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Hasegawa S, Tanaka A, Uehara Y, Yabuta H, Kato K. Successful chemical ablation for intraventricular septal ventricular tachycardia-An alternative approach to the septal branch. Clin Case Rep 2024; 12:e8965. [PMID: 39091619 PMCID: PMC11291298 DOI: 10.1002/ccr3.8965] [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: 01/12/2024] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 08/04/2024] Open
Abstract
Trans-coronary ethanol ablation for ventricular tachycardia originating from the ventricular septum is effective, but there are cases with no septal perforator from left anterior descending artery. CT and angiography can reveal the optimal vessel.
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Affiliation(s)
- Shin Hasegawa
- Department of CardiologyNagoya Tokushukai General HospitalKasugaiAichiJapan
| | - Akimitsu Tanaka
- Department of CardiologyNagoya Tokushukai General HospitalKasugaiAichiJapan
| | - Yukihiro Uehara
- Department of CardiologyNagoya Tokushukai General HospitalKasugaiAichiJapan
| | - Hiroki Yabuta
- Department of CardiologyNagoya Tokushukai General HospitalKasugaiAichiJapan
| | - Kazuo Kato
- Department of CardiologyNagoya Tokushukai General HospitalKasugaiAichiJapan
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Enriquez A, Muser D, Markman TM, Garcia F. Mapping and Ablation of Premature Ventricular Complexes: State of the Art. JACC Clin Electrophysiol 2024; 10:1206-1222. [PMID: 38639702 DOI: 10.1016/j.jacep.2024.02.008] [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: 10/25/2023] [Revised: 02/06/2024] [Accepted: 02/07/2024] [Indexed: 04/20/2024]
Abstract
Premature ventricular complexes (PVCs) are common arrhythmias in clinical practice. Although benign and asymptomatic in most cases, PVCs may result in disabling symptoms, left ventricular systolic dysfunction, or PVC-induced ventricular fibrillation. Catheter ablation has emerged as a first-line therapy in such cases, with high rates of efficacy and low risk of complications. Significant progress in mapping and ablation technology has been made in the past 2 decades, along with the development of a growing body of knowledge and accumulated experience regarding PVC sites of origin, anatomical relationships, electrocardiographic characterization, and mapping/ablation strategies. This paper provides an overview of the main indications for catheter ablation of PVCs, electrocardiographic features, PVC mapping techniques, and contemporary ablation approaches. The authors also review the most common sites of PVC origin and the main considerations and challenges with ablation in each location.
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Affiliation(s)
- Andres Enriquez
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Daniele Muser
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Timothy M Markman
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fermin Garcia
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Aguilera J, Cabrera J, Saenz LC, Santangeli P. Catheter Ablation of Idiopathic Epicardial Outflow Tract Premature Ventricular Contractions: A Case Report and Review of the Literature. Card Electrophysiol Clin 2024; 16:187-193. [PMID: 38749640 DOI: 10.1016/j.ccep.2023.10.005] [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: 05/26/2024]
Abstract
The epicardial outflow tract can be a site of origin of idiopathic ventricular arrhythmias. These arrhythmias are most commonly perivalvular and can be targeted from within the coronary venous system or from other adjacent structures, such as the right ventricular and left ventricular outflow tracts or the coronary cusp region. The authors report a case of an epicardial idiopathic outflow tract premature ventricular contraction originating from the midseptal epicardial left ventricle. In this case, direct epicardial access was crucial to identify early local activation and achieve successful catheter ablation.
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Affiliation(s)
- Jose Aguilera
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Juan Cabrera
- Section of Electrophysiology, Fundación Cardioinfantil, Bogotá, Colombia
| | - Luis Carlos Saenz
- Section of Electrophysiology, Fundación Cardioinfantil, Bogotá, Colombia
| | - Pasquale Santangeli
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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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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Jiang Z, Guo C, Liu Q, Tian Y, Tian L, Yang Y, Wang J, Chen C, Zheng Y, Li Y, Ou Q, Yang L. Outcomes of single-procedure radiofrequency catheter ablation for idiopathic ventricular arrhythmias: a single-centre retrospective cohort study. BMJ Open 2024; 14:e081815. [PMID: 38382956 PMCID: PMC10882318 DOI: 10.1136/bmjopen-2023-081815] [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] [Indexed: 02/23/2024] Open
Abstract
OBJECTIVES Radiofrequency catheter ablation is the first-line treatment for idiopathic premature ventricular complexes (PVCs) and ventricular tachycardias (VTs). However, the outcomes were less compared among the categories. The study aims to assess the effectiveness and safety of catheter ablation for idiopathic PVC/VTs in a single high-volume centre, using the right ventricular outflow tract (RVOT) as a reference. DESIGN Retrospective cohort study. SETTING Patient data were collected from a tertiary hospital in Guizhou, China. PARTICIPANTS Between September 2013 and September 2022, 1028 patients (male: 41.3%; age: 46.5±15.6 years) who underwent the first catheter ablation for idiopathic monomorphic PVC/VTs were enrolled. OUTCOME MEASURES Acute success, procedure-related complications, and long-term recurrence were assessed. Antiarrhythmic drugs (AADs) were not administrated after procedures unless recurrence was identified. RESULTS The overall acute success rate was 90.3%, with 368 patients (35.8%) experiencing left ventricular PVC/VTs. No cases of third-degree atrioventricular block or death were reported. Complications were more common in patients with left ventricular PVC/VTs than those with right-sided ones (4.6% vs 0.1%, p<0.001). A total of 926 patients (90.1%) were followed up for an average of 9.7±3.7 months, and only the PVC/VTs category was found to be associated with long-term success rates. The RVOT, endocardial left ventricular outflow tract (endoLVOT), tricuspid annulus (TA) free wall, posterior septum and fascicular VT had long-term success rates exceeding 85%. Other types of PVC/VTs showed significantly higher risks of recurrence. CONCLUSIONS Besides RVOT and fascicular VT, single-procedure catheter ablation without AADs is highly effective for endoLVOT, TA-free wall and posterior septum. Patients with left ventricular PVC/VTs have higher complication risks compared with right ones.
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Affiliation(s)
- Zhi Jiang
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
- Guizhou Provincial Cardiovascular Disease Institute, Guiyang, China
| | - Chuxian Guo
- Guizhou Medical University, Guiyang, Guizhou, China
| | - Qifang Liu
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
- Guizhou Provincial Cardiovascular Disease Institute, Guiyang, China
| | - Ye Tian
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
- Guizhou Provincial Cardiovascular Disease Institute, Guiyang, China
| | - Longhai Tian
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
- Guizhou Provincial Cardiovascular Disease Institute, Guiyang, China
| | - Ying Yang
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
- Guizhou Provincial Cardiovascular Disease Institute, Guiyang, China
| | - Junxian Wang
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
- Guizhou Provincial Cardiovascular Disease Institute, Guiyang, China
| | - Chunyan Chen
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
- Guizhou Provincial Cardiovascular Disease Institute, Guiyang, China
| | - Yaxi Zheng
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
- Guizhou Provincial Cardiovascular Disease Institute, Guiyang, China
| | - Yu Li
- Guizhou Medical University, Guiyang, Guizhou, China
| | - Qiaoqiao Ou
- Guizhou Medical University, Guiyang, Guizhou, China
| | - Long Yang
- Cardiology Department, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
- Guizhou Provincial Cardiovascular Disease Institute, Guiyang, China
- Guizhou Medical University, Guiyang, Guizhou, China
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Xuan F, Zuo Z, Zhang J, Zhang S, Liu Z, Meng Y, Sun K, Han Y, Liang M, Wang Z. Guidewire Ablation within the Coronary Venous System for Epicardial or Intramural Ventricular Arrhythmia: A Preclinical Study of Biophysical Characterization. Cardiol Res Pract 2024; 2024:4412758. [PMID: 38213678 PMCID: PMC10783981 DOI: 10.1155/2024/4412758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 12/12/2023] [Accepted: 12/19/2023] [Indexed: 01/13/2024] Open
Abstract
Background Catheter ablation failure poses a clinical challenge for epicardial or intramural ventricular arrhythmia (VA); however, guidewire ablation within the coronary venous system (CVS) may be effective and safe for targeting VAs. Methods The ex vivo phase included four steps. In step 1, the steam pop incidence rates during guidewire ablation at power settings of 5, 10, 15, 20, and 25 W were analyzed using 10 mm- and 20 mm-tip guidewires. In step 2, guidewire ablation was performed for application durations of 10, 20, 30, 40, 50, 60, and 90 s, and the lesion size was measured. In step 3, the effects of saline infusion (0, 1, 2, 3, and 4 mL/min) on lesion dimensions and steam pop formation were examined. In step 4, an orthogonal array was constructed to obtain the optimal guidewire ablation parameters. In the in vivo phase, guidewire ablation within the CVS was performed in three dogs, and the lesion features in 10 days after ablation were observed. Results In step 1, the steam pop incidence rates at 5, 10, 15, 20, and 25 W were 0%, 0%, 12.5%, 62.5%, and 100% using the 10 mm-tip guidewires and 0%, 0%, 0%, 25%, and 75% using the 20 mm-tip guidewires, respectively. In step 2, we found that the lesion areas increased with an increase in the ablation duration (the maximum lesion diameters at 30, 60, and 90 s were 4.9 ± 0.4, 7.0 ± 0.8, and 9.2 ± 0.7 mm in the 10 mm group and 3.2 ± 0.5, 4.5 ± 0.4, and 5.3 ± 0.7 mm in the 20 mm-tip group, respectively). In step 3, we observed that saline infusion was negatively correlated with ablation lesions but had a lower risk of steam pop. The optimal parameters for the 20 mm-tip guidewire ablation were 15 W, 50 s, and 2 mL/min or 20 W, 70 s, and 2 mL/min. In the in vivo phase, effective ablation lesions with maximum and minimum diameters of 3.2 ± 0.3 and 2.8 ± 0.5 mm, respectively, were created by the guidewires during the 10-day observation period after ablation. Conclusion This novel radiofrequency guidewire ablation technique can feasibly create effective lesions within the CVS, which may improve the efficacy of catheter ablation for challenging epicardial or intramural VA.
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Affiliation(s)
- Fengqi Xuan
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110016, China
- Department of Cardiology, Tianjin Chest Hospital, Tianjin 300222, China
| | - Zhongyin Zuo
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - Jie Zhang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - Shibei Zhang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - Zichen Liu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - Yunfan Meng
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - Kuo Sun
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - Ming Liang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - Zulu Wang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110016, China
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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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Darden D, Lakkireddy D. Diving deeper: Essential role of advanced ventricular tachycardia ablation techniques in hypertrophic cardiomyopathy. Indian Pacing Electrophysiol J 2024; 24:14-15. [PMID: 38242287 PMCID: PMC10927976 DOI: 10.1016/j.ipej.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2024] Open
Affiliation(s)
- Douglas Darden
- Kansas City Heart Rhythm Institute, Overland Park, KS, USA
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9
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Yang J, Li M, Jiang C, Tang R, Sang C, Wang W, Zhao X, Li C, Li S, Guo X, Jia C, Ning M, Feng L, Wen D, Zhu H, Jiang Y, Liu T, Liu F, Long D, Dong J, Ma C. Electrophysiological characteristics and ablation of ventricular arrhythmias originating from the intramural basal inferior septum. Europace 2023; 26:euae001. [PMID: 38180948 PMCID: PMC10799636 DOI: 10.1093/europace/euae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/28/2023] [Indexed: 01/07/2024] Open
Abstract
AIMS The electrocardiographic and electrophysiological characteristics of ventricular arrhythmia (VA) arising from the intramural basal inferior septum (BIS) have not been specifically addressed to date. The aim of the current study was to characterize intramural BIS-VA and distinguish it from those with endocardial origins besides clarifying the anatomical configurations of the pyramidal space. METHODS AND RESULTS Fifty-five consecutive patients undergoing catheter ablation of VAs from BIS were identified and divided into three groups: the left ventricular (LV)-BIS group (n = 28), right ventricular (RV)-BIS group (n = 8), and intramural group (Intra, n = 19). Compared with the LV-BIS and RV-BIS groups, patients in the Intra group presented with no adequate earliest activation time at the two-sided BIS and epicardial coronary system [right: 7.79 ± 2.38 vs. left: 7.16 ± 2.59 vs. the middle cardiac vein (MCV): 6.26 ± 1.73 ms, P = 0.173] and poor-matched pacing-produced QRS at each site. Under the intracardiac echocardiography view, the pyramidal base was the broadest part of the septum and served as the division of the two-sided BIS. Focal ablation yielded promising acute-term and long-term procedural success in the LV-BIS and RV-BIS groups. But for the Intra group, VAs disappeared only after stepwise ablation successively targeted early preferential exit. After follow-up, three patients in the Intra group had recurrent VA, and all of them were treated well by a redo procedure or drug therapy. CONCLUSION Intramural VAs were relatively common in the BIS region in our series. Intra-procedural mapping was important to distinguish the intramural VAs from other VAs by comparing the local activation time and pacing mapping. Procedural success could be achieved by stepwise ablation on the counterpart sides of the BIS and within the MCV.
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Affiliation(s)
- Jie Yang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Mengmeng Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Chenxi Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Ribo Tang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Caihua Sang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Wei Wang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Xin Zhao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Changyi Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Songnan Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Xueyuan Guo
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Changqi Jia
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Man Ning
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Li Feng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Dan Wen
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Hui Zhu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Yuexin Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Tong Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Fang Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Deyong Long
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Jianzeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular Diseases, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
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10
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Futyma P, Chen S, Enriquez A, Pürerfellner H, Santangeli P. Bipolar ablation of ventricular arrhythmias: Step-by-step. J Cardiovasc Electrophysiol 2023; 34:2599-2606. [PMID: 37968834 DOI: 10.1111/jce.16131] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 10/29/2023] [Accepted: 11/01/2023] [Indexed: 11/17/2023]
Abstract
Radiofrequency (RF) ablation of intramural ventricular arrhythmias (VAs) may require advanced ablation techniques to achieve effective energy transfer to the targeted tissue. As an alternative to standard RF ablation, catheter ablation can also be conducted in bipolar configuration when two ablation catheters participate in the RF circuit. This strategy has proved to result in deeper lesion formation and may be effective for eliminating arrhythmias that have been refractory to standard ablation. In this article, we provide a step-by-step guide on when and how to perform bipolar ablation of VAs.
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Affiliation(s)
- Piotr Futyma
- St. Joseph's Heart Rhythm Center, Rzeszów, Poland
- Medical College, University of Rzeszów, Rzeszów, Poland
| | - Shaojie Chen
- Department Kardiologe, Markus Krankenhaus, Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
| | - Andres Enriquez
- Kingston Health Science Centre, Queen's University, Kingston, Ontario, Canada
| | | | - Pasquale Santangeli
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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11
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Sudo K, Kuroki K, Asakawa T, Aonuma K, Sato A. Management of refractory intramural left ventricular summit ventricular arrhythmia: Acute success using bipolar radiofrequency catheter ablation with recurrence. J Arrhythm 2023; 39:979-983. [PMID: 38045468 PMCID: PMC10692834 DOI: 10.1002/joa3.12937] [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] [Received: 06/01/2023] [Revised: 09/11/2023] [Accepted: 09/23/2023] [Indexed: 12/05/2023] Open
Abstract
Bipolar radiofrequency catheter ablation (RFCA) is a novel strategy for refractory or recurrent ventricular arrhythmias (VAs) resistant to conventional ablation methods. Lesions created during bipolar RFCA are larger than those created during sequential unipolar ablation. We present a case of refractory LV summit VAs, which identified the origin using a 2.7-F over-the-wire microelectrodes catheter, and it was successfully treated with bipolar RFCA in the acute phase.
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Affiliation(s)
- Koji Sudo
- Department of Cardiovascular MedicineUniversity of YamanashiChuoJapan
| | - Kenji Kuroki
- Department of Cardiovascular MedicineUniversity of YamanashiChuoJapan
| | - Tetsuya Asakawa
- Department of CardiologyYamanashi Kosei HospitalYamanashiJapan
| | - Kazutaka Aonuma
- Department of CardiologyMito Saiseikai General HospitalMitoJapan
| | - Akira Sato
- Department of Cardiovascular MedicineUniversity of YamanashiChuoJapan
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12
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Dong Y, Wang H, Ma K, Ling Z, Zhao D, Wang Y, Zhang Z, Shao M, Song H, Jiang W, Yang K, Chen Q, Kojodjojo P, Ullah I, Cao K, Chen M, Zhang F. Half versus normal saline irrigation during catheter ablation of outflow tract ventricular arrhythmias (HALF): a multi-center, parallel, open-label, randomized controlled study. J Interv Card Electrophysiol 2023; 66:2143-2151. [PMID: 37204671 DOI: 10.1007/s10840-023-01558-0] [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: 01/23/2023] [Accepted: 05/01/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Animal studies demonstrated that deeper lesions could be achieved during radio-frequency catheter ablation (RFCA) by using half saline (HS) compared to normal saline (NS) as irrigation. OBJECTIVES This study sought to compare the efficiency and safety of HS and NS for irrigation during RFCA of idiopathic outflow tract ventricular arrhythmia (OT-VA). METHODS In this multicenter, randomized controlled study, 167 patients undergoing RFCA of OT-VA were randomized 1:1 to receive HS- or NS-irrigated ablation. Acute success was defined as the absence of induced targeted premature ventricular contraction (PVC) at the end of the procedure. The 6-month success was defined as a ≥ 80% reduction of pre-procedural PVC burden. RESULTS There were no differences of baseline characteristics between the HS and NS group. Patients in HS group had shorter total ablation time (259.5 ± 155.5 S vs. 355.6 ± 230.7 S, P = 0.04) than that in NS group. The acute and 6-month success rates were similar between the HS and NS group (92.8 vs. 91.7%, P = 0.79; 90.9 vs. 92.1%, P = 0.79, respectively). No significant difference was observed in the incidence of steam pops between the HS and NS group (2.4 vs. 1.2%, P = 0.62). CONCLUSIONS The ablation using HS irrigation achieved similar success rate and safety compared to that using NS irrigation but was associated with a shorter total ablation time. TRIAL REGISTRATION Chinese Clinical Trial Registry (ChiCTR2200059205).
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Affiliation(s)
- Yan Dong
- Section of Pacing and Electrophysiology, Division of Cardiology, the First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing, 210029, China
| | - Hongtao Wang
- Department of Cardiology, the Second Affiliated Hospital of Xi'an JiaoTong University, Xi'an, China
| | - Kezhong Ma
- Department of Cardiology, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Xiangyang, Hubei, China
| | - Zhiyu Ling
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dongsheng Zhao
- Section of Pacing and Electrophysiology, Division of Cardiology, the First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing, 210029, China
| | - Yuegang Wang
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhiyong Zhang
- Department of Cardiology, the Affiliated Suqian First People's Hospital of Nanjing Medical University, Jiangsu, China
| | - Mingliang Shao
- Department of Cardiology, the Affiliated Xuancheng Hospital of Wannan Medical College, Wuhu, China
| | - Hejian Song
- Department of Cardiology, the First Affiliated Hospital of Kangda College of Nanjing Medical University, Nanjing, China
| | - Wei Jiang
- Department of Cardiology, the Second Affiliated Hospital of Xi'an JiaoTong University, Xi'an, China
| | - Kai Yang
- Department of Cardiology, the First Affiliated Hospital of Kangda College of Nanjing Medical University, Nanjing, China
| | - Qiushi Chen
- Section of Pacing and Electrophysiology, Division of Cardiology, the First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing, 210029, China
| | - Pipin Kojodjojo
- National University of Singapore, Asian Heart and Vascular Centre, Singapore, Singapore
| | - Inam Ullah
- Section of Pacing and Electrophysiology, Division of Cardiology, the First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing, 210029, China
| | - Kejiang Cao
- Section of Pacing and Electrophysiology, Division of Cardiology, the First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing, 210029, China
| | - Minglong Chen
- Section of Pacing and Electrophysiology, Division of Cardiology, the First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing, 210029, China
| | - Fengxiang Zhang
- Section of Pacing and Electrophysiology, Division of Cardiology, the First Affiliated Hospital with Nanjing Medical University, Guangzhou Road 300, Nanjing, 210029, China.
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13
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Fuentes S, Valderrábano M. Venous Ethanol Ablation Approaches for Radiofrequency-Refractory Cardiac Arrhythmias. Curr Cardiol Rep 2023; 25:917-924. [PMID: 37450261 DOI: 10.1007/s11886-023-01914-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/27/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE OF REVIEW In this review, we summarize the procedural approach and outcomes of venous ethanol infusion in the treatment of ventricular arrhythmias with intramural site of origin. RECENT FINDINGS Coronary venous ethanol infusion has emerged as a novel, safe, and effective adjunctive strategy to radiofrequency ablation of drug refractory ventricular arrhythmias with an intramural origin. Radiofrequency catheter ablation is the first-line treatment for drug refractory ventricular arrythmias. Its success is highly dependent on the ability to reach targeted myocardium. Radiofrequency failures are common in patients with ventricular arrhythmias arising from deep intramural substrates, and those whose origin is in close proximity to vital structures such as coronary arteries or the phrenic nerve. Coronary venous ethanol infusion has emerged as a novel technique that circumvents these limitations.
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Affiliation(s)
- Stephanie Fuentes
- Houston Methodist DeBakey Heart and Vascular Center, 6550 Fannin St. Suite 1801 Smith Tower. Houston, TX, 77030, USA
| | - Miguel Valderrábano
- Houston Methodist DeBakey Heart and Vascular Center, 6550 Fannin St. Suite 1801 Smith Tower. Houston, TX, 77030, USA.
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14
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Natale A, Zeppenfeld K, Della Bella P, Liu X, Sabbag A, Santangeli P, Sommer P, Sticherling C, Zhang X, Di Biase L. Twenty-five years of catheter ablation of ventricular tachycardia: a look back and a look forward. Europace 2023; 25:euad225. [PMID: 37622589 PMCID: PMC10451002 DOI: 10.1093/europace/euad225] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/14/2023] [Indexed: 08/26/2023] Open
Abstract
This article will discuss the past, present, and future of ventricular tachycardia ablation and the continuing contribution of the Europace journal as the platform for publication of milestone research papers in this field of ventricular tachycardia ablation.
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Affiliation(s)
- Andrea Natale
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, 3000 N. I-35, Suite 720, Austin, TX 78705, USA
| | - Katja Zeppenfeld
- Department of Cardiology, Willem Einthoven Center of Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands
| | - Paolo Della Bella
- Department of Cardiac Electrophysiology and Arrhythmology, San Raffaele University Hospital, Milan, Italy
| | - Xu Liu
- Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Avi Sabbag
- Sheba Medical Center, Tel HaShomer, Israel and the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Philipp Sommer
- Heart and Diabetes Center NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
| | | | - Xiaodong Zhang
- Montefiore Health System, Einstein Medical School, New York, USA
| | - Luigi Di Biase
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, 3000 N. I-35, Suite 720, Austin, TX 78705, USA
- Montefiore Health System, Einstein Medical School, New York, USA
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15
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Nehoff HL, Melton I, Crozier IG. A case report of a rare complication of an iatrogenic ventricular septal defect secondary to radiofrequency ablation. HeartRhythm Case Rep 2023; 9:542-544. [PMID: 37614390 PMCID: PMC10444561 DOI: 10.1016/j.hrcr.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023] Open
Affiliation(s)
- Hayley L. Nehoff
- Department of Cardiology, Christchurch Public Hospital, Christchurch, New Zealand
| | | | - Ian G. Crozier
- Department of Cardiology, Christchurch Public Hospital, Christchurch, New Zealand
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16
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Hanson M, Futyma P, Bode W, Liang JJ, Tapia C, Adams C, Zarębski Ł, Wrzos A, Saenz L, Sadek M, Muser D, Baranchuk A, Marchlinski F, Santangeli P, Garcia F, Enriquez A. Catheter ablation of intramural outflow tract premature ventricular complexes: a multicentre study. Europace 2023; 25:euad100. [PMID: 37096979 PMCID: PMC10228610 DOI: 10.1093/europace/euad100] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 03/20/2023] [Indexed: 04/26/2023] Open
Abstract
AIMS Ablation of outflow tract ventricular arrhythmias may be limited by a deep intramural location of the arrhythmogenic source. This study evaluates the acute and long-term outcomes of patients undergoing ablation of intramural outflow tract premature ventricular complexes (PVCs). METHODS AND RESULTS This multicenter series included patients with structurally normal heart or nonischemic cardiomyopathy and intramural outflow tract PVCs defined by: (a) ≥ 2 of the following criteria: (1) earliest endocardial or epicardial activation < 20ms pre-QRS; (2) Similar activation in different chambers; (3) no/transient PVC suppression with ablation at earliest endocardial/epicardial site; or (b) earliest ventricular activation recorded in a septal coronary vein. Ninety-two patients were included, with a mean PVC burden of 21.5±10.9%. Twenty-six patients had had previous ablations. All PVCs had inferior axis, with LBBB pattern in 68%. In 29 patients (32%) direct mapping of the intramural septum was performed using an insulated wire or multielectrode catheter, and in 13 of these cases the earliest activation was recorded within a septal vein. Most patients required special ablation techniques (one or more), including sequential unipolar ablation in 73%, low-ionic irrigation in 26%, bipolar ablation in 15% and ethanol ablation in 1%. Acute PVC suppression was achieved in 75% of patients. Following the procedure, the PVC burden was reduced to 5.8±8.4%. The mean follow-up was 15±14 months and 16 patients underwent a repeat ablation. CONCLUSION Ablation of intramural PVCs is challenging; acute arrhythmia elimination is achieved in 3/4 patients, and non-conventional approaches are often necessary for success.
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Affiliation(s)
- Matthew Hanson
- Division of Cardiology, Queen’s University, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada
| | - Piotr Futyma
- University of Rzeszów and St. Joseph's Heart Rhythm Center, Rzeszów, Poland
| | - Weeranun Bode
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jackson J Liang
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Carlos Tapia
- Fundación Cardioinfantil, Instituto de Cardiología, Bogotá, Colombia
| | - Christian Adams
- Fundación Cardioinfantil, Instituto de Cardiología, Bogotá, Colombia
| | - Łukasz Zarębski
- University of Rzeszów and St. Joseph's Heart Rhythm Center, Rzeszów, Poland
| | - Aleksandra Wrzos
- University of Rzeszów and St. Joseph's Heart Rhythm Center, Rzeszów, Poland
| | - Luis Saenz
- Fundación Cardioinfantil, Instituto de Cardiología, Bogotá, Colombia
| | - Mouhannad Sadek
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Daniele Muser
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Adrian Baranchuk
- Division of Cardiology, Queen’s University, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada
| | - Francis Marchlinski
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pasquale Santangeli
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fermin Garcia
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andres Enriquez
- Division of Cardiology, Queen’s University, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada
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17
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Mathuria N. The "Other" Ventricle: The Role of RV Mapping in Postinfarction Ventricular Tachycardia. JACC Clin Electrophysiol 2023; 9:26-27. [PMID: 36697198 DOI: 10.1016/j.jacep.2022.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 10/12/2022] [Indexed: 01/25/2023]
Affiliation(s)
- Nilesh Mathuria
- Division of Cardiac Electrophysiology, DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas, USA.
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18
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Venous Ethanol for Left Ventricular Summit Arrhythmia: Control of the Extent of Scar. JACC Clin Electrophysiol 2023; 9:40-42. [PMID: 36697199 DOI: 10.1016/j.jacep.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 09/27/2022] [Accepted: 10/03/2022] [Indexed: 01/25/2023]
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19
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Futyma P, Zarębski Ł, Chen S, Enriquez A, Pürerfellner H, Santangeli P. Risk Assessment and Management of Outflow Tract Arrhythmias Refractory to Prior Treatments. CURRENT CARDIOVASCULAR RISK REPORTS 2022. [DOI: 10.1007/s12170-022-00712-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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20
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Atreya AR, Yalagudri SD, Subramanian M, Rangaswamy VV, Saggu DK, Narasimhan C. Best Practices for the Catheter Ablation of Ventricular Arrhythmias. Card Electrophysiol Clin 2022; 14:571-607. [PMID: 36396179 DOI: 10.1016/j.ccep.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Techniques for catheter ablation have evolved to effectively treat a range of ventricular arrhythmias. Pre-operative electrocardiographic and cardiac imaging data are very useful in understanding the arrhythmogenic substrate and can guide mapping and ablation. In this review, we focus on best practices for catheter ablation, with emphasis on tailoring ablation strategies, based on the presence or absence of structural heart disease, underlying clinical status, and hemodynamic stability of the ventricular arrhythmia. We discuss steps to make ablation safe and prevent complications, and techniques to improve the efficacy of ablation, including optimal use of electroanatomical mapping algorithms, energy delivery, intracardiac echocardiography, and selective use of mechanical circulatory support.
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Affiliation(s)
- Auras R Atreya
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India; Division of Cardiovascular Medicine, Electrophysiology Section, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sachin D Yalagudri
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India
| | - Muthiah Subramanian
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India
| | | | - Daljeet Kaur Saggu
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India
| | - Calambur Narasimhan
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India.
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21
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Ghannam M, Bogun F. Improving Outcomes in Ventricular Tachycardia Ablation Using Imaging to Identify Arrhythmic Substrates. Card Electrophysiol Clin 2022; 14:609-620. [PMID: 36396180 DOI: 10.1016/j.ccep.2022.06.009] [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 tachycardia (VT) ablation is limited by modest acute and long-term success rates, in part due to the challenges in accurately identifying the arrhythmogenic substrate. The combination of multimodality imaging along with information from electroanatomic mapping allows for a more comprehensive assessment of the arrhythmogenic substrate which facilitates VT ablation, and the use of preprocedural imaging has been shown to improve long-term ablation outcomes. Beyond regional recognition of the arrhythmogenic substrate, advanced imaging techniques can be used to create tailored ablation strategies preprocedurally. This review will focus on how imaging can be used to guide ablation planning and execution with a focus on clinical applications aimed at improving the outcome of VT ablation procedures.
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Affiliation(s)
- Michael Ghannam
- Division of Cardiovascular Medicine, University of Michigan, 1500 E. Medical Center Dr., SPC5853, Ann Arbor, Michigan 48109-5853, USA.
| | - Frank Bogun
- Division of Cardiovascular Medicine, University of Michigan, 1500 E. Medical Center Dr., SPC5853, Ann Arbor, Michigan 48109-5853, USA
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22
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Valderrábano M. What to do when everything fails…Is alcohol the answer? HeartRhythm Case Rep 2022; 9:6-7. [PMID: 36685683 PMCID: PMC9845640 DOI: 10.1016/j.hrcr.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Miguel Valderrábano
- Address reprint requests and correspondence: Dr Miguel Valderrábano, 6550 Fannin St, Suite 1801, Smith Tower. Houston, TX 77030.
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23
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Fuentes Rojas SC, Malahjfi M, Tavares L, Patel A, Schurmann PA, Dave AS, Tapias C, Rodríguez D, Sáenz LC, Korolev S, Papiashvili G, Peichl P, Kautzner J, Blaszyk K, Malaczynska-Rajpold K, Chen T, Santangeli P, Shah DJ, Valderrábano M. Acute and Long-Term Scar Characterization of Venous Ethanol Ablation in the Left Ventricular Summit. JACC Clin Electrophysiol 2022; 9:28-39. [PMID: 37166222 DOI: 10.1016/j.jacep.2022.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/09/2022] [Accepted: 08/22/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Venous ethanol ablation (VEA) can be effective for ventricular arrhythmias from the left ventricular summit (LVS); however, there are concerns about excessive ablation by VEA. OBJECTIVES The purpose of this study was to delineate and quantify the location, extent, and evolution of ablated tissue after VEA as an intramural ablation technique in the LVS. METHODS VEA was performed in 59 patients with LVS ventricular arrhythmias. Targeted intramural veins were selected by electrograms from a 2F octapolar catheter or by guide-wire unipolar signals. Median ethanol delivered was 4 mL (IQR: 4-7 mL). Ablated areas were estimated intraprocedurally as increased echogenicity on intracardiac echocardiography (ICE) and incorporated into 3-dimensional maps. In 44 patients, late gadolinium enhancement cardiac magnetic resonance (CMR) imaged VEA scar and its evolution. RESULTS ICE-demonstrated increased intramural echogenicity (median volume of 2 mL; IQR: 1.7-4.3) at the targeted region of the 3-dimensional maps. Post-ethanol CMR showed intramural scar of 2.5 mL (IQR: 2.1-3.5 mL). Early (within 48 hours after VEA) CMR showed microvascular obstruction (MVO) in 30 of 31 patients. Follow-up CMR after a median of 51 (IQR: 41-170) days showed evolution of MVO to scar. ICE echogenicity and CMR scar volumes correlated with each other and with ethanol volume. Ventricular function and interventricular septum remained intact. CONCLUSIONS VEA leads to intramural ablation that can be tracked intraprocedurally by ICE and creates regions of MVO that are chronically replaced by myocardial scar. VEA scar volume does not compromise septal integrity or ventricular function.
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24
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Kattel S, Enriquez AD. Contemporary approach to catheter ablation of ventricular tachycardia in nonischemic cardiomyopathy. J Interv Card Electrophysiol 2022; 66:793-805. [PMID: 36056222 DOI: 10.1007/s10840-022-01363-1] [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: 07/18/2022] [Accepted: 08/29/2022] [Indexed: 11/30/2022]
Abstract
Nonischemic cardiomyopathy (NICM) comprises a heterogenous group of disorders with myocardial dysfunction unrelated to significant coronary disease. As the use of implantable defibrillators has increased in this patient population, catheter ablation is being utilized more frequently to treat NICM patients with ventricular tachycardia (VT). Progress has been made in identifying multiple subtypes of NICM with variable scar patterns. The distribution of scar is often mid-myocardial and subepicardial, and identifying and ablating this substrate can be challenging. Here, we will review the current understanding of NICM subtypes and the outcomes of VT ablation in this population. We will discuss the use of cardiac imaging, electrocardiography, and electroanatomic mapping to define the VT substrate and the ablation techniques required to successfully prevent VT recurrence.
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Affiliation(s)
- Sharma Kattel
- Cardiovascular Medicine, Yale University School of Medicine, PO Box 208017, New Haven, CT, 06520-8017, USA
| | - Alan D Enriquez
- Cardiovascular Medicine, Yale University School of Medicine, PO Box 208017, New Haven, CT, 06520-8017, USA.
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25
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Letsas KP, Vlachos K. Revisiting the Value of Unipolar Electrograms for Guiding Mapping and Ablation of Ventricular Arrhythmic Focus. JACC Clin Electrophysiol 2022; 8:854-856. [PMID: 35863810 DOI: 10.1016/j.jacep.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 05/04/2022] [Indexed: 10/17/2022]
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26
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Tan NY, Ladas TP, Christopoulos G, Sugrue AM, van Zyl M, Ladejobi AO, Lodhi FK, Hu TY, Ezzeddine FM, Agboola K, Uecker D, Maor E, Tri JA, Jiang Z, Yasin OZ, DeSimone CV, Killu AM, Asirvatham SJ, Del-Carpio Munoz F. Ventricular nanosecond pulsed electric field delivery using active fixation leads: a proof-of-concept preclinical study. J Interv Card Electrophysiol 2022:10.1007/s10840-022-01268-z. [PMID: 35771400 DOI: 10.1007/s10840-022-01268-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 06/02/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Mid-myocardial ventricular arrhythmias are challenging to treat. Cardiac electroporation via pulsed electric fields (PEFs) offers significant promise. We therefore tested PEF delivery using screw-in pacemaker leads as proof-of-concept. METHODS In 5 canine models, we applied nanosecond PEF (pulse width 300 ns) across the right ventricular (RV) septum using a single lead bipolar configuration (n = 2) and between two leads (n = 3). We recorded electrograms (EGMs) prior to, immediately post, and 5 min after PEF. Cardiac magnetic resonance imaging (cMRI) and histopathology were performed at 2 weeks and 1 month. RESULTS Nanosecond PEF induced minimal extracardiac stimulation and frequent ventricular ectopy that terminated post-treatment; no canines died with PEF delivery. With 1 lead, energy delivery ranged from 0.64 to 7.28 J. Transient ST elevations were seen post-PEF. No myocardial delayed enhancement (MDE) was seen on cMRI. No lesions were noted on the RV septum at autopsy. With 2 leads, energy delivery ranged from 56.3 to 144.9 J. Persistent ST elevations and marked EGM amplitude decreases developed post-PEF. MDE was seen along the septum 2 weeks and 1 month post-PEF. There were discrete fibrotic lesions along the septum; pathology revealed dense connective tissue with < 5% residual cardiomyocytes. CONCLUSIONS Ventricular electroporation is feasible and safe with an active fixation device. Reversible changes were seen with lower energy PEF delivery, whereas durable lesions were created at higher energies. Central illustration: pulsed electric field delivery into ventricular myocardium with active fixation leads.
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Affiliation(s)
- Nicholas Y Tan
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Thomas P Ladas
- Department of Cardiovascular Medicine, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Georgios Christopoulos
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Alan M Sugrue
- Department of Cardiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Martin van Zyl
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Adetola O Ladejobi
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Fahad K Lodhi
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Tiffany Y Hu
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Fatima M Ezzeddine
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Kolade Agboola
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | | | - Elad Maor
- Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Jason A Tri
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Zhi Jiang
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Omar Z Yasin
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Christopher V DeSimone
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Ammar M Killu
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA
| | - Freddy Del-Carpio Munoz
- Department of Cardiovascular Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN, 55905, USA.
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Stevenson WG, Sapp JL. Newer Methods for VT Ablation and When to Use Them. Can J Cardiol 2021; 38:502-514. [PMID: 34942300 DOI: 10.1016/j.cjca.2021.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 12/03/2021] [Accepted: 12/11/2021] [Indexed: 02/07/2023] Open
Abstract
Radiofrequency (RF) catheter ablation has long been an important therapy for ventricular tachycardia and frequent symptomatic premature ventricular beats and nonsustained arrhythmias when antiarrhythmic drugs fail to suppress the arrhythmias. It is increasingly used in preference to antiarrhythmic drugs, sparing the patient drug adverse effects. Ablation success varies with the underlying heart disease and type of arrhythmia, being very effective for patients without structural heart disease, less in structural heart disease. Failure occurs when a target for ablation cannot be identified, or ablation lesions fail to reach and abolish the arrhythmia substrate that may be extensive, intramural or subepicardial in location. Approaches to improving ablation lesion creation are modifications to RF ablation and emerging investigational techniques. Easily implemented modifications to RF methods include manipulating the size and location of the cutaneous dispersive electrode, increasing RF delivery duration, and use of lower tonicity catheter irrigation (usually 0.45% saline). When catheters can be placed on either side of culprit substrate RF can be delivered in a bipolar or simultaneous unipolar configuration that can be successful. Catheters with extendable/retractable irrigated needles for RF delivery are under investigation in clinical trials. Cryoablation is potentially useful in specific situations when maintaining contact is difficult. Transvascular ethanol ablation and stereotactic radioablation have both shown promise for arrhythmias that fail other ablation strategies. Although substantial clinical progress has been achieved, further improvement is clearly needed. With ability to increase ablation lesion size, continued careful evaluation of safety, which has been excellent for standard RF ablation, remains important.
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Affiliation(s)
- William G Stevenson
- The Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; The Heart Rhythm Service, Department of Medicine, Division of Cardiology, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada.
| | - John L Sapp
- The Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; The Heart Rhythm Service, Department of Medicine, Division of Cardiology, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
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28
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Xuan F, Liang M, Li S, Zuo Z, Han Y, Wang Z. Guidewire ablation of epicardial ventricular arrhythmia within the coronary venous system: A case report. HeartRhythm Case Rep 2021; 8:195-199. [PMID: 35492837 PMCID: PMC9039544 DOI: 10.1016/j.hrcr.2021.12.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Fengqi Xuan
- Department of Cardiology, General Hospital of Northern Theater Command of China Medical University, Shenyang, China
| | - Ming Liang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Sainan Li
- Department of Cardiology, General Hospital of Northern Theater Command of China Medical University, Shenyang, China
| | - Zhongyin Zuo
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Zulu Wang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
- Address reprint requests and correspondence: Dr Zulu Wang, Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China.
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Cardiac stereotactic ablative radiotherapy for refractory ventricular arrhythmias: A radical alternative? A narrative review of rationale and cardiological aspects. J Med Imaging Radiat Sci 2021; 52:626-635. [PMID: 34593358 DOI: 10.1016/j.jmir.2021.09.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 09/10/2021] [Accepted: 09/10/2021] [Indexed: 11/21/2022]
Abstract
Ventricular arrhythmias are serious life-threatening cardiac disorders. Despite many technological improvements, a non-negligible number of patients present refractory ventricular tachycardias, resistant to a catheter ablation procedure, placing these patients in a therapeutic impasse. Recently, a cardiac stereotactic radioablative technique has been developed to treat patients with refractory ventricular arrhythmias, as a bail out strategy. This new therapeutic option historically brings together two fields of expertise unknown to each other, pointing out the necessity of an optimal partnership between cardiologists and radiation oncologists. As described in this narrative review, the understanding of cardiological aspects of the technique for radiation oncologists and treatment technical aspects comprehension for cardiologists represent a major challenge for the application and the future development of this promising treatment.
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Abstract
Electrical storm is present when a cluster of ventricular arrhythmias (VAs) occurs within a short time frame. The most widely accepted definition is 3 or more episodes of VA within a 24-h period, although prognostic risk begins to rise when 2 or more events occur within 3months. Electrical storm often presents as a medical emergency in the form of recurrent implantable cardiac defibrillator (ICD) shocks, recurrent syncope in patients with no ICD or low cardiac output symptoms. Management often requires a multimodality approach including ICD management, pharmacologic therapy, catheter ablation and modulations of the autonomic nervous system. In this article, we review the definition, prognosis and management of electrical storm.
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31
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Futyma P, Chen S. Ablation Target Out of Range: A Journey Deep Into the Interventricular Septum. JACC Case Rep 2021; 3:1125-1127. [PMID: 34471896 PMCID: PMC8314120 DOI: 10.1016/j.jaccas.2021.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Piotr Futyma
- Department of Cardiology, St Joseph’s Heart Rhythm Center, Rzeszów, Poland
| | - Shaojie Chen
- Department Kardiologe, Markus Krankenhaus, Cardioangiologisches Centrum Bethanien (CCB), Frankfurt am Main, Germany
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32
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Yamada T. What Can the Current Technology Tell Us About the Relationship Between Intramural Scar and PVCs? JACC Clin Electrophysiol 2021; 7:742-744. [PMID: 34167751 DOI: 10.1016/j.jacep.2020.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 12/18/2020] [Accepted: 12/19/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Takumi Yamada
- Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota, USA.
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33
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Pothineni NVK, Garcia FC, Santangeli P. Radiofrequency Ablation Strategies for Intramural Ventricular Arrhythmias. Methodist Debakey Cardiovasc J 2021; 17:8-12. [PMID: 34104314 DOI: 10.14797/peyf3776] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Catheter ablation is an established treatment strategy for ventricular arrhythmias. However, the presence of intramural substrate poses challenges with mapping and delivery of radiofrequency energy, limiting overall success of catheter ablation. Advances over the past decade have improved our understanding of intramural substrate and paved the way for innovative treatment approaches. Modifications in catheter ablation techniques and development of novel ablation technologies have led to improved clinical outcomes for patients with ventricular arrhythmias. In this review, we explore mapping techniques to identify intramural substrate and describe available radiofrequency energy delivery techniques that can improve overall success rates of catheter ablation.
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Affiliation(s)
| | - Fermin C Garcia
- Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
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34
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Thosani A, Trombetta M, Shaw G, Oh S, Sohn J, Liu E. Stereotactic arrhythmia radioablation for intramural basal septal ventricular tachycardia originating near the His bundle. HeartRhythm Case Rep 2021; 7:246-250. [PMID: 34026506 PMCID: PMC8129041 DOI: 10.1016/j.hrcr.2021.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Amit Thosani
- Division of Cardiac Electrophysiology, Cardiovascular Institute, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Mark Trombetta
- Division of Radiation Oncology, Cancer Institute, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - George Shaw
- Division of Cardiac Electrophysiology, Cardiovascular Institute, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Seungjong Oh
- Division of Radiation Oncology, Cancer Institute, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Jason Sohn
- Division of Radiation Oncology, Cancer Institute, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Emerson Liu
- Division of Cardiac Electrophysiology, Cardiovascular Institute, Allegheny General Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
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35
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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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36
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Sapp J. Streamlining Ventricular Tachycardia Ablation Workflow. JACC Clin Electrophysiol 2020; 6:1449-1451. [PMID: 33121674 DOI: 10.1016/j.jacep.2020.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 09/04/2020] [Indexed: 10/23/2022]
Affiliation(s)
- John Sapp
- Department of Medicine, QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada.
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37
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Tavares L, Lador A, Fuentes S, Da-wariboko A, Blaszyk K, Malaczynska-Rajpold K, Papiashvili G, Korolev S, Peichl P, Kautzner J, Webber M, Hooks D, Rodríguez-Mañero M, Di Toro D, Labadet C, Sasaki T, Okishige K, Patel A, Schurmann PA, Dave AS, Rami TG, Valderrábano M. Intramural Venous Ethanol Infusion for Refractory Ventricular Arrhythmias. JACC Clin Electrophysiol 2020; 6:1420-1431. [DOI: 10.1016/j.jacep.2020.07.023] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/22/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023]
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38
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Kucukseymen S, Yavin H, Barkagan M, Jang J, Shapira-Daniels A, Rodriguez J, Shim D, Pashakhanloo F, Pierce P, Botzer L, Manning WJ, Anter E, Nezafat R. Discordance in Scar Detection Between Electroanatomical Mapping and Cardiac MRI in an Infarct Swine Model. JACC Clin Electrophysiol 2020; 6:1452-1464. [DOI: 10.1016/j.jacep.2020.08.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/29/2020] [Accepted: 08/11/2020] [Indexed: 12/18/2022]
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39
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Rangaswamy VV, Saggu DK, Yalagudri S, Ramasubrahmanyam G, Narasimhan C. Management of refractory ventricular tachycardia by direct intramyocardial injection of alcohol: A novel method. HeartRhythm Case Rep 2020; 6:618-621. [PMID: 32983879 PMCID: PMC7498516 DOI: 10.1016/j.hrcr.2020.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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40
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Anatomic approach with bipolar ablation between the left pulmonic cusp and left ventricular outflow tract for left ventricular summit arrhythmias. Heart Rhythm 2020; 17:1519-1527. [DOI: 10.1016/j.hrthm.2020.04.029] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/13/2020] [Accepted: 04/15/2020] [Indexed: 11/23/2022]
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41
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Jazayeri MA, Sheldon SH. Retrograde Transvenous Ethanol Ablation of Refractory Premature Ventricular Contractions: Re-Evaluating the Electrophysiologist's Toolbox. JACC Case Rep 2020; 2:979-981. [PMID: 34317395 PMCID: PMC8302093 DOI: 10.1016/j.jaccas.2020.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Mohammad-Ali Jazayeri
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Seth H. Sheldon
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas
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42
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Double-balloon technique for retrograde venous ethanol ablation of ventricular arrhythmias in the absence of suitable intramural veins. Heart Rhythm 2020; 17:2126-2134. [PMID: 32470622 DOI: 10.1016/j.hrthm.2020.05.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 05/16/2020] [Accepted: 05/21/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Venous ethanol infusion via an occlusive balloon has been used as a bailout approach to treat ablation-refractory ventricular arrhythmias (VAs). Unfavorable venous anatomy (lack of intramural veins at the targeted site or collateral vein-ethanol shunting) limits its efficacy. Blocking collateral flow with a second balloon may optimize myocardial ethanol delivery. OBJECTIVE The purpose of this study was to validate the "double-balloon" approach to enhance ethanol delivery in cases of unfavorable venous anatomy. METHODS Eight patients referred after failed ablations (3 left ventricular [LV] summit, 5 scar-related ventricular tachycardia) underwent endocardial mapping and additional radiofrequency ablation without VA resolution. Coronary veins were mapped using a multipolar catheter or wire, and selective venograms were obtained. The double balloon was used when (1) distal collateral branches shunted flow away from the targeted region; (2) the target vein had optimal signals only proximally; or (3) a large vein was targeted that had multiple branches for a large area of interest. RESULTS Acute successful ethanol infusion myocardial delivery and resolution of VA was accomplished using the posterolateral LV veins (n = 2 patients, 3 procedures), lateral LV vein (n = 1), apical anterior interventricular vein (AIV; n = 1), middle cardiac vein (n = 1), and septal branches of the AIV (n = 3). At median follow-up of 313.5 days, 2 patients experienced recurrence. CONCLUSION The double-balloon technique can enhance ethanol delivery to target isolated vein segments, block collateral flow, or target extensive areas, and can expand the utility of venous ethanol for treatment of VAs.
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