arrhythmias in Athletes. ACTA ACUST UNITED AC 2021; 57:medicina57030205. [PMID: 33652714 PMCID: PMC7996951 DOI: 10.3390/medicina57030205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/22/2021] [Accepted: 02/22/2021] [Indexed: 12/22/2022]
Abstract
A recent surveillance analysis indicates that cardiac arrest/death occurs in ≈1:50,000 professional or semi-professional athletes, and the most common cause is attributable to life-threatening ventricular arrhythmias (VAs). It is critically important to diagnose any inherited/acquired cardiac disease, including coronary artery disease, since it frequently represents the arrhythmogenic substrate in a substantial part of the athletes presenting with major VAs. New insights indicate that athletes develop a specific electro-anatomical remodeling, with peculiar anatomic distribution and VAs patterns. However, because of the scarcity of clinical data concerning the natural history of VAs in sports performers, there are no dedicated recommendations for VA ablation. The treatment remains at the mercy of several individual factors, including the type of VA, the athlete’s age, and the operator’s expertise. With the present review, we aimed to illustrate the prevalence, electrocardiographic (ECG) features, and imaging correlations of the most common VAs in athletes, focusing on etiology, outcomes, and sports eligibility after catheter ablation.
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22
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Impact of Intramural Scar on Mapping and Ablation of Premature Ventricular Complexes. JACC Clin Electrophysiol 2020; 7:733-741. [PMID: 33358663 DOI: 10.1016/j.jacep.2020.11.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 11/02/2020] [Accepted: 11/03/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVES This study sought to determine intramural scar characteristics associated with successful premature ventricular complex (PVC) ablations. BACKGROUND Ablating ventricular arrhythmias (VAs) originating from intramural scarring can be challenging. Imaging of intramural scar location may help to determine whether the scar is within reach of the ablation catheter. METHODS Mapping and ablation of premature ventricular complexes (PVCs) was performed in a consecutive series of patients with intramural scarring and frequent PVCs. Data from delayed enhanced cardiac magnetic resonance were assessed and the proximity of the endocardium containing the breakout site to the intramural scar was correlated with outcomes. RESULTS Fifty-six patients were included, and intramural VAs were successfully targeted in 42 patients (75%) and ablation failed in 14 patients (25%). Scarring was more superficial to the endocardium in patients with successful ablations compared with patients with failed procedures (0.35 mm [interquartile range (IQR): 0.22 to 1.20 mm] vs. 2.45 mm [IQR: 1.60 to 3.13 mm]; p < 0.001). In 18 (32%) patients, ablation at the breakout site resulted in a significant change of the PVC-QRS morphology that could successfully be ablated in 9 of 12 patients from another anatomical aspect of the wall harboring the intramural scar. The scar was larger in size (1.79 cm3 [IQR: 1.25 to 2.85 cm3] vs. 1.00 cm3 [IQR: 0.59 to 1.68 cm3]; p < 0.005) compared with patients who did not have a change in the PVC-QRS morphology with ablation. CONCLUSIONS VAs in patients with intramural scaring can be successfully ablated especially if the intramural scar is within close proximity to the anatomic area containing the breakout site. Changes in the QRS-PVC morphology often precede successful ablation at another breakout site and indicate larger intramural scars.
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23
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Igarashi M, Nogami A, Fukamizu S, Sekiguchi Y, Nitta J, Sakamoto N, Sakamoto Y, Kurosaki K, Takahashi Y, Kimata A, Komatsu Y, Machino T, Kuroki K, Yamasaki H, Aonuma K, Ieda M. Acute and long-term results of bipolar radiofrequency catheter ablation of refractory ventricular arrhythmias of deep intramural origin. Heart Rhythm 2020; 17:1500-1507. [DOI: 10.1016/j.hrthm.2020.04.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 03/23/2020] [Accepted: 04/01/2020] [Indexed: 11/25/2022]
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24
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Ghannam M, Liang J, Sharaf-Dabbagh G, Latchamsetty R, Jongnarangsin K, Morady F, Bogun F. Mapping and Ablation of Intramural Ventricular Arrhythmias: A Stepwise Approach Focused on the Site of Origin. JACC Clin Electrophysiol 2020; 6:1339-1348. [PMID: 33121661 DOI: 10.1016/j.jacep.2020.05.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/14/2020] [Accepted: 05/17/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVES This study sought to establish a mapping and ablation strategy to target intramural ventricular arrhythmias (VAs) by identifying the precise arrhythmia site of origin (SOO). BACKGROUND Radiofrequency ablation of intramural VAs is challenging because the arrhythmia origin is difficult to localize. METHODS In 83 consecutive patients with intramural VAs, a stepwise mapping approach was performed: ablation targeted directly the SOO when possible followed by the closest adjacent anatomical structure when necessary. If the SOO could not be identified, the earliest endocardial breakout sites were ablated. Safety and procedural outcomes between patients in whom the SOO could and could not be identified were compared. RESULTS The SOO was identified in 19 of 83 (23%) patients, and radiofrequency ablation was effective in eliminating VAs in all 19 (100%) patients by ablation at the SOO alone (n = 3), at the SOO and an anatomically adjacent area (n = 7), or at an anatomically adjacent area alone (n = 9). Breakout site mapping and ablation in the remaining 64 patients in whom the SOO was not identified was effective in 43 of 64 patients, which was significantly less than in patients in whom the SOO was identified (67% vs. 100%; p < 0.05). CONCLUSIONS Identification of the SOO was associated with a successful ablation procedure by either targeting the SOO directly or targeting an adjacent anatomical structure. Ablation at the breakout sites of intramural VAs has a lower efficacy than when the SOO can be directly targeted.
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Affiliation(s)
- Michael Ghannam
- Division of Cardiovascular Medicine and Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jackson Liang
- Division of Cardiovascular Medicine and Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Ghaith Sharaf-Dabbagh
- Division of Cardiovascular Medicine and Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Rakesh Latchamsetty
- Division of Cardiovascular Medicine and Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Krit Jongnarangsin
- Division of Cardiovascular Medicine and Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Fred Morady
- Division of Cardiovascular Medicine and Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Frank Bogun
- Division of Cardiovascular Medicine and Radiology, University of Michigan, Ann Arbor, Michigan, USA.
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25
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Muser D, Santangeli P. Epicardial Ablation of Idiopathic Ventricular Tachycardia. Card Electrophysiol Clin 2020; 12:295-312. [PMID: 32771184 DOI: 10.1016/j.ccep.2020.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Ventricular arrhythmias (VAs) occurring in the absence of structural heart disease or ion channelopathies are referred to as idiopathic. They can clinically present with frequent monomorphic premature ventricular contractions, nonsustained ventricular tachycardia (VT), or sustained VT, and generally share a benign prognosis. Approximately 4% to 10% of idiopathic VAs have an epicardial site of origin, represented in most cases by the left ventricular summit and, less frequently, by the cardiac crux. Epicardial foci can be addressed by catheter ablation via the coronary venous system tributaries. In rarer instances, a direct epicardial access from a subxiphoid approach is needed.
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Affiliation(s)
- Daniele Muser
- Electrophysiology Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Pasquale Santangeli
- Electrophysiology Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
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26
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Romero J, Shivkumar K, Valderrabano M, Diaz JC, Alviz I, Briceno D, Natale A, Di Biase L. Modern mapping and ablation techniques to treat ventricular arrhythmias from the left ventricular summit and interventricular septum. Heart Rhythm 2020; 17:1609-1620. [PMID: 32333973 DOI: 10.1016/j.hrthm.2020.04.026] [Citation(s) in RCA: 18] [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: 02/19/2020] [Revised: 04/04/2020] [Accepted: 04/10/2020] [Indexed: 11/18/2022]
Abstract
Managing arrhythmias from the left ventricular summit and interventricular septum is a major challenge for the clinical electrophysiologist requiring intimate knowledge of cardiac anatomy, advanced training and expertise. Novel mapping and ablation strategies are needed to treat arrhythmias originating from these regions given the current suboptimal long-term success rates with standard techniques. Herein, we describe innovative approaches to improve acute and long-term clinical outcomes such as mapping and ablation using the septal coronary venous system and the septal coronary arteries, alcohol ablation, coil embolization, and ablation of all early sites among others.
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Affiliation(s)
- Jorge Romero
- Division of Cardiology, Department of Medicine, Cardiac Arrhythmia Center, Montefiore Einstein Center for Heart and Vascular Care, Bronx, New York
| | - Kalayanam Shivkumar
- Division of Cardiology, Department of Medicine, Cardiac Arrhythmia Center, University of California, Los Angeles (UCLA) Medical Center, Los Angeles, California
| | - Miguel Valderrabano
- Division of Cardiology, Department of Medicine, Cardiac Arrhythmia Center, Houston Methodist, Houston, Texas
| | - Juan Carlos Diaz
- Division of Cardiology, Department of Medicine, Cardiac Arrhythmia Center, Montefiore Einstein Center for Heart and Vascular Care, Bronx, New York
| | - Isabella Alviz
- Division of Cardiology, Department of Medicine, Cardiac Arrhythmia Center, Montefiore Einstein Center for Heart and Vascular Care, Bronx, New York
| | - David Briceno
- Division of Cardiology, Department of Medicine, Cardiac Arrhythmia Center, Montefiore Einstein Center for Heart and Vascular Care, Bronx, New York
| | - Andrea Natale
- Cardiac Arrhythmia Center, St David's Medical Center, Austin, Texas
| | - Luigi Di Biase
- Division of Cardiology, Department of Medicine, Cardiac Arrhythmia Center, Montefiore Einstein Center for Heart and Vascular Care, Bronx, New York.
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27
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Electrocardiographic features, mapping and ablation of idiopathic outflow tract ventricular arrhythmias. J Interv Card Electrophysiol 2019; 57:207-218. [PMID: 31650457 DOI: 10.1007/s10840-019-00617-9] [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: 07/02/2019] [Accepted: 08/27/2019] [Indexed: 01/01/2023]
Abstract
PURPOSE Idiopathic outflow tract ventricular arrhythmias are ventricular tachycardias or premature ventricular contractions presumably not related to myocardial scar or disorders of ion channels. These arrhythmias have focal origin and display characteristic electrocardiographic features. The purpose of this article is to review the state of the art of diagnosis and treatment of idiopathic outflow tract ventricular arrhythmias. METHODS We systematically reviewed scientific literature about idiopathic outflow tract ventricular arrhythmias selecting the most relevant papers on this topic. RESULTS The right ventricle outflow tract is the most common site of origin for outflow tract ventricular arrhythmias, but also left ventricle outflow tract can harbour these arrhythmias. Outflow tract ventricular arrhythmias are generally benign and may require treatment if they are symptomatic, incessant or give rise to cardiomyopathy. Radiofrequency catheter ablation is an effective and safe therapeutic strategy. A successful procedure requires a thorough preoperative analysis of the 12-lead electrocardiogram of the spontaneous arrhythmia combined with a detailed electroanatomical mapping and intracardiac echocardiography. CONCLUSIONS Idiopathic outflow tract arrhythmias are frequent in daily clinical practice and can be successfully eliminated through discrete radiofrequency catheter ablation with low rates of complications.
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28
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Qifang L, Ye T, Zhi J, Jing H, Yidong Z, Long Y. Variation of QRS morphology of premature ventricular contractions originate from the left-ventricular outflow tract during ablation. J Cardiovasc Electrophysiol 2019; 30:2990-2994. [PMID: 31642151 PMCID: PMC6916391 DOI: 10.1111/jce.14228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/26/2019] [Accepted: 09/27/2019] [Indexed: 11/30/2022]
Abstract
Idiopathic ventricular arrhythmias originating from the aortic sinus of Valsalva often show preferential conduction to the right‐ventricular outflow tract, which may render radiofrequency ablation more difficult. We describe a patient with symptomatic premature ventricular contractions of left‐ventricular outflow tract origin presenting with a variation of QRS morphology during ablation. The correlation between the characteristics of local voltage potentials and the real origin site of the ventricular arrhythmia is discussed.
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Affiliation(s)
- Liu Qifang
- Department of Cardiology, Guizhou Provincial People's Hospital, Guiyang, China
| | - Tian Ye
- Department of Cardiology, Guizhou Provincial People's Hospital, Guiyang, China
| | - Jiang Zhi
- Department of Cardiology, Guizhou Provincial People's Hospital, Guiyang, China
| | - Huang Jing
- Department of Cardiology, Guizhou Provincial People's Hospital, Guiyang, China
| | - Zhao Yidong
- Department of Cardiology, Guizhou Provincial People's Hospital, Guiyang, China
| | - Yang Long
- Department of Cardiology, Guizhou Provincial People's Hospital, Guiyang, China
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29
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Chung FP, Vicera JJB, Lin YJ, Chang SL, Lo LW, Hu YF, Lin CY, Tuan TC, Chao TF, Liao JN, Chang TY, Salim S, Liu CM, Chuang CM, Chen CC, Chin CG, Wu CI, Chou CY, Chen SA. Clinical efficacy of open-irrigated electrode cooled with half-normal saline for initially failed radiofrequency ablation of idiopathic outflow tract ventricular arrhythmias. J Cardiovasc Electrophysiol 2019; 30:1508-1516. [PMID: 31257650 DOI: 10.1111/jce.14057] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/04/2019] [Accepted: 06/24/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Acute failure of radiofrequency ablation (RFA) of ventricular arrhythmias (VAs) occur in 10%-20% of patients and is partly attributed to inadequate lesion depth acquired with standard ablation protocols. Half-normal saline (HNS)-irrigation is a promising strategy to improve the success rate of VA ablation. OBJECTIVE This study investigated the efficacy of HNS-irrigated ablation after a failed standard plain normal saline solution (PNSS)-irrigated ablation on idiopathic outflow tract ventricular arrhythmia (OT-VA). METHOD This is a prospective observational study of consecutive patients undergoing RFA of idiopathic OT-VA comparing the efficacy of additional HNS-irrigated ablation for failed standard PNSS-irrigated ablation. Acute failure was defined as persistence of spontaneous VA or persistent inducibility of the clinical VA. RESULTS Out of 160 OT-VA cases (51 ± 15-year-old, 62 males), 31 underwent HNS irrigation after a failed standard PNSS-irrigated ablation. The HNS group had a significantly longer procedure time (60.06 ± 43.83 vs 37.51 ± 33.40 minutes; P = .013) and higher radiation exposure (31.45 ± 20.24 vs 17.22 ± 15.25 minutes; P = .001) than the PNSS group but provided an additional acute success in 21 of 31 (67.7%) patients. Over a follow-up duration of 7.8 ± 4.6 months, 24 recurrences were identified, including 8 (25.8%) in the HNS and 16 (12.4%) in the PNSS group, with lower freedom from recurrence in the HNS group (log rank P = .009). No major complication was observed. CONCLUSION HNS-irrigated ablation after failed standard PNSS-irrigated ablation is safe and additionally improves acute ablation success by 67.7% for idiopathic OT-VA but with a higher rate of recurrence on follow-up. Whether the application of HNS as initial irrigant could result in better outcome requires further investigation.
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Affiliation(s)
- Fa-Po Chung
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Jennifer Jeanne B Vicera
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Shih-Lin Chang
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Li-Wei Lo
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Yu-Feng Hu
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Chin-Yu Lin
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Ta-Chuan Tuan
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Tze-Fan Chao
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Jo-Nan Liao
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Ting-Yung Chang
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Simon Salim
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Internal Medicine, Rumah Sakit Bethsaida Tangerang, Kabupaten Tangerang, Banten, Indonesia
| | - Chih-Min Liu
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Chieh-Mao Chuang
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Division of Pediatric Cardiology, China Medical University Children's Hospital, China Medical University, Taichung, Taiwan
| | - Chun-Chao Chen
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Internal Medicine, Division of Cardiology, Shuang Ho Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chye Gen Chin
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Internal Medicine, Division of Cardiovascular Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Internal Medicine, Division of Cardiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Cheng-I Wu
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ching-Yao Chou
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Internal Medicine, Division of Cardiology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Shih-Ann Chen
- Heart Rhythm Center and Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
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