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Gupta A, Danaila V, De Silva K, Bhaskaran A, Turnbull S, Wong MS, Campbell TG, Kumar S. The Current Landscape of Ventricular Tachycardia Trials: A Systematic Review of Registered Studies. Heart Lung Circ 2024; 33:1082-1096. [PMID: 38821759 DOI: 10.1016/j.hlc.2024.01.041] [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: 10/10/2023] [Revised: 01/02/2024] [Accepted: 01/04/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Although there are evolving techniques and technologies for treating ventricular tachycardia (VT), the current landscape of clinical trials for managing VT remains understudied. OBJECTIVE The objective of this study was to provide a systematic characterisation of the interventional management of VT through an analysis of the ClinicalTrials.gov, clinicaltrialsregister.eu, anzctr.org.au and chictr.org.cn databases. METHODS We queried all phase II to IV interventional trials registered up to November 2023 that enrolled patients with VT. Published, completed but unpublished, terminated, or ongoing trials were included for final analysis. RESULTS Of the 698 registered studies, 135 were related to VT, with 123 trials included in the final analysis. Among these trials, 25 (20%) have been published, enrolling a median of 35 patients (interquartile range [IQR] 20-132) over a median of 43 months (IQR 19-62). Out of the published trials, 14 (56%) were randomised, and 12 (48%) focused on catheter ablation. Twenty-two (18%) have been completed but remain unpublished, even after a median of 36 months (IQR 15-60). Furthermore, 27 (22%) trials were terminated or withdrawn, with the most common cause being poor enrolment. Currently, 49 (40%) trials are ongoing and novel non-ablative technologies, such as radioablation and autonomic modulation, account for 35% and 8% of ongoing trials, respectively. CONCLUSIONS Our analysis revealed that many registered trials remain unpublished or incomplete, and randomised controlled trial evidence is limited to only a few studies. Furthermore, many ongoing trials are focused on non-catheter ablation-based strategies. Therefore, larger pragmatic trials are needed to create stronger evidence in the future.
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Affiliation(s)
- Anunay Gupta
- Department of Cardiology, Westmead Hospital, NSW, Australia; Westmead Applied Research Centre, University of Sydney, NSW, Australia
| | - Vlad Danaila
- Department of Cardiology, Westmead Hospital, NSW, Australia
| | - Kasun De Silva
- Department of Cardiology, Westmead Hospital, NSW, Australia; Westmead Applied Research Centre, University of Sydney, NSW, Australia
| | - Ashwin Bhaskaran
- Department of Cardiology, Westmead Hospital, NSW, Australia; Westmead Applied Research Centre, University of Sydney, NSW, Australia
| | - Samual Turnbull
- Department of Cardiology, Westmead Hospital, NSW, Australia; Westmead Applied Research Centre, University of Sydney, NSW, Australia
| | - Mary S Wong
- Department of Cardiology, Westmead Hospital, NSW, Australia; Westmead Applied Research Centre, University of Sydney, NSW, Australia
| | - Timothy G Campbell
- Department of Cardiology, Westmead Hospital, NSW, Australia; Westmead Applied Research Centre, University of Sydney, NSW, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, NSW, Australia.
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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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3
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Verma A, Essebag V, Neuzil P, Dyrda K, Balt J, Dinov B, Darma A, Arya A, Sacher F, Reddy VY, Boersma L, Grigorov I, De Potter T. Cryocure-VT: the safety and effectiveness of ultra-low-temperature cryoablation of monomorphic ventricular tachycardia in patients with ischaemic and non-ischaemic cardiomyopathies. Europace 2024; 26:euae076. [PMID: 38582974 PMCID: PMC10998960 DOI: 10.1093/europace/euae076] [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: 02/29/2024] [Accepted: 03/18/2024] [Indexed: 04/08/2024] Open
Abstract
AIMS The ultra-low-temperature cryoablation (ULTC) ablation system using -196°C N2 cryogen has been reported to create lesions with freeze duration-dependent depth titratable to over 10 mm with minimum attenuation by scar. Cryocure-VT (NCT04893317) was a first-in-human clinical trial evaluating the safety and efficacy of a novel, purpose-built ULTC catheter in endocardial ablation of scar-dependent ventricular tachycardias (VTs). METHODS AND RESULTS This prospective, multi-centre study enrolled patients referred for de novo or second ablations of recurrent monomorphic VT of both ischaemic and non-ischaemic aetiologies. Primary safety and efficacy endpoints of the study were freedom from device- or procedure-related major adverse events (MAEs) up to 30 days post-ablation, acute non-inducibility of clinical VTs at the end of the procedure, and freedom from sustained VT or implantable defibrillator intervention at 6 months. Ultra-low-temperature cryoablation was performed in 64 patients (age 67 ± 11 years, 78% ischaemic, ejection fraction = 35 ± 10%) at 9 centres. The primary acute effectiveness endpoint was achieved in 94% (51/54) of patients in whom post-ablation induction was attempted. There were no protocol-defined MAEs; four procedure-related serious adverse events resolved without clinical sequelae. At 6-month follow-up, 38 patients (60.3%) remained VT-free, and freedom from defibrillator shock was 81.0%, with no significant difference between ischaemic and non-ischaemic cohorts. In 47 patients with defibrillator for at least 6 months prior to the ablation, the VT burden was reduced from median of 4, inter-quartile range (IQR, 1-9) to 0, IQR (0-2). CONCLUSION In this first-in-human multi-centre experience, endocardial ULTC ablation of monomorphic VT appears safe and effective in patients with both ischaemic-cardiomyopathy and non-ischaemic-cardiomyopathy. CLINICAL TRIAL REGISTRATION NCT04893317.
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Affiliation(s)
- Atul Verma
- Division of Cardiology, McGill University Health Centre, D13.173, 1650 Cedar Avenue, Montreal, QC H3G 1A4, Canada
| | - Vidal Essebag
- Division of Cardiology, McGill University Health Centre, D13.173, 1650 Cedar Avenue, Montreal, QC H3G 1A4, Canada
| | - Petr Neuzil
- Department of Cardiology, Na Homolce Hospital, Prague, Czech Republic
| | - Katia Dyrda
- Department of Medicine, Montreal Heart Institute, Montreal, QC, Canada
| | - Jippe Balt
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Borislav Dinov
- Department of Electrophysiology, Leipzig Heart Center, Leipzig, Germany
| | - Angeliki Darma
- Department of Electrophysiology, Leipzig Heart Center, Leipzig, Germany
| | - Arash Arya
- Department for Internal Medicine, University Hospital Halle, Halle, Germany
| | - Frederic Sacher
- Bordeaux University Hospital, IHU LIRYC, University of Bordeaux, Bordeaux, France
| | - Vivek Y Reddy
- Department of Cardiology, Na Homolce Hospital, Prague, Czech Republic
- Helmsley Electrophysiology Center, Mount Sinai Fuster Heart Hospital, New York, NY, USA
| | - Lucas Boersma
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Heart Failure and Arrhythmias,Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Tom De Potter
- Cardiovascular Center, OLV Hospital, Moorselbaan 164, 9300 Aalst, Belgium
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4
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Hasegawa K, Yoneda ZT, Powers EM, Tokutake K, Kurata M, Richardson TD, Montgomery JA, Shen S, Estrada JC, Saavedra PJ, Emerson A, Walker ML, Tandri H, Michaud GF, Kanagasundram AN, Stevenson WG. Safety of ventricular arrhythmia radiofrequency ablation with half-normal saline irrigation. Europace 2024; 26:euae018. [PMID: 38367008 PMCID: PMC10898929 DOI: 10.1093/europace/euae018] [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: 11/02/2023] [Accepted: 01/05/2024] [Indexed: 02/19/2024] Open
Abstract
AIMS Failure of radiofrequency (RF) ablation of ventricular arrhythmias is often due to inadequate lesion size. Irrigated RF ablation with half-normal saline (HNS) has the potential to increase lesion size and reduce sodium delivery to the patient if the same volume of RF irrigant were used for normal saline (NS) and HNS but could increase risks related to steam pops and lesion size. This study aims to assess periprocedural complications and acute ablation outcome of ventricular arrhythmias ablation with HNS. METHODS AND RESULTS Prospective assessment of outcomes was performed in 1024 endocardial and/or epicardial RF ablation procedures in 935 consecutive patients (median age 64 years, 71.2% men, 73.4% cardiomyopathy, 47.2% sustained ventricular tachycardia). Half-normal saline was selected at the discretion of the treating physician. Radiofrequency ablation power was generally titrated to a ≤15 Ω impedance fall with intracardiac echocardiography monitoring. Half-normal saline was used in 900 (87.9%) and NS in 124 (12.1%) procedures. Any adverse event within 30 days occurred in 13.0% of patients treated with HNS RF ablation including 4 (0.4%) strokes/transient ischaemic attacks and 34 (3.8%) pericardial effusions requiring treatment (mostly related to epicardial access). Two steam pops with perforation required surgical repair (0.2%). Patients who received NS irrigation had less severe disease and arrhythmias. In multivariable models, adverse events and acute success of the procedure were not related to the type of irrigation. CONCLUSION Half-normal saline irrigation RF ablation with power guided by impedance fall and intracardiac echocardiography has an acceptable rate of complications and acute ablation success while administering half of the saline load expected for NS irrigation.
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Affiliation(s)
- Kanae Hasegawa
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, 1215 21st Ave South, MCE 5th Floor, South Tower, Nashville, TN 37232, USA
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Zachary T Yoneda
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, 1215 21st Ave South, MCE 5th Floor, South Tower, Nashville, TN 37232, USA
| | - Edward M Powers
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, 1215 21st Ave South, MCE 5th Floor, South Tower, Nashville, TN 37232, USA
| | - Kenichi Tokutake
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, 1215 21st Ave South, MCE 5th Floor, South Tower, Nashville, TN 37232, USA
| | - Masaaki Kurata
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, 1215 21st Ave South, MCE 5th Floor, South Tower, Nashville, TN 37232, USA
| | - Travis D Richardson
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, 1215 21st Ave South, MCE 5th Floor, South Tower, Nashville, TN 37232, USA
| | - Jay A Montgomery
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, 1215 21st Ave South, MCE 5th Floor, South Tower, Nashville, TN 37232, USA
| | - Sharon Shen
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, 1215 21st Ave South, MCE 5th Floor, South Tower, Nashville, TN 37232, USA
| | - Juan C Estrada
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, 1215 21st Ave South, MCE 5th Floor, South Tower, Nashville, TN 37232, USA
| | - Pablo J Saavedra
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, 1215 21st Ave South, MCE 5th Floor, South Tower, Nashville, TN 37232, USA
| | - Amy Emerson
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, 1215 21st Ave South, MCE 5th Floor, South Tower, Nashville, TN 37232, USA
| | - Marilyn L Walker
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, 1215 21st Ave South, MCE 5th Floor, South Tower, Nashville, TN 37232, USA
| | - Harikrishna Tandri
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, 1215 21st Ave South, MCE 5th Floor, South Tower, Nashville, TN 37232, USA
| | - Gregory F Michaud
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, 1215 21st Ave South, MCE 5th Floor, South Tower, Nashville, TN 37232, USA
| | - Arvindh N Kanagasundram
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, 1215 21st Ave South, MCE 5th Floor, South Tower, Nashville, TN 37232, USA
| | - William G Stevenson
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, 1215 21st Ave South, MCE 5th Floor, South Tower, Nashville, TN 37232, USA
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5
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Hasegawa K, Yoneda ZT, Powers EM, Tokutake K, Kurata M, Richardson TD, Montgomery JA, Shen S, Estrada JC, Saavedra PJ, Emerson A, Walker ML, Tandri H, Michaud GF, Kanagasundram AN, Stevenson WG. Stroke and Bleeding Risks of Endocardial Ablation for Ventricular Arrhythmias. JACC Clin Electrophysiol 2024; 10:193-202. [PMID: 38069975 DOI: 10.1016/j.jacep.2023.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 10/04/2023] [Accepted: 10/11/2023] [Indexed: 03/01/2024]
Abstract
BACKGROUND Risks of radiofrequency catheter ablation for ventricular arrhythmias include emboli and bleeding complications but data on antithrombotic regimens are limited and guidelines do not specify a systematic approach. OBJECTIVES This study sought to assess embolic and bleeding complications in relation to pre-periprocedure and post-periprocedure antithrombotic regimens. METHODS Prospective assessment for complications was performed for 663 endocardial radiofrequency catheter ablation procedures in 616 consecutive patients (median age 64 years [Q1-Q3: 54-73 years], 70.3% men, 71.6% with cardiomyopathy, 44.5% with sustained ventricular tachycardia). RESULTS There were 2 strokes (0.3%; 95% CI: 0.0%-0.8%), 1 transient ischemic attack (0.15%), and 2 pulmonary emboli (0.3%). There were 39 bleeding complications (5.9%) including 11 pericardial effusions (1.7%), and 28 related to vascular access (4.2%). Consistent with the prevalence of coronary artery disease (47.5%), atrial fibrillation (30.0%), and prior stroke (10.6%), preprocedure, 464 patients (70.0%) were taking antithrombotic agents including 220 (33.2%) taking aspirin alone (ASA), and 163 (24.6%) taking warfarin or a direct acting oral anticoagulant (DOAC). Preprocedure non-ASA antiplatelet use (OR: 2.846; P = 0.011) and DOAC use (OR: 2.585; P = 0.032) were associated with risk of bleeding complications. Following ablation, 49.8% of patients were treated with ASA 325 mg/d and 30.3% received DOACs or warfarin. New DOAC or warfarin administration was initiated in only 6.6% of patients. Overall, 39.7% of patients continued the same preprocedure antithrombotic regimen. CONCLUSIONS Stroke is a rare complication of radiofrequency catheter ablation for ventricular arrhythmia using ASA 325 mg/d as a minimal postprocedure regimen with more potent regimens for selected patients.
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Affiliation(s)
- Kanae Hasegawa
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui, Fukui, Japan
| | - Zachary T Yoneda
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Edward M Powers
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kenichi Tokutake
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Masaaki Kurata
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Travis D Richardson
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jay A Montgomery
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sharon Shen
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Juan C Estrada
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Pablo J Saavedra
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amy Emerson
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marilyn L Walker
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Harikrishna Tandri
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gregory F Michaud
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Arvindh N Kanagasundram
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William G Stevenson
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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Verma Y, Arachchige ASPM. Revolutionizing cardiovascular care: the power of histotripsy. J Ultrasound 2024:10.1007/s40477-023-00848-7. [PMID: 38217765 DOI: 10.1007/s40477-023-00848-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/13/2023] [Indexed: 01/15/2024] Open
Abstract
Histotripsy, an innovative ultrasonic technique, is poised to transform the landscape of cardiovascular disease management. This review explores the multifaceted applications of histotripsy across various domains of cardiovascular medicine. In thrombolysis, histotripsy presents a non-invasive, drug-free, and precise method for recanalizing blood vessels obstructed by clots, minimizing the risk of vessel damage and embolism. Additionally, histotripsy showcases its potential in congenital heart defect management, offering a promising alternative to invasive procedures by creating intracardiac communications noninvasively. For patients with calcified aortic stenosis, histotripsy demonstrates its effectiveness in softening calcified bioprosthetic valves, potentially revolutionizing valve interventions. In the realm of arrhythmias, histotripsy could play an important role in scar-based ventricular tachycardia ablation, eliminating channel-like isthmuses of slowly conducting myocardium. Histotripsy`s potential applications also extend to structural heart interventions, enabling the safe sectioning of basal chordae and potentially addressing mitral regurgitation. Furthermore, it showcases its versatility by safely generating ventricular septal defects, providing a non-invasive means of creating intracardiac communications in neonates with congenital heart disease. Yet, most supporting studies are in-vitro or animal studies and there are possible challenges in translating experimental data on cardiac histotripsy to the clinical level. As histotripsy continues to evolve and mature, its remarkable potential in cardiovascular disease management holds promise for improving patient outcomes and reducing the burden of invasive procedures in the field of cardiology.
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Affiliation(s)
- Yash Verma
- Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
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7
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Repp ML, Chinyere IR. Opportunities and Challenges in Catheter-Based Irreversible Electroporation for Ventricular Tachycardia. PATHOPHYSIOLOGY 2024; 31:32-43. [PMID: 38251047 PMCID: PMC10801500 DOI: 10.3390/pathophysiology31010003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 12/22/2023] [Accepted: 01/09/2024] [Indexed: 01/23/2024] Open
Abstract
The use of catheter-based irreversible electroporation in clinical cardiac laboratories, termed pulsed-field ablation (PFA), is gaining international momentum among cardiac electrophysiology proceduralists for the non-thermal management of both atrial and ventricular tachyrhythmogenic substrates. One area of potential application for PFA is in the mitigation of ventricular tachycardia (VT) risk in the setting of ischemia-mediated myocardial fibrosis, as evidenced by recently published clinical case reports. The efficacy of tissue electroporation has been documented in other branches of science and medicine; however, ventricular PFA's potential advantages and pitfalls are less understood. This comprehensive review will briefly summarize the pathophysiological mechanisms underlying VT and then summarize the pre-clinical and adult clinical data published to date on PFA's effectiveness in treating monomorphic VT. These data will be contrasted with the effectiveness ascribed to thermal cardiac ablation modalities to treat VT, namely radiofrequency energy and liquid nitrogen-based cryoablation.
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Affiliation(s)
| | - Ikeotunye Royal Chinyere
- Department of Medecine, Banner University Medicine, Tucson, AZ 85724, USA
- Sarver Heart Center, University of Arizona, 1501 North Campbell Avenue, Room 6154, Tucson, AZ 85724, USA
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8
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Dhruva SS, Zhang S, Chen J, Noseworthy PA, Doshi AA, Agboola KM, Herrin J, Jiang G, Yu Y, Cafri G, Farr KC, Mbwana MS, Ross JS, Coplan PM, Drozda JP. Using real-world data from health systems to evaluate the safety and effectiveness of a catheter to treat ischemic ventricular tachycardia. J Interv Card Electrophysiol 2023; 66:1817-1825. [PMID: 36738387 DOI: 10.1007/s10840-023-01496-x] [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] [Received: 12/20/2022] [Accepted: 01/25/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND The ThermoCool STSF catheter is used for ablation of ischemic ventricular tachycardia (VT) in routine clinical practice, although outcomes have not been studied and the catheter does not have Food and Drug Administration (FDA) approval for this indication. We used real-world health system data to evaluate its safety and effectiveness for this indication. METHODS Among patients undergoing ischemic VT ablation with the ThermoCool STSF catheter pooled across two health systems (Mercy Health and Mayo Clinic), the primary safety composite outcome of death, thromboembolic events, and procedural complications within 7 days was compared to a performance goal of 15%, which is twice the expected proportion of the primary composite safety outcome based on prior studies. The exploratory effectiveness outcome of rehospitalization for VT or heart failure or repeat VT ablation at up to 1 year was averaged across health systems among patients treated with the ThermoCool STSF vs. ST catheters. RESULTS Seventy total patients received ablation for ischemic VT using the ThermoCool STSF catheter. The primary safety composite outcome occurred in 3/70 (4.3%; 90% CI, 1.2-10.7%) patients, meeting the pre-specified performance goal, p = 0.0045. At 1 year, the effectiveness outcome risk difference (STSF-ST) at Mercy was - 0.4% (90% CI: - 25.2%, 24.3%) and at Mayo Clinic was 12.6% (90% CI: - 13.0%, 38.4%); the average risk difference across both institutions was 5.8% (90% CI: - 12.0, 23.7). CONCLUSIONS The ThermoCool STSF catheter was safe and appeared effective for ischemic VT ablation, supporting continued use of the catheter and informing possible FDA label expansion. Health system data hold promise for real-world safety and effectiveness evaluation of cardiovascular devices.
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Affiliation(s)
- Sanket S Dhruva
- Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Medical Center and University of California, San Francisco School of Medicine, 4150 Clement St, Building 203, 111C, San Francisco, CA, 94121, USA.
| | - Shumin Zhang
- MedTech Epidemiology and Real-World Data Sciences, Office of the Chief Medical Officer, Johnson & Johnson, New Brunswick, NJ, USA
| | | | | | | | - Kolade M Agboola
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jeph Herrin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Guoqian Jiang
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Yue Yu
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, USA
| | - Guy Cafri
- MedTech Epidemiology and Real-World Data Sciences, Office of the Chief Medical Officer, Johnson & Johnson, New Brunswick, NJ, USA
| | | | - Mwanatumu S Mbwana
- National Evaluation System for Health Technology Coordinating Center (NESTcc), Medical Device Innovation Consortium, Arlington, VA, USA
| | - Joseph S Ross
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Paul M Coplan
- MedTech Epidemiology and Real-World Data Sciences, Office of the Chief Medical Officer, Johnson & Johnson, New Brunswick, NJ, USA
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9
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Filgueiras-Rama D, Ramos-Prada A, Cluitmans MJM. Arrhythmogenic vulnerability of reentrant pathways in post-infarct ventricular tachycardia assessed by advanced computational modelling. Europace 2023; 25:euad258. [PMID: 37647101 PMCID: PMC10481246 DOI: 10.1093/europace/euad258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 08/24/2023] [Indexed: 09/01/2023] Open
Affiliation(s)
- David Filgueiras-Rama
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Novel Arrhythmogenic Mechanisms Program, Melchor Fernández Almagro, 3, 28029 Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Cardiovascular Institute, Profesor Martín Lagos s/n, 28040Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Monforte de Lemos 3-5, 28029 Madrid, Spain
| | - Alba Ramos-Prada
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Novel Arrhythmogenic Mechanisms Program, Melchor Fernández Almagro, 3, 28029 Madrid, Spain
- Fundación Interhospitalaria para la Investigación Cardiovascular (FIC), Madrid, Spain
| | - Matthijs J M Cluitmans
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Department of Cardiology, Maastricht, The Netherlands
- Philips Research, Eindhoven, The Netherlands
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10
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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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11
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Tryon DN, Deshmukh AJ, Kowlgi GN. When to sear, when to burn, and when to chop: The art of substrate modification. HeartRhythm Case Rep 2023; 9:576-580. [PMID: 37614382 PMCID: PMC10444547 DOI: 10.1016/j.hrcr.2023.05.018] [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)
- David N. Tryon
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
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12
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Mumtaz M, Downar E, Kawada S, Zammit-Burg M, Anderson R, Massé S, Nair MKK, Nanthakumar J, Ghauri FM, Sánchez AP, Bhaskaran A. Utility of Substrate Mapping Using Extrasystole to Localise Comprehensive Ventricular Tachycardia Circuits: Results From Intra-operative Mapping Studies. Can J Cardiol 2023; 39:912-921. [PMID: 36918097 DOI: 10.1016/j.cjca.2023.02.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 01/28/2023] [Accepted: 02/21/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND Substrate mapping-based identification of all ventricular tachycardia (VT) circuits (diastolic activation), including partial and complete diastolic circuits in clinical and nonclinical VT, could be beneficial in guiding VT ablation to prevent VT recurrence. The utility of extrasystole induced late potentials has not been compared with late potentials in sinus rhythm (SR) and right ventricular pacing (RVp). METHODS Intraoperative simultaneous panoramic endocardial mapping of 21 VTs in 16 ischemic heart disease patients was performed with the use of a 112-bipole endocardial balloon. The decrement of near-field electrogram later than surface QRS during extrasystole (eLP) was studied. RESULTS Patients had a mean age of 52 ± 9 years and were predominantly (75%) male. The mean sensitivity of eLP (0.75 [95% confidence interval [CI] 0.72-0.78]) to detect VT circuits was better than SR (0.33 [0.30-0.36]; P < 0.001) and RVp (0.36 [0.33-0.39]; P < 0.001) without significant differences in specificity, eLP (0.77 [0.74-0.81], SR (0.82 [0.80-0.84]; P = 0.23), and RVp (0.81 [0.78-0.83]; P = 0.11). Both negative (NPV) and positivie (PPV) predictive values were significantly better for eLP mapping. The mean NPV was 0.77 (95% CI 0.74-0.81), 0.57 (0.55-0.59), and 0.58 (0.55-0.61) for eLP, SR, and RVp, respectively (P < 0.0001). PPV was 0.75 (95% CI 0.72-0.78), 0.63 (0.59-0.67), and 0.63 (0.59-0.67) for eLP, SR, and RVp, respectively (P < 0.001). Overall diagnostic performance (area under the receiver operating characteristic curve) was significantly better for eLP (0.85 [95% CI 0.80-0.90] compared with SR (0.63 [0.56-0.72]; P < 0.001) or RVp (0.61 [0.52-0.74]; P < 0.001). CONCLUSIONS Evoked late potential mapping is a better tool to detect comprehensive diastolic circuits activated during VT, compared with eLP mapping in sinus rhythm or RV pacing.
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Affiliation(s)
- Maroosh Mumtaz
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network Toronto, Ontario, Canada; Department of Medicine, Cardiology, University of Toronto, Ontario, Canada
| | - Eugene Downar
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network Toronto, Ontario, Canada
| | - Satoshi Kawada
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network Toronto, Ontario, Canada
| | - Melanie Zammit-Burg
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network Toronto, Ontario, Canada
| | - Robert Anderson
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network Toronto, Ontario, Canada
| | - Stéphane Massé
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network Toronto, Ontario, Canada
| | - Madhav Krishna Kumar Nair
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network Toronto, Ontario, Canada
| | - Jared Nanthakumar
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network Toronto, Ontario, Canada
| | | | - Andreu Porta- Sánchez
- Arrhythmia Unit, Hospital Universitario Quirónsalud Fundación Centro Nacional de Investigaciones Cardiovasculares Carlos III, Madrid, Spain.
| | - Abhishek Bhaskaran
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network Toronto, Ontario, Canada.
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13
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Vu BV, Phan PD, Pham LT, Hoang KT, Do TD, Nguyen HM, Ngo LTH, Le DT, Phan NT, Nguyen HC, Luong TC. Efficacy and safety of zero‐fluoroscopy ablation of ventricular arrhythmias originating from the right ventricular outflow tract: Comparison with fluoroscopy‐guided ablation without a three‐dimensional electroanatomic mapping system. J Arrhythm 2023; 39:185-191. [PMID: 37021031 PMCID: PMC10068933 DOI: 10.1002/joa3.12815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 12/29/2022] [Accepted: 01/01/2023] [Indexed: 01/25/2023] Open
Abstract
Background Radiofrequency catheter ablation is the preferred treatment choice for ventricular arrhythmias (VAs) originating from right ventricular outflow tract (RVOT) in symptomatic patients and is usually performed under fluoroscopy guidance. Zero-fluoroscopy (ZF) ablations using 3D mapping system applied for treatment of various types of arrhythmias are trending and practiced in many centers around the world, but rarely done in Vietnam. The objective of this study was to evaluate the efficacy and safety of zero-fluoroscopy ablation of RVOT VAs, compared with fluoroscopy-guided ablation without a 3D electroanatomic mapping (EAM) system. Methods and Results We conducted a nonrandomized, prospective single-center study including 114 patients with RVOT VAs that had electrocardiographic features of typical left bundle branch block, inferior axis QRS morphology, and a precordial transition ≥ V3, from May 2020 to July 2022. The patients were assigned (without randomization) to two different approaches of either zero-fluoroscopy ablation under the guidance of the Ensite system (ZF group) or fluoroscopy-guided ablation without a 3D EAM (fluoroscopy group) in a 1:1 ratio. After a follow-up time of 5.0 ± 4.9 months and 6.9 ± 9.3 months in the ZF and fluoroscopy groups, respectively, the results showed a higher success rate in the fluoroscopy group than in the complete ZF group (87.3% vs 86.8%), although the difference was not statistically significant. No major complication was noted in both the groups. Conclusion ZF ablation for RVOT VAs can be done safely and effectively using the 3D electroanatomic mapping system. The results of ZF approach are comparable to that of the fluoroscopy-guided approach without a 3D EAM system.
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Affiliation(s)
- Ba Van Vu
- Cardiology Department Vietnam Military Medical University Hanoi Vietnam
- Cardiovascular Center E Hospital Hanoi Vietnam
| | - Phong Dinh Phan
- Cardiology Department Hanoi Medical University Hanoi Vietnam
| | - Linh Tran Pham
- Vietnam National Heart Institute Bach Mai Hospital Hanoi Vietnam
| | | | | | | | - Linh Thi Hai Ngo
- School of Clinical Medicine The University of Queensland Herston Queensland Australia
| | | | - Nguyen Thao Phan
- Cardiovascular Center E Hospital Hanoi Vietnam
- University of Medicine and Pharmacy Hanoi National University Hanoi Vietnam
| | - Huu Cong Nguyen
- Cardiovascular Center E Hospital Hanoi Vietnam
- University of Medicine and Pharmacy Hanoi National University Hanoi Vietnam
| | - Thuc Cong Luong
- Cardiology Department Vietnam Military Medical University Hanoi Vietnam
- Cardiology Department Military Hospital 103 Hanoi Vietnam
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14
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Nakahara S. Catheter ablation of ventricular tachycardia associated with structural heart disease: Current status and perspectives. J Cardiol 2023; 81:57-62. [PMID: 36174816 DOI: 10.1016/j.jjcc.2022.09.008] [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: 09/06/2022] [Accepted: 09/06/2022] [Indexed: 11/25/2022]
Abstract
Catheter ablation is an effective and safe treatment for ventricular tachycardia attributable to structural heart disease, reducing the risk of recurrent arrhythmias and defibrillator shock therapy. Advances in medical technology and an accumulation of data have led to the development of detailed guidelines. Successful ablation requires accurate identification of the arrhythmia substrate and effective delivery of radiofrequency energy to the target tissue. Modern practice requires use of traditional electrophysiological mapping processes such as entrainment mapping and three-dimensional activation sequence mapping in combination with newer functional mapping techniques for which there is growing support. Thorough non-invasive preoperative assessment is also necessary before an invasive procedure is undertaken. In this review, we summarize contemporary practice and recent randomized controlled trials underpinning the latest developments in mapping and ablation and discuss potential future developments in this field.
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Affiliation(s)
- Shiro Nakahara
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan.
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15
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Abstract
Sex and racial disparities in the presentation, diagnosis, and management of cardiac arrhythmias are recognized. Sex-specific differences in electrophysiological parameters are well known and are predominantly related to differences in ion channel expression and the influence of sex hormones. However, the relationship between hormonal or racial influence and arrhythmia mechanisms, presentation, and management needs to be better defined. Women and racial and ethnic groups are less likely to undergo catheter ablation procedures for treatment of cardiac arrhythmias. Underrepresentation of women and racial/ethnic groups in clinical trials has resulted in significant knowledge gaps. Whether sex and racial disparities in arrhythmia management reflect barriers in access to care, physician bias, patient values, and preferences or other factors requires further study.
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Affiliation(s)
- Bert Vandenberk
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Derek S. Chew
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ratika Parkash
- Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Anne M. Gillis
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada,Address reprint requests and correspondence: Dr Anne M. Gillis, Libin Cardiovascular Institute, University of Calgary, Foothills Medical Centre, 1403–29 St NW, Calgary T2N 2T9, Alberta, Canada.
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16
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Haskova J, Sramko M, Cvek J, Kautzner J. Stereotactic Radiotherapy in the Management of Ventricular Tachycardias: More Questions than Answers? Card Electrophysiol Clin 2022; 14:779-792. [PMID: 36396193 DOI: 10.1016/j.ccep.2022.06.010] [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
Stereotactic body radiotherapy is a recent promising therapeutic alternative in cases of failed catheter ablation for recurrent ventricular tachycardias (VTs) in patients with structural heart disease. Initial clinical experience with a single radiation dose of 25 Gy shows reasonable efficacy in the reduction of VT recurrences with acceptable acute toxicity. Many unanswered questions remain, including unknown mechanism of action, variable time to effect, optimal method of substrate targeting, long-term safety, and definition of an optimal candidate for this treatment."
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Affiliation(s)
- Jana Haskova
- Department of Cardiology, IKEM, Vídeňská 1958/9, Prague 140 21, Czech Republic.
| | - Marek Sramko
- Department of Cardiology, IKEM, Vídeňská 1958/9, Prague 140 21, Czech Republic
| | - Jakub Cvek
- Department of Oncology, University Hospital Ostrava and Ostrava University Medical School, 17 listopadu 1790/5, Ostrava-Poruba 708 00 Czech Republic
| | - Josef Kautzner
- Department of Cardiology, IKEM, Vídeňská 1958/9, Prague 140 21, Czech Republic; Palacky University Medical School, Olomouc, Czech Republic
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17
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Valderrábano M, Rojas SCF, Lador A, Patel A, Schurmann PA, Tapias C, Rodríguez D, Sáenz LC, Malahjfi M, Shah DJ, Mathuria N, Dave AS. Substrate Ablation by Multivein, Multiballoon Coronary Venous Ethanol for Refractory Ventricular Tachycardia in Structural Heart Disease. Circulation 2022; 146:1644-1656. [PMID: 36321460 PMCID: PMC9712228 DOI: 10.1161/circulationaha.122.060882] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/15/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Ablation of ventricular tachycardia (VT) in the setting of structural heart disease often requires extensive substrate elimination that is not always achievable by endocardial radiofrequency ablation. Epicardial ablation is not always feasible. Case reports suggest that venous ethanol ablation (VEA) through a multiballoon, multivein approach can lead to effective substrate ablation, but large data sets are lacking. METHODS VEA was performed in 44 consecutive patients with ablation-refractory VT (ischemic, n=21; sarcoid, n=3; Chagas, n=2; idiopathic, n=18). Targeted veins were selected by mapping coronary veins on the epicardial aspect of endocardial scar (identified by bipolar voltage <1.5 mV), using venography and signal recording with a 2F octapolar catheter or by guidewire unipolar signals. Epicardial mapping was performed in 15 patients. Vein segments in the epicardial aspect of VT substrates were treated with double-balloon VEA by blocking flow with 1 balloon while injecting ethanol through the lumen of the second balloon, forcing (and restricting) ethanol between balloons. Multiple balloon deployments and multiple veins were used as needed. In 22 patients, late gadolinium enhancement cardiac magnetic resonance imaged the VEA scar and its evolution. RESULTS Median ethanol delivered was 8.75 (interquartile range, 4.5-13) mL. Injected veins included interventricular vein (6), diagonal (5), septal (12), lateral (16), posterolateral (7), and middle cardiac vein (8), covering the entire range of left ventricular locations. Multiple veins were targeted in 14 patients. Ablated areas were visualized intraprocedurally as increased echogenicity on intracardiac echocardiography and incorporated into 3-dimensional maps. After VEA, vein and epicardial ablation maps showed elimination of abnormal electrograms of the VT substrate. Intracardiac echocardiography demonstrated increased intramural echogenicity at the targeted region of the 3-dimensional maps. At 1 year of follow-up, median of 314 (interquartile range, 198-453) days of follow-up, VT recurrence occurred in 7 patients, for a success of 84.1%. CONCLUSIONS Multiballoon, multivein intramural ablation by VEA can provide effective substrate ablation in patients with ablation-refractory VT in the setting of structural heart disease over a broad range of left ventricular locations.
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Affiliation(s)
- Miguel Valderrábano
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | | | - Adi Lador
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Apoor Patel
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Paul A. Schurmann
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | | | | | | | - Maan Malahjfi
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Dipan J. Shah
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Nilesh Mathuria
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Amish S. Dave
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
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18
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Nakasone K, Fukuzawa K, Kiuchi K, Takami M, Sakai J, Nakamura T, Yatomi A, Sonoda Y, Takahara H, Yamamoto K, Suzuki Y, Tani K, Iwai H, Nakanishi Y, Hirata K. Predictors of recurrence in patients without non-inducibility of ventricular tachycardia at the end of ablation. J Arrhythm 2022; 39:52-60. [PMID: 36733320 PMCID: PMC9885314 DOI: 10.1002/joa3.12796] [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: 07/15/2022] [Revised: 10/26/2022] [Accepted: 11/03/2022] [Indexed: 11/17/2022] Open
Abstract
Background Ventricular tachycardia (VT) non-inducibility at the end of ablation is associated with a less likely VT recurrence. However, it is not clear whether we should use VT non-inducibility as a routine end point of VT ablation. The aim of this study was to evaluate VT recurrence in patients in whom VT non-inducibility was not achieved at the end of the radiofrequency (RF) ablation and the factors attributing to the VT recurrence. Methods We analyzed that 62 patients in whom VT non-inducibility was not achieved at the end of the RF ablation were studied. Results Over 2 years, 22 (35%) of the cases had VT recurrences. A multivariate analysis showed that an LVEF ≥35% (HR: 0.19; 95% CI: 0.06-0.49; p < .01) and elimination of the clinical VT as an acute ablation efficacy (HR: 0.23; 95% CI: 0.04-0.81; p = .02) were independent predictors of fewer VT recurrences. RF ablation was associated with a 91.1% reduction in VT episodes. Conclusion Even if VT non-inducibility was not achieved, patients with an LVEF ≥35% or in whom the clinical VT could be eliminated might be prevented from having VT recurrences. The validity of the VT non-inducibility of any VT should be evaluated considering each patient's background and the results of the procedure.
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Affiliation(s)
- Kazutaka Nakasone
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Koji Fukuzawa
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan,Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Kunihiko Kiuchi
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan,Section of Arrhythmia, Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Mitsuru Takami
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Jun Sakai
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Toshihiro Nakamura
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Atsusuke Yatomi
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Yusuke Sonoda
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Hiroyuki Takahara
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Kyoko Yamamoto
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Yuya Suzuki
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Ken‐ichi Tani
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Hidehiro Iwai
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Yusuke Nakanishi
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Ken‐ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal MedicineKobe University Graduate School of MedicineKobeJapan
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19
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Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 2022; 43:3997-4126. [PMID: 36017572 DOI: 10.1093/eurheartj/ehac262] [Citation(s) in RCA: 818] [Impact Index Per Article: 409.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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20
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Sung E, Prakosa A, Zhou S, Berger RD, Chrispin J, Nazarian S, Trayanova NA. Fat infiltration in the infarcted heart as a paradigm for ventricular arrhythmias. NATURE CARDIOVASCULAR RESEARCH 2022; 1:933-945. [PMID: 36589896 PMCID: PMC9802586 DOI: 10.1038/s44161-022-00133-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Infiltrating adipose tissue (inFAT) has been recently found to co-localize with scar in infarcted hearts and may contribute to ventricular arrhythmias (VAs), a life-threatening heart rhythm disorder. However, the contribution of inFAT to VA has not been well-established. We investigated the role of inFAT versus scar in VA through a combined prospective clinical and mechanistic computational study. Using personalized computational heart models and comparing the results from simulations of VA dynamics with measured electrophysiological abnormalities during the clinical procedure, we demonstrate that inFAT, rather than scar, is a primary driver of arrhythmogenic propensity and is frequently present in critical regions of the VA circuit. We determined that, within the VA circuitry, inFAT, as opposed to scar, is primarily responsible for conduction slowing in critical sites, mechanistically promoting VA. Our findings implicate inFAT as a dominant player in infarct-related VA, challenging existing paradigms and opening the door for unexplored anti-arrhythmic strategies.
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Affiliation(s)
- Eric Sung
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA
| | - Adityo Prakosa
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA
| | - Shijie Zhou
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA
| | - Ronald D. Berger
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA.,Department of Medicine, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jonathan Chrispin
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA.,Department of Medicine, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, USA.,These authors jointly supervised this work: Jonathan Chrispin, Saman Nazarian, Natalia A. Trayanova
| | - Saman Nazarian
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,These authors jointly supervised this work: Jonathan Chrispin, Saman Nazarian, Natalia A. Trayanova
| | - Natalia A. Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA.,These authors jointly supervised this work: Jonathan Chrispin, Saman Nazarian, Natalia A. Trayanova.,Correspondence and requests for materials should be addressed to Natalia A. Trayanova.
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21
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Packer DL, Wilber DJ, Kapa S, Dyrda K, Nault I, Killu AM, Kanagasundram A, Richardson T, Stevenson W, Verma A, Curley M. Ablation of Refractory Ventricular Tachycardia Using Intramyocardial Needle Delivered Heated Saline-Enhanced Radiofrequency Energy: A First-in-Man Feasibility Trial. Circ Arrhythm Electrophysiol 2022; 15:e010347. [PMID: 35776711 PMCID: PMC9388560 DOI: 10.1161/circep.121.010347] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 05/23/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ablation of ventricular tachycardia (VT) is limited by the inability to create penetrating lesions to reach intramyocardial origins. Intramural needle ablation using in-catheter, heated saline-enhanced radio frequency (SERF) energy uses convective heating to increase heat transfer and produce deeper, controllable lesions at intramural targets. This first-in-human trial was designed to evaluate the safety and efficacy of SERF needle ablation in patients with refractory VT. METHODS Thirty-two subjects from 6 centers underwent needle electrode ablation. Each had recurrent drug-refractory monomorphic VT after implantable cardioverter defibrillator implantation and prior standard ablation. During the SERF study procedure, one or more VTs were induced and mapped. The SERF needle catheter was used to create intramural lesions at targeted VT site(s). Acute procedural success was defined as noninducibility of the clinical VT after the procedure. Patients underwent follow-up at 30 days, and 3 and 6 months, with implantable cardioverter defibrillator interrogation at follow-up to determine VT recurrence. RESULTS These refractory VT patients (91% male, 66±10 years, ejection fraction 35±11%; 56% ischemic, and 44% nonischemic) had a median of 45 device therapies (shock/antitachycardia pacing) for VT in the 3 to 6 months pre-SERF ablation. The study catheter was used to deliver an average of 10±5 lesions per case, with an average of 430±295 seconds of radiofrequency time, 122±65 minute of catheter use time, and a procedural duration of 4.3±1.3 hours. Acute procedural success was 97% for eliminating the clinical VT. At average follow-up of 5 months (n=32), device therapies were reduced by 89%. Complications included 2 periprocedural deaths: an embolic mesenteric infarct and cardiogenic shock, 2 mild strokes, and a pericardial effusion treated with pericardiocentesis (n=1). CONCLUSIONS Intramural heated saline needle ablation showed complete acute and satisfactory mid-term control of difficult VTs failing 1 to 5 prior ablations and drug therapy. Further study is warranted to define safety and longer-term efficacy. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique Identifier: NCT03628534 and NCT02994446.
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Affiliation(s)
| | | | | | | | - Isabelle Nault
- Canada Quebec Heart and Lung Institute, Quebec City, QC, Canada
| | | | | | | | | | - Atul Verma
- Southlake Regional Health Centre, Newmarket Ontario, Canada
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König S, Schröter T, Borger MA, Bertagnolli L, Nedios S, Darma A, Hindricks G, Arya A, Dinov B. Outcomes following cardiac sympathetic denervation in patients with structural heart disease and refractory ventricular arrhythmia. Europace 2022; 24:1800-1808. [DOI: 10.1093/europace/euac078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 05/02/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Aim
Cardiac sympathetic denervation (CSD) has been introduced as a bailout therapy in patients with structural heart disease and refractory ventricular arrhythmias (VAs), but available data are scarce. Purpose of this study was to estimate immediate results, complications, and mid-term outcomes of CSD following recurrent VA after catheter ablation.
Methods and results
Adult patients who underwent CSD in the Heart Center Leipzig from March 2017 to February 2021 were retrospectively analysed. Follow-up (FU) was executed via implantable cardioverter defibrillator (ICD) interrogation, telephone interviews, and reviewing medical records. Twenty-one patients (age 63.7 ± 14.4 years, all men, 71.4% non-ischaemic cardiomyopathy, left ventricular ejection fraction 31.6 ± 12.6%) received CSD via video-assisted thoracoscopic surgery (90.5% bilateral, 9.5% left-sided only). Indication for CSD was monomorphic ventricular tachycardia in 76.2% and ventricular fibrillation in 23.8 with 71.4% of patients presenting with electrical storm before index hospitalization. Procedure-related major complications occurred in 9.5% of patients. In-hospital adverse events not related to surgery were common (28.6%) and two patients died during the index hospital stay. During FU (mean duration 9.1 ± 6.5 months), five more patients died. Of the remaining patients, 38.5 and 76.9% were free from any VA or ICD shocks, respectively.
Conclusions
The CSD showed additional moderate efficacy to suppress VAs, when performed as a bailout therapy after previously unsuccessful catheter ablation. At 9 months, it was associated with freedom of ICD shocks in two-thirds of patients. In a population with many comorbidities, the rate of CSD-related complications was acceptable, although there was an overall high risk of procedure unrelated adverse events and death.
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Affiliation(s)
- Sebastian König
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig , Strümpellstraße 39, Leipzig 04289 , Germany
- Leipzig Heart Institute , Leipzig , Germany
| | - Thomas Schröter
- Heart Center Leipzig at University of Leipzig, Department of Cardiac Surgery , Leipzig , Germany
| | - Michael A Borger
- Heart Center Leipzig at University of Leipzig, Department of Cardiac Surgery , Leipzig , Germany
| | - Livio Bertagnolli
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig , Strümpellstraße 39, Leipzig 04289 , Germany
| | - Sotirios Nedios
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig , Strümpellstraße 39, Leipzig 04289 , Germany
| | - Angeliki Darma
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig , Strümpellstraße 39, Leipzig 04289 , Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig , Strümpellstraße 39, Leipzig 04289 , Germany
- Leipzig Heart Institute , Leipzig , Germany
| | - Arash Arya
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig , Strümpellstraße 39, Leipzig 04289 , Germany
| | - Borislav Dinov
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig , Strümpellstraße 39, Leipzig 04289 , Germany
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Pellegrino PL, Di Monaco A, Santoro F, Grimaldi M, D'Arienzo G, Casavecchia G, Ieva R, Di Biase M, Iacoviello M, Brunetti ND. Near zero vascular complications using echo-guided puncture during catheter ablation of arrhythmias: A retrospective study and literature review. J Arrhythm 2022; 38:395-399. [PMID: 35785379 PMCID: PMC9237317 DOI: 10.1002/joa3.12723] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/31/2022] [Accepted: 04/14/2022] [Indexed: 11/23/2022] Open
Abstract
Background Catheter ablation (CA) is routinely used for the treatment of arrhythmias. Vascular complications are the most common complications during these procedures. Previous data reported that ultrasound (US)-guided puncture is a useful method to avoid vascular complications. We reported our experience using US-guided puncture in patients undergoing CA for arrhythmias. Methods A total of 273 patients (mean age 57 ± 17 years; 58% male) were referred to our center for CA of arrhythmias from January 2016 to December 2019. All procedures were performed by expert operators, and US-guided vascular access was performed on all patients. Doppler sonography was performed the day after the procedure on all patients. Results Eighty-four patients (31%) underwent atrioventricular nodal reentrant tachycardia ablation, 49 patients (18%) atrioventricular reentrant tachycardia ablation, 14 patients (5%) atrial tachycardia ablation, 25 patients (9%) atrial flutter ablation, 63 patients (23%) atrial fibrillation ablation, and 38 patients (14%) ventricular tachycardia ablation. Vascular pseudo-aneurysms and arteriovenous fistula were defined as major complications; furthermore, venous thrombosis and inguinal hematomas were as defined minor complications. The percentage of major vascular complications was 0.3% (1 arteriovenous fistula) and the percentage of minor vascular complications was 0.3% (1 venous thrombosis). Discussion Ultrasound-guided vascular puncture in patients undergoing CA is useful to improve procedural success and reduce complications.
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Affiliation(s)
| | - Antonio Di Monaco
- Department of CardiologyGeneral Regional Hospital "F. Miulli"BariItaly
- Department of Clinical and Experimental MedicineUniversity of FoggiaFoggiaItaly
| | - Francesco Santoro
- Cardiology UnitPoliclinico Riuniti University HospitalFoggiaItaly
- Department of Medical and Surgical SciencesUniversity of FoggiaFoggiaItaly
| | - Massimo Grimaldi
- Department of CardiologyGeneral Regional Hospital "F. Miulli"BariItaly
| | | | | | - Riccardo Ieva
- Cardiology UnitPoliclinico Riuniti University HospitalFoggiaItaly
| | - Matteo Di Biase
- Department of Medical and Surgical SciencesUniversity of FoggiaFoggiaItaly
| | - Massimo Iacoviello
- Cardiology UnitPoliclinico Riuniti University HospitalFoggiaItaly
- Department of Medical and Surgical SciencesUniversity of FoggiaFoggiaItaly
| | - Natale Daniele Brunetti
- Cardiology UnitPoliclinico Riuniti University HospitalFoggiaItaly
- Department of Medical and Surgical SciencesUniversity of FoggiaFoggiaItaly
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A novel ECG finding in patients with epicardial infarct-associated ventricular tachycardia: a case series. Herzschrittmacherther Elektrophysiol 2022; 33:217-223. [PMID: 35277790 DOI: 10.1007/s00399-022-00849-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 02/01/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES This study analyzes the incidence, characteristics, and ECG morphology of ventricular tachycardia (VT) in post-infarction patients undergoing epicardial VT ablation. BACKGROUND Ablation of recurrent VTs in patients with ischemic cardiomyopathy is typically performed endocardially. In rare cases, epicardial access is required to achieve non-inducibility. METHODS AND RESULTS The study evaluated the baseline characteristics, procedural data, and ECG morphology of clinical VT in patients undergoing epicardial VT ablation. From the initial 491 patients with coronary heart disease (CHD) and recurrent VTs undergoing ablation at the Heart Center of Leipzig, Germany, between 2012 and 2020, only 39 patients required an additional epicardial access. In 17 patients, the VTs were associated with infarction scar, while the remaining patients had concomitant CHD without infarction-associated scar and were excluded from the analysis. A propensity match study was performed at a 1:2 ratio for these 17 patients, with 34 patients of the initial cohort as a control group to evaluate the differences in baseline characteristics, procedural data, and ECG morphology of the VTs. The specific VT morphology of negative concordance and superior axis in patients with inferior scar as well as the history of VT ablation were independent predictors of the need for epicardial access. CONCLUSIONS In addition to previous endocardial ablation, VT ECG morphology with negative concordance and superior axis in post-infarction patients with inferior scar predicted the need for epicardial VT ablation.
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25
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[Catheter ablation of ventricular tachycardia in patients with structural heart disease]. Herz 2022; 47:129-134. [PMID: 35262743 DOI: 10.1007/s00059-022-05103-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 11/04/2022]
Abstract
Ventricular cardiac rhythm disorders are potentially life-threatening arrhythmias. Ventricular tachycardia (VT) in patients with structural heart disease carries an increased risk of sudden cardiac death. Interventional radiofrequency catheter ablation is increasingly becoming the focus of treatment for ventricular arrhythmias. So far, no randomized study has been able to demonstrate a reduction in mortality; however, depending on the existing cardiomyopathy, interventional VT ablation has proven to be more effective for rhythm stabilization than antiarrhythmic therapy and is subsequently associated with improve quality of life through reduced implantable cardioverter defibrillator (ICD) treatment. The aim of this work is to discuss the pathophysiology, mechanism and treatment of VT with structural heart disease in order to define the role of catheter ablation.
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Abstract
PURPOSE OF REVIEW This review presents the current state of imaging approaches that enable real-time molecular imaging in the interventional suite and discusses the potential future use of integrated nuclear imaging and fluoroscopy for intraprocedural guidance in the evaluation and treatment of both cardiovascular and oncological diseases. RECENT FINDINGS Although there are no commercially available real-time hybrid nuclear imaging devices that are approved for use in the interventional suite, prototype open gantry hybrid nuclear imaging and x-ray c-arm imaging systems and theranostic catheter for location radiotracer detection are currently undergoing development and testing by multiple groups. The integration of physiological and molecular targeted nuclear imaging for real-time delivery of targeted theranostics in the interventional laboratory may enable more personalized care for a wide variety of cardiovascular procedures and improve patient outcomes.
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Soejima K, Ueda A, Ogiri M, Ichishima Y, Park H, Yu Lee SH. A Real-World Analysis of the Effectiveness, Resource Use, and Costs Associated with Ventricular Tachycardia Catheter Ablation In Japanese Patients < 75 Years. Heart Rhythm O2 2022; 3:204-207. [PMID: 35496457 PMCID: PMC9043398 DOI: 10.1016/j.hroo.2022.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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28
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de Oliveira Dietrich C, de Oliveira Hollanda L, Cirenza C, de Paola AAV. Epicardial and Endocardial Ablation Based on Channel Mapping in Patients With Ventricular Tachycardia and Chronic Chagasic Cardiomyopathy: Importance of Late Potential Mapping During Sinus Rhythm to Recognize the Critical Substrate. J Am Heart Assoc 2021; 11:e021889. [PMID: 34927451 PMCID: PMC9075208 DOI: 10.1161/jaha.121.021889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Ventricular tachycardia (VT) in patients with chronic chagasic cardiomyopathy (CCC) is associated with considerable morbidity and mortality. Catheter ablation of VT in patients with CCC is very complex and challenging. The main goal of this work was to assess the efficacy of VT catheter ablation guided by late potentials (LPs) in patients with CCC. Methods and Results Seventeen consecutive patients with refractory VT and CCC were prospectively included in the study. Combined endo‐epicardial voltage and late activation mapping were obtained during baseline rhythm to define scarred and LP areas, respectively. The end point of the ablation procedure was the elimination of all identified LPs. Epicardial and endocardial dense scars (<0.5 mV) were detected in 17/17 and 15/17 patients, respectively. LPs were detected in the epicardial scars of 16/17 patients and in the endocardial scars of 14/15 patients. A total of 63 VTs were induced in 17 patients; 22/63 (33%) were stable and entrained, presenting LPs recorded in the isthmus sites. The end point of ablation was achieved in 15 of 17 patients. Ablation was not completed in 2 patients because of cardiac tamponade or vicinity of the phrenic nerve and circumflex artery. Three patients (2 with unsuccessful ablation) had VT recurrence during follow‐up (39 months). Conclusions Endo‐epicardial LP mapping allows us to identify the putative isthmuses of different VTs and effectively perform catheter ablation in patients with CCC and drug‐refractory VTs.
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Affiliation(s)
- Cristiano de Oliveira Dietrich
- Clinical Cardiac Electrophysiology Cardiology Division Department of Medicine Hospital São Paulo Escola Paulista de Medicina - Universidade Federal of São Paulo São Paulo Brazil
| | - Lucas de Oliveira Hollanda
- Clinical Cardiac Electrophysiology Cardiology Division Department of Medicine Hospital São Paulo Escola Paulista de Medicina - Universidade Federal of São Paulo São Paulo Brazil
| | - Claudio Cirenza
- Clinical Cardiac Electrophysiology Cardiology Division Department of Medicine Hospital São Paulo Escola Paulista de Medicina - Universidade Federal of São Paulo São Paulo Brazil
| | - Angelo Amato Vincenzo de Paola
- Clinical Cardiac Electrophysiology Cardiology Division Department of Medicine Hospital São Paulo Escola Paulista de Medicina - Universidade Federal of São Paulo São Paulo Brazil
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Sandhu U, Kovacs AH, Nazer B. Psychosocial symptoms of ventricular arrhythmias: Integrating patient-reported outcomes into clinical care. Heart Rhythm O2 2021; 2:832-839. [PMID: 34988534 PMCID: PMC8710626 DOI: 10.1016/j.hroo.2021.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Patient-reported outcome measures (PROMs) are a valuable metric for assessing the quality of life and overall well-being in patients with ventricular arrhythmias (VAs) and/or implantable cardioverter-defibrillators (ICDs). The incorporation of PROMs into the workflow of a VA clinic not only allows for more patient-centered care but also may improve detection and treatment of clinically relevant anxiety or depression symptoms. Awareness of the factors known to correlate with adverse PROM scores may guide PROM administration and subsequent referral to mental health services. Further, change or stability in PROM scores can be used as a gauge to guide the effectiveness of cardiac and psychological treatment in certain populations that are the focus of this manuscript: patients with ICDs (with and without shocks), cardiac arrest survivors, and those with inherited arrhythmia syndromes.
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Affiliation(s)
- Uday Sandhu
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Adrienne H. Kovacs
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
| | - Babak Nazer
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon
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Q. M. Reis C, Little B, Lee MacDonald R, Syme A, Thomas CG, Robar JL. SBRT of ventricular tachycardia using 4pi optimized trajectories. J Appl Clin Med Phys 2021; 22:72-86. [PMID: 34679247 PMCID: PMC8664144 DOI: 10.1002/acm2.13454] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 09/05/2021] [Accepted: 10/03/2021] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To investigate the possible advantages of using 4pi-optimized arc trajectories in stereotactic body radiation therapy of ventricular tachycardia (VT-SBRT) to minimize exposure of healthy tissues. METHODS AND MATERIALS Thorax computed tomography (CT) data for 15 patients were used for contouring organs at risk (OARs) and defining realistic planning target volumes (PTVs). A conventional trajectory plan, defined as two full coplanar arcs was compared to an optimized-trajectory plan provided by a 4pi algorithm that penalizes geometric overlap of PTV and OARs in the beam's-eye-view. A single fraction of 25 Gy was prescribed to the PTV in both plans and a comparison of dose sparing to OARs was performed based on comparisons of maximum, mean, and median dose. RESULTS A significant average reduction in maximum dose was observed for esophagus (18%), spinal cord (26%), and trachea (22%) when using 4pi-optimized trajectories. Mean doses were also found to decrease for esophagus (19%), spinal cord (33%), skin (18%), liver (59%), lungs (19%), trachea (43%), aorta (11%), inferior vena cava (25%), superior vena cava (33%), and pulmonary trunk (26%). A median dose reduction was observed for esophagus (40%), spinal cord (48%), skin (36%), liver (72%), lungs (41%), stomach (45%), trachea (53%), aorta (45%), superior vena cava (38%), pulmonary veins (32%), and pulmonary trunk (39%). No significant difference was observed for maximum dose (p = 0.650) and homogeneity index (p = 0.156) for the PTV. Average values of conformity number were 0.86 ± 0.05 and 0.77 ± 0.09 for the conventional and 4pi optimized plans respectively. CONCLUSIONS 4pi optimized trajectories provided significant reduction to mean and median doses to cardiac structures close to the target but did not decrease maximum dose. Significant improvement in maximum, mean and median doses for noncardiac OARs makes 4pi optimized trajectories a suitable delivery technique for treating VT.
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Affiliation(s)
- Cristiano Q. M. Reis
- Department of Radiation OncologyDalhousie UniversityHalifaxNova ScotiaCanada
- Department of Medical PhysicsScotia Health Authority, NovaHalifaxNova ScotiaCanada
- Department of Physics and Atmospheric ScienceDalhousie UniversityHalifaxNova ScotiaCanada
- Department of Radiation Oncology, London Regional Cancer ProgramLondon Health Sciences Centre790 Commissioners Road EastLondonONN6A 4L6Canada
| | - Brian Little
- Department of Radiation OncologyDalhousie UniversityHalifaxNova ScotiaCanada
- Department of Medical PhysicsScotia Health Authority, NovaHalifaxNova ScotiaCanada
- Department of Physics and Atmospheric ScienceDalhousie UniversityHalifaxNova ScotiaCanada
- Adaptiiv Medical Technologies Inc405‐1344 Summer Street Halifax, NS B3H 0A8Canada
| | - Robert Lee MacDonald
- Department of Radiation OncologyDalhousie UniversityHalifaxNova ScotiaCanada
- Department of Medical PhysicsScotia Health Authority, NovaHalifaxNova ScotiaCanada
- Department of Physics and Atmospheric ScienceDalhousie UniversityHalifaxNova ScotiaCanada
| | - Alasdair Syme
- Department of Radiation OncologyDalhousie UniversityHalifaxNova ScotiaCanada
- Department of Medical PhysicsScotia Health Authority, NovaHalifaxNova ScotiaCanada
- Department of Physics and Atmospheric ScienceDalhousie UniversityHalifaxNova ScotiaCanada
- Beatrice Hunter Cancer Research InstituteHalifaxNova ScotiaCanada
| | - Christopher G. Thomas
- Department of Radiation OncologyDalhousie UniversityHalifaxNova ScotiaCanada
- Department of Medical PhysicsScotia Health Authority, NovaHalifaxNova ScotiaCanada
- Department of Physics and Atmospheric ScienceDalhousie UniversityHalifaxNova ScotiaCanada
- Beatrice Hunter Cancer Research InstituteHalifaxNova ScotiaCanada
- Department of RadiologyDalhousie UniversityHalifaxNova ScotiaCanada
| | - James L. Robar
- Department of Radiation OncologyDalhousie UniversityHalifaxNova ScotiaCanada
- Department of Medical PhysicsScotia Health Authority, NovaHalifaxNova ScotiaCanada
- Department of Physics and Atmospheric ScienceDalhousie UniversityHalifaxNova ScotiaCanada
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Gao LL, Wu CH. Transient ventricular arrhythmia as a rare cause of dizziness during exercise: A case report. World J Clin Cases 2021; 9:9205-9210. [PMID: 34786406 PMCID: PMC8567521 DOI: 10.12998/wjcc.v9.i30.9205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/24/2021] [Accepted: 08/30/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Dizziness is a common symptom in adults and usually due to peripheral causes affecting semicircular canal function or central causes affecting the pons, medulla, or cerebellum. Arrhythmia is a recognized cause of dizziness in people with structural or ischemic heart disease. We report a case of exercise-induced transient ventricular tachycardia and dizziness in a man with no evidence of organic heart disease.
CASE SUMMARY A 42-year-old man presented with a 6 mo history of transient exercise-induced dizziness and prodromal palpitations. The patient was otherwise asymptomatic. Physical examination, otoscopy, vestibular tests, cerebellar tests, laboratory investigations, and imaging investigations were all unremarkable. Twenty-four hour Holter monitoring revealed four episodes of transient ventricular tachycardia during exercise. The patient was started on metoprolol and subsequently underwent radiofrequency catheter ablation. The patient reported a full recovery and no dizziness during daily activities. These results were maintained at the 6 mo follow-up.
CONCLUSION Ventricular tachycardia is an uncommon but potentially serious cause of dizziness. The outcome of this case illustrates the benefits of careful clinical examination and communication with specialized centers. High clinical suspicion of arrhythmia in a patient with dizziness merits consultation with a cardiologist and referral to a specialized center to ensure timely diagnosis and treatment.
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Affiliation(s)
- Li-Li Gao
- Department of Neurology, The Second Affiliated Hospital of Fujian Traditional Chinese Medical University, Fuzhou 350003, Fujian Province, China
| | - Cheng-Han Wu
- Department of Neurology, The Second Affiliated Hospital of Fujian Traditional Chinese Medical University, Fuzhou 350003, Fujian Province, China
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Sung E, Prakosa A, Trayanova NA. Analyzing the Role of Repolarization Gradients in Post-infarct Ventricular Tachycardia Dynamics Using Patient-Specific Computational Heart Models. Front Physiol 2021; 12:740389. [PMID: 34658925 PMCID: PMC8514757 DOI: 10.3389/fphys.2021.740389] [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: 07/13/2021] [Accepted: 09/06/2021] [Indexed: 11/20/2022] Open
Abstract
Aims: Disease-induced repolarization heterogeneity in infarcted myocardium contributes to VT arrhythmogenesis but how apicobasal and transmural (AB-TM) repolarization gradients additionally affect post-infarct VT dynamics is unknown. The goal of this study is to assess how AB-TM repolarization gradients impact post-infarct VT dynamics using patient-specific heart models. Method: 3D late gadolinium-enhanced cardiac magnetic resonance images were acquired from seven post-infarct patients. Models representing the patient-specific scar and infarct border zone distributions were reconstructed without (baseline) and with repolarization gradients along both the AB-TM axes. AB only and TM only models were created to assess the effects of each ventricular gradient on VT dynamics. VTs were induced in all models via rapid pacing. Results: Ten baseline VTs were induced. VT inducibility in AB-TM models was not significantly different from baseline (p>0.05). Reentry pathways in AB-TM models were different than baseline pathways due to alterations in the location of conduction block (p<0.05). VT exit sites in AB-TM models were different than baseline VT exit sites (p<0.05). VT inducibility of AB only and TM only models were not significantly different than that of baseline (p>0.05) or AB-TM models (p>0.05). Reentry pathways and VT exit sites in AB only and TM only models were different than in baseline (p<0.05). Lastly, repolarization gradients uncovered multiple VT morphologies with different reentrant pathways and exit sites within the same structural, conducting channels. Conclusion: VT inducibility was not impacted by the addition of AB-TM repolarization gradients, but the VT reentrant pathway and exit sites were greatly affected due to modulation of conduction block. Thus, during ablation procedures, physiological and pharmacological factors that impact the ventricular repolarization gradient might need to be considered when targeting the VTs.
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Affiliation(s)
- Eric Sung
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, United States
| | - Adityo Prakosa
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, United States
| | - Natalia A Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, United States
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Fernandez-Armenta J, Soto-Iglesias D, Silva E, Penela D, Jáuregui B, Linhart M, Bisbal F, Acosta J, Fernandez M, Borras R, Villuendas R, Cano L, Guasch E, Mont L, Berruezo A. Safety and Outcomes of Ventricular Tachycardia Substrate Ablation During Sinus Rhythm: A Prospective Multicenter Registry. JACC Clin Electrophysiol 2021; 6:1435-1448. [PMID: 33121673 DOI: 10.1016/j.jacep.2020.07.028] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/16/2020] [Accepted: 07/29/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study sought to analyze safety and outcomes of ventricular tachycardia (VT) substrate ablation during sinus rhythm (SR), without baseline VT induction. BACKGROUND Safety and outcomes after scar-related VT ablation during SR are not well known. Hemodynamic instability and need for electrical cardioversion can compromise safety of VT ablation procedures. METHODS Four hundred twelve consecutive patients with structural heart disease undergoing VT ablation were included in a prospective multicenter registry. Substrate ablation during SR, without baseline VT induction, was the first step of the ablation procedure and the standard protocol. Scar dechanneling was the substrate ablation technique used. VT inducibility was tested after substrate ablation. RESULTS VT induction protocol was negative after substrate ablation in 289 patients (70.1%), completing the procedure in SR. Procedure-related complication rate was 6.5%, including 1 death (0.2%). Thirty-day mortality after first VT ablation procedure was 1.7%. Overall survival was 95.8% and 88.6% at 1 and 3 years of follow-up, respectively. In a multivariable proportional hazards regression model, age ≥70 years (hazard ratio [HR]: 4.95 [2.59 to 9.47]; p < 0.001), chronic obstructive pulmonary disease (HR: 2.37 [1.24 to 4.52]; p = 0.008), left ventricular ejection fraction <30% (HR: 2.43 [1.37 to 4.33]; p = 0.002), and incomplete substrate ablation (HR: 2.37 [1.24 to 4.52]; p = 0.026) were independent predictors of overall mortality. At 12 months' follow-up, VT-free survival was 82.5% after 1 procedure and 87.8% after n procedures CONCLUSIONS: Substrate ablation during SR avoiding multiple VT induction has low procedure-related complications and low early mortality. Age, chronic obstructive pulmonary disease, and reduced left ventricular ejection fraction, but also incomplete substrate elimination, are predictors of mortality.
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Affiliation(s)
- Juan Fernandez-Armenta
- Department of Cardiology, Puerta del Mar University Hospital, Cadiz, Spain; Biomedical Research and Innovation Institute of Cadiz (INiBICA), Cadiz, Spain
| | - David Soto-Iglesias
- Arrhythmia Unit, Department of Cardiology, Cardiovascular Clinical Institute, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain; Heart Institute, Teknon Medical Center, Barcelona, Spain
| | - Etel Silva
- Department of Cardiology, Puerta del Mar University Hospital, Cadiz, Spain; Biomedical Research and Innovation Institute of Cadiz (INiBICA), Cadiz, Spain
| | - Diego Penela
- Heart Institute, Teknon Medical Center, Barcelona, Spain; Department of Cardiology, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Beatriz Jáuregui
- Arrhythmia Unit, Department of Cardiology, Cardiovascular Clinical Institute, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain; Heart Institute, Teknon Medical Center, Barcelona, Spain
| | - Markus Linhart
- Arrhythmia Unit, Department of Cardiology, Cardiovascular Clinical Institute, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Felipe Bisbal
- Institut del Cor (iCor), Germans Trias i Pujol University Hospital, Badalona, Spain
| | - Juan Acosta
- Department of Cardiology, Virgen del Rocio University Hospital, Seville, Spain
| | - Marcos Fernandez
- Department of Cardiology, Puerta del Mar University Hospital, Cadiz, Spain; Biomedical Research and Innovation Institute of Cadiz (INiBICA), Cadiz, Spain
| | - Roger Borras
- Arrhythmia Unit, Department of Cardiology, Cardiovascular Clinical Institute, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Roger Villuendas
- Institut del Cor (iCor), Germans Trias i Pujol University Hospital, Badalona, Spain
| | - Lucas Cano
- Department of Cardiology, Puerta del Mar University Hospital, Cadiz, Spain; Biomedical Research and Innovation Institute of Cadiz (INiBICA), Cadiz, Spain
| | - Eduard Guasch
- Arrhythmia Unit, Department of Cardiology, Cardiovascular Clinical Institute, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Lluis Mont
- Arrhythmia Unit, Department of Cardiology, Cardiovascular Clinical Institute, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Antonio Berruezo
- Arrhythmia Unit, Department of Cardiology, Cardiovascular Clinical Institute, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain; Heart Institute, Teknon Medical Center, Barcelona, Spain.
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto S, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 guideline on non-pharmacotherapy of cardiac arrhythmias. J Arrhythm 2021; 37:709-870. [PMID: 34386109 PMCID: PMC8339126 DOI: 10.1002/joa3.12491] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Kantharia BK. Implantable cardioverter defibrillator shocks from ventricular tachyarrhythmias in patients with ischemic heart disease: Preventative measures, shortcomings, cost-effectiveness, and global practice perspectives. J Cardiovasc Electrophysiol 2021; 32:2558-2566. [PMID: 34258823 DOI: 10.1111/jce.15161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 05/08/2021] [Accepted: 07/05/2021] [Indexed: 11/29/2022]
Abstract
Implantable cardioverter defibrillators (ICDs) have proven to be life-saving devices in patients with ischemic cardiomyopathy (ICM) who are prone to develop ventricular tachycardia (VT) and fibrillation (VF). Antiarrhythmic drugs (AADs) are commonly prescribed in many such patients with ICDs to treat and prevent different forms of arrhythmias in clinical practice. When these patients experience recurrent monomorphic VT despite chronic AADs therapy, or when AAD therapy is contraindicated or not tolerated, and VT storm is refractory to AAD therapy, catheter ablation constitute guideline-based class I indication of treatment. However, what should be the most appropriate strategy to prevent first ICD shock or subsequent multiple shocks from VT/VF in patients with ICM who undergo ICD implantation without prior incidence of cardiac arrest, remains debatable. The purpose of this review is to discuss preventative aspects of ICD shocks for VT and the shortcomings of these measures along with the cost-effectiveness and global perspectives based on the current knowledge of the topic.
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Affiliation(s)
- Bharat K Kantharia
- Cardiovascular and Heart Rhythm Consultants, Icahn School of Medicine at Mount Sinai, New York, USA
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36
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Affiliation(s)
- Junaid Zaman
- Cardiology, Royal Brompton Hospital, London, UK.,Cardiac Rhythm Management, Royal Papworth Hospital, Cambridge, Cambridgeshire, UK
| | - Sharad Agarwal
- Department of Cardiology, Royal Papworth Hospital NHS Trust, Cambridge, UK
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37
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias: executive summary. Europace 2021; 22:450-495. [PMID: 31995197 DOI: 10.1093/europace/euz332] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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38
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Klein H. All for one and one for All? - Do we need a VT network? IJC HEART & VASCULATURE 2021; 34:100769. [PMID: 33869729 PMCID: PMC8042342 DOI: 10.1016/j.ijcha.2021.100769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 03/19/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Helmut.U. Klein
- University of Rochester, Medical Center, Clinical Cardiovascular Research Center, Rochester, NY, USA
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39
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto SI, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 Guideline on Non-Pharmacotherapy of Cardiac Arrhythmias. Circ J 2021; 85:1104-1244. [PMID: 34078838 DOI: 10.1253/circj.cj-20-0637] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Haruhiko Abe
- Department of Heart Rhythm Management, University of Occupational and Environmental Health, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital
| | - Toshiyuki Ishikawa
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University
| | - Katsuhiko Imai
- Department of Cardiovascular Surgery, Kure Medical Center and Chugoku Cancer Center
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kaoru Okishige
- Department of Cardiology, Yokohama City Minato Red Cross Hospital
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Morio Shoda
- Department of Cardiology, Tokyo Women's Medical University
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Yoshihiro Seo
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui
| | | | - Yuji Nakazato
- Department of Cardiovascular Medicine, Juntendo University Urayasu Hospital
| | - Takashi Nishimura
- Department of Cardiac Surgery, Tokyo Metropolitan Geriatric Hospital
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | | | - Yuji Murakawa
- Fourth Department of Internal Medicine, Teikyo University Hospital Mizonokuchi
| | - Teiichi Yamane
- Department of Cardiology, Jikei University School of Medicine
| | - Takeshi Aiba
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Koichi Inoue
- Division of Arrhythmia, Cardiovascular Center, Sakurabashi Watanabe Hospital
| | - Yuki Iwasaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kikuya Uno
- Arrhythmia Center, Chiba Nishi General Hospital
| | - Michio Ogano
- Department of Cardiovascular Medicine, Shizuoka Medical Center
| | - Masaomi Kimura
- Advanced Management of Cardiac Arrhythmias, Hirosaki University Graduate School of Medicine
| | | | - Shingo Sasaki
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine
| | | | - Tsuyoshi Shiga
- Department of Cardiology, Tokyo Women's Medical University
| | - Tsugutoshi Suzuki
- Departments of Pediatric Electrophysiology, Osaka City General Hospital
| | - Yukio Sekiguchi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Kyoko Soejima
- Arrhythmia Center, Second Department of Internal Medicine, Kyorin University Hospital
| | - Masahiko Takagi
- Division of Cardiac Arrhythmia, Department of Internal Medicine II, Kansai Medical University
| | - Masaomi Chinushi
- School of Health Sciences, Faculty of Medicine, Niigata University
| | - Nobuhiro Nishi
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hitoshi Hachiya
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | | | | | - Yasushi Miyauchi
- Department of Cardiovascular Medicine, Nippon Medical School Chiba-Hokusoh Hospital
| | - Aya Miyazaki
- Department of Pediatric Cardiology, Congenital Heart Disease Center, Tenri Hospital
| | - Tomoshige Morimoto
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Hiro Yamasaki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | | | - Takeshi Kimura
- Department of Cardiology, Graduate School of Medicine and Faculty of Medicine, Kyoto University
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
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Clementy N, Bodin A, Bisson A, Teixeira-Gomes AP, Roger S, Angoulvant D, Labas V, Babuty D. The Defibrillation Conundrum: New Insights into the Mechanisms of Shock-Related Myocardial Injury Sustained from a Life-Saving Therapy. Int J Mol Sci 2021; 22:5003. [PMID: 34066832 PMCID: PMC8125879 DOI: 10.3390/ijms22095003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/03/2021] [Accepted: 05/05/2021] [Indexed: 11/16/2022] Open
Abstract
Implantable cardiac defibrillators (ICDs) are recommended to prevent the risk of sudden cardiac death. However, shocks are associated with an increased mortality with a dose response effect, and a strategy of reducing electrical therapy burden improves the prognosis of implanted patients. We review the mechanisms of defibrillation and its consequences, including cell damage, metabolic remodeling, calcium metabolism anomalies, and inflammatory and pro-fibrotic remodeling. Electrical shocks do save lives, but also promote myocardial stunning, heart failure, and pro-arrhythmic effects as seen in electrical storms. Limiting unnecessary implantations and therapies and proposing new methods of defibrillation in the future are recommended.
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Affiliation(s)
- Nicolas Clementy
- Service de Cardiologie, Hôpital Trousseau, Université de Tours, 37044 Tours, France; (A.B.); (A.B.); (D.A.); (D.B.)
- Transplantation, Immunologie et Inflammation T2I-EA 4245, Université de Tours, 37044 Tours, France;
| | - Alexandre Bodin
- Service de Cardiologie, Hôpital Trousseau, Université de Tours, 37044 Tours, France; (A.B.); (A.B.); (D.A.); (D.B.)
| | - Arnaud Bisson
- Service de Cardiologie, Hôpital Trousseau, Université de Tours, 37044 Tours, France; (A.B.); (A.B.); (D.A.); (D.B.)
- Transplantation, Immunologie et Inflammation T2I-EA 4245, Université de Tours, 37044 Tours, France;
| | - Ana-Paula Teixeira-Gomes
- Plate-forme de Chirurgie et d’Imagerie pour la Recherche et l’Enseignement (CIRE), INRA, Université de Tours, CHU de Tours, 37380 Nouzilly, France; (A.-P.T.-G.); (V.L.)
| | - Sebastien Roger
- Transplantation, Immunologie et Inflammation T2I-EA 4245, Université de Tours, 37044 Tours, France;
| | - Denis Angoulvant
- Service de Cardiologie, Hôpital Trousseau, Université de Tours, 37044 Tours, France; (A.B.); (A.B.); (D.A.); (D.B.)
- Transplantation, Immunologie et Inflammation T2I-EA 4245, Université de Tours, 37044 Tours, France;
| | - Valérie Labas
- Plate-forme de Chirurgie et d’Imagerie pour la Recherche et l’Enseignement (CIRE), INRA, Université de Tours, CHU de Tours, 37380 Nouzilly, France; (A.-P.T.-G.); (V.L.)
| | - Dominique Babuty
- Service de Cardiologie, Hôpital Trousseau, Université de Tours, 37044 Tours, France; (A.B.); (A.B.); (D.A.); (D.B.)
- Transplantation, Immunologie et Inflammation T2I-EA 4245, Université de Tours, 37044 Tours, France;
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41
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Daimee UA, Berger RD. Success after ventricular tachycardia ablation: All or nothing? Heart Rhythm 2021; 18:905-906. [PMID: 33713855 DOI: 10.1016/j.hrthm.2021.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 03/08/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Usama A Daimee
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ronald D Berger
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
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Knybel L, Cvek J, Neuwirth R, Jiravsky O, Hecko J, Penhaker M, Sramko M, Kautzner J. Real-time measurement of ICD lead motion during stereotactic body radiotherapy of ventricular tachycardia. ACTA ACUST UNITED AC 2021; 26:128-137. [PMID: 34046223 DOI: 10.5603/rpor.a2021.0020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Accepted: 12/18/2020] [Indexed: 11/25/2022]
Abstract
Background Here we aimed to evaluate the respiratory and cardiac-induced motion of a ICD lead used as surrogate in the heart during stereotactic body radiotherapy (SBRT) of ventricular tachycardia (VT). Data provides insight regarding motion and motion variations during treatment. Materials and methods We analyzed the log files of surrogate motion during SBRT of ventricular tachycardia performed in 20 patients. Evaluated parameters included the ICD lead motion amplitudes; intrafraction amplitude variability; correlation error between the ICD lead and external markers; and margin expansion in the superior-inferior (SI), latero-lateral (LL), and anterior-posterior (AP) directions to cover 90% or 95% of all amplitudes. Results In the SI, LL, and AP directions, respectively, the mean motion amplitudes were 5.0 ± 2.6, 3.4. ± 1.9, and 3.1 ± 1.6 mm. The mean intrafraction amplitude variability was 2.6 ± 0.9, 1.9 ± 1.3, and 1.6 ± 0.8 mm in the SI, LL, and AP directions, respectively. The margins required to cover 95% of ICD lead motion amplitudes were 9.5, 6.7, and 5.5 mm in the SI, LL, and AP directions, respectively. The mean correlation error was 2.2 ± 0.9 mm. Conclusions Data from online tracking indicated motion irregularities and correlation errors, necessitating an increased CTV-PTV margin of 3 mm. In 35% of cases, the motion variability exceeded 3 mm in one or more directions. We recommend verifying the correlation between CTV and surrogate individually for every patient, especially for targets with posterobasal localization where we observed the highest difference between the lead and CTV motion.
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Affiliation(s)
- Lukas Knybel
- Department of Oncology, University Hospital Ostrava, Ostrava, Czech Republic
| | - Jakub Cvek
- Department of Oncology, University Hospital Ostrava, Ostrava, Czech Republic
| | | | - Otakar Jiravsky
- Department of Cardiology, Podlesi Hospital, Trinec, Czech Republic
| | - Jan Hecko
- VŠB-Technical University of Ostrava, Ostrava, Czech Republic
| | - Marek Penhaker
- VŠB-Technical University of Ostrava, Ostrava, Czech Republic
| | - Marek Sramko
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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Quinto L, Sanchez-Somonte P, Alarcón F, Garre P, Castillo À, San Antonio R, Borras R, Guasch E, Arbelo E, Tolosana JM, Berruezo A, Mont L, Roca-Luque I. Ventricular tachycardia burden reduction after substrate ablation: Predictors of recurrence. Heart Rhythm 2021; 18:896-904. [PMID: 33639298 DOI: 10.1016/j.hrthm.2021.02.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/14/2021] [Accepted: 02/19/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Substrate-based ventricular tachycardia (VT) ablation is a first-line treatment in patients with structural cardiac disease and sustained VT refractory to medical therapy. Despite technological improvements and increased knowledge of VT substrate, recurrence still is frequent. Published data are lacking on the possible reduction in VT burden after ablation despite recurrence. OBJECTIVE The purpose of this study was to assess VT burden reduction during long-term follow-up after substrate ablation and identify predictors of VT recurrence. METHODS We analyzed 234 consecutive VT ablation procedures in 207 patients (age 63 ± 14.9 years; 92% male; ischemic heart disease in 65%) who underwent substrate ablation in a single center from 2013 to 2018. RESULTS After follow-up of 3.14 ± 1.8 years, the VT recurrence rate was 41.4%. Overall, a 99.6% reduction in VT burden (median VT episodes per year: preprocedural 3.546 [1.347-13.951] vs postprocedural 0.001 [0-0.689]; P = .001) and a 96.3% decrease in implantable cardioverter-defibrillator (ICD) shocks (preprocedural 1.145 [0.118-4.467] vs postprocedural 0.042 [0-0.111] per year; P = .017) were observed. In the subgroup of patients who experienced VT recurrences, VT burden decreased by 69.2% (median VT episodes per year: preprocedural 2.876 [1.105-8.801] vs postprocedural 0.882 [0.505-2.283]; P <.001). Multivariable analysis showed persistence of late potentials (67% vs 19%; hazard ratio 3.18 [2.18-6.65]; P <.001) and lower left ventricular ejection fraction (EF) (30 [25-40] vs 39 [30-50]; P = .022) as predictors of VT recurrence. CONCLUSION Despite a high recurrence rate during long-term follow-up, substrate-based VT ablation is related to a large reduction in VT burden and a decrease in ICD therapies. Lower EF and persistence of late potentials are predictors of recurrence.
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Affiliation(s)
- Levio Quinto
- Department of Cardiology, Cardiovascular Clinical Institute, Arrhythmia Unit, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Paula Sanchez-Somonte
- Department of Cardiology, Cardiovascular Clinical Institute, Arrhythmia Unit, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Francisco Alarcón
- Department of Cardiology, Cardiovascular Clinical Institute, Arrhythmia Unit, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Paz Garre
- Department of Cardiology, Cardiovascular Clinical Institute, Arrhythmia Unit, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Àngel Castillo
- Department of Cardiology, Cardiovascular Clinical Institute, Arrhythmia Unit, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Rodolfo San Antonio
- Department of Cardiology, Cardiovascular Clinical Institute, Arrhythmia Unit, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Roger Borras
- Department of Cardiology, Cardiovascular Clinical Institute, Arrhythmia Unit, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Eduard Guasch
- Department of Cardiology, Cardiovascular Clinical Institute, Arrhythmia Unit, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Elena Arbelo
- Department of Cardiology, Cardiovascular Clinical Institute, Arrhythmia Unit, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - José Maria Tolosana
- Department of Cardiology, Cardiovascular Clinical Institute, Arrhythmia Unit, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Antonio Berruezo
- Department of Cardiology, Cardiovascular Clinical Institute, Arrhythmia Unit, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Lluís Mont
- Department of Cardiology, Cardiovascular Clinical Institute, Arrhythmia Unit, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Ivo Roca-Luque
- Department of Cardiology, Cardiovascular Clinical Institute, Arrhythmia Unit, Hospital Clinic, Universitat de Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
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Bennett R, Turnbull S, Kotake Y, Campbell T, Kumar S. Ventricular Arrhythmia Burden as a Marker of Success Following Catheter Ablation of Ventricular Arrhythmias in Patients with Structural Heart Disease. Korean Circ J 2021; 51:455-468. [PMID: 33764012 PMCID: PMC8112175 DOI: 10.4070/kcj.2020.0415] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/09/2020] [Accepted: 01/12/2021] [Indexed: 01/19/2023] Open
Abstract
Background and Objectives There is little emphasis on the efficacy of catheter ablation for ventricular arrhythmia (VA) when using VA burden reduction as a marker for success. We examined the efficacy of catheter ablation using VA burden, rather than VA recurrence as a marker of success, following catheter ablation of structural heart disease (SHD) related VA. Methods Catheter ablation of SHD related VA was performed at a single centre over 4-years. VA episodes and implantable cardioverter defibrillator (ICD) therapies were recorded over the 6-months before and after final ablation. Outcomes were reported in terms of burden reduction and compared to singular VA recurrence. Results Overall, 108 patients were included in the study. Mean age 64.2±13.9 years, 86% male, mean left ventricular ejection fraction (LVEF) 42±16%. Median VA episodes and ICD therapy were significantly reduced after ablation (VA before: 10 [interquartile range, IQR: 2–38] vs. VA after: 0 [IQR: 0–2], p<0.001; anti–tachycardia pacing [ATP] before: 16 (IQR: 1.5–57) vs. ATP after: 0 [IQR: 0–2], p<0.001; shocks before: 1 [IQR: 0–5] vs. shocks after: 0 [IQR: 0–0], p<0.001). Procedural success at 6-months was significantly higher when considering ≥75% reduction in VA burden, rather than a singular VA-free survival (83% vs. 67%, p=0.001). Conclusions The vast majority (>80%) of patients achieve reduction in VA burden (≥75% reduction) after catheter ablation for VA. This data suggests that catheter ablation is highly therapeutic when procedure success is defined as reduction in VA, rather than using a single VA recurrence as a metric for failure.
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Affiliation(s)
- Richard Bennett
- Department of Cardiology, Westmead Hospital, The University of Sydney, Westmead, Australia
| | - Samual Turnbull
- Department of Cardiology, Westmead Hospital, The University of Sydney, Westmead, Australia
| | - Yasuhito Kotake
- Department of Cardiology, Westmead Hospital, The University of Sydney, Westmead, Australia
| | - Timothy Campbell
- Department of Cardiology, Westmead Hospital, The University of Sydney, Westmead, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, The University of Sydney, Westmead, Australia.
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de Riva M, Naruse Y, Ebert M, Watanabe M, Scholte AJ, Wijnmaalen AP, Trines SA, Schalij MJ, Montero-Cabezas JM, Zeppenfeld K. Myocardial calcification is associated with endocardial ablation failure of post-myocardial infarction ventricular tachycardia. Europace 2021; 23:1275-1284. [PMID: 33550383 DOI: 10.1093/europace/euab003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Indexed: 11/14/2022] Open
Abstract
AIMS In patients with post-myocardial infarction (post-MI) ventricular tachycardia (VT), the presence of myocardial calcification (MC) may prevent heating of a subepicardial VT substrate contributing to endocardial ablation failure. The aims of this study were to assess the prevalence of MC in patients with post-MI VT and evaluate the impact of MC on outcome after endocardial ablation. METHODS AND RESULTS In 158 patients, the presence of MC was retrospectively assessed on fluoroscopy recordings in seven standard projections obtained during pre-procedural coronary angiograms. Myocardial calcification, defined as a distinct radiopaque area that moved synchronously with the cardiac contraction, was detected in 30 patients (19%). After endocardial ablation, only 6 patients (20%) with MC were rendered non-inducible compared with 56 (44%) without MC (P = 0.033) and of importance, 8 (27%) remained inducible for the clinical VT [compared with 9 (6%) patients without MC; P = 0.003] requiring therapy escalation. After a median follow-up of 31 months, 61 patients (39%) had VT recurrence and 47 (30%) died. Patients with MC had a lower survival free from the composite endpoint of VT recurrence or therapy escalation at 24-month follow-up (26% vs. 59%; P = 0.003). Presence of MC (HR 1.69; P = 0.046), a lower LV ejection fraction (HR 1.03 per 1% decrease; P = 0.017), and non-complete procedural success (HR 2.42; P = 0.002) were independently associated with a higher incidence of VT recurrence or therapy escalation. CONCLUSION Myocardial calcification was present in 19% of post-MI patients referred for VT ablation and was associated with a high incidence of endocardial ablation failure.
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Affiliation(s)
- Marta de Riva
- Department of Cardiology, Leiden University Medical Center, C-05-P, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Yoshihisa Naruse
- Department of Cardiology, Leiden University Medical Center, C-05-P, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Micaela Ebert
- Department of Cardiology, Leiden University Medical Center, C-05-P, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Masaya Watanabe
- Department of Cardiology, Leiden University Medical Center, C-05-P, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Arthur J Scholte
- Department of Cardiology, Leiden University Medical Center, C-05-P, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Adrianus P Wijnmaalen
- Department of Cardiology, Leiden University Medical Center, C-05-P, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Serge A Trines
- Department of Cardiology, Leiden University Medical Center, C-05-P, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Martin J Schalij
- Department of Cardiology, Leiden University Medical Center, C-05-P, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Jose M Montero-Cabezas
- Department of Cardiology, Leiden University Medical Center, C-05-P, PO Box 9600, 2300 RC Leiden, The Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, C-05-P, PO Box 9600, 2300 RC Leiden, The Netherlands
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46
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Conte E, Mushtaq S, Carbucicchio C, Piperno G, Catto V, Mancini ME, Formenti A, Annoni A, Guglielmo M, Baggiano A, Muscogiuri G, Belmonte M, Cattani F, Pontone G, Jereczek-Fossa BA, Orecchia R, Tondo C, Andreini D. State of the art paper: Cardiovascular CT for planning ventricular tachycardia ablation procedures. J Cardiovasc Comput Tomogr 2021; 15:394-402. [PMID: 33563533 DOI: 10.1016/j.jcct.2021.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/22/2020] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
In the last 20 years coronary computed tomography angiography (CCTA) gained a pivotal role in the evaluation of patients with suspected coronary artery disease (CAD) as finally recognized by the ESC guidelines on stable CAD. Technological advances have progressively improved the temporal resolution of CT scanners, contemporary reducing acquisition time, radiation dose and contrast volume needed for the whole heart volume acquisition, further expanding the role of cardiac CT beyond coronary anatomy evaluation. Aim of the present review is to discuss use and benefit of cardiac CT for the planning and preparation of VT ablation.
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Affiliation(s)
| | | | | | - Gaia Piperno
- Division of Radiotherapy IEO, European Institute of Oncology, IRCCS, Milan, Italy
| | | | | | | | | | | | | | | | | | - Federica Cattani
- Unit of Medical Physics, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | | | - Barbara Alicja Jereczek-Fossa
- Unit of Medical Physics, IEO European Institute of Oncology, IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
| | - Roberto Orecchia
- Scientific Directorate, IEO European Institute of Oncology, IRCCS, Milan, Italy
| | - Claudio Tondo
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | - Daniele Andreini
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy.
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47
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Yoon N. Meaning of Ventricular Arrhythmia Burden Reduction as a Marker of Ablation Success. Korean Circ J 2021; 51:469-470. [PMID: 33975390 PMCID: PMC8112174 DOI: 10.4070/kcj.2021.0069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 03/08/2021] [Indexed: 12/04/2022] Open
Affiliation(s)
- Namsik Yoon
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea.,Heart Center, Chonnam National University Hospital, Gwangju, Korea.
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48
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Nazer B, Giraud D, Zhao Y, Qi Y, Mason O, Jones PD, Diederich CJ, Gerstenfeld EP, Lindner JR. Microbubble-Facilitated Ultrasound Catheter Ablation Causes Microvascular Damage and Fibrosis. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:131-138. [PMID: 33092899 PMCID: PMC8211318 DOI: 10.1016/j.ultrasmedbio.2020.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/30/2020] [Accepted: 09/08/2020] [Indexed: 06/11/2023]
Abstract
High-intensity ultrasound (US) ablation produces deeper myocardial lesions than radiofrequency ablation. The presence of intravascular microbubble (MB) contrast agents enhances pulsed-wave US ablation via cavitation-related histotripsy, potentially facilitating ablation in persistently perfused/conducting myocardium. US ablation catheters were developed and tested in the presence of MBs using ex vivo and in vivo models. High-frame-rate videomicroscopy and US imaging of gel phantom models confirmed MB destruction by inertial cavitation. MB-facilitated US ablation in an ex vivo perfused myocardium model generated shallow (2 mm) lesions and, in an in vivo murine hindlimb model, reduced perfusion by 42% with perivascular hemorrhage and inflammation, but no myonecrosis.
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Affiliation(s)
- Babak Nazer
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA.
| | - David Giraud
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Yan Zhao
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Yue Qi
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - O'Neil Mason
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
| | - Peter D Jones
- Thermal Therapy Research Group, Department of Radiation Oncology, University of California, San Francisco, San Francisco, California, USA
| | - Chris J Diederich
- Thermal Therapy Research Group, Department of Radiation Oncology, University of California, San Francisco, San Francisco, California, USA
| | - Edward P Gerstenfeld
- Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Jonathan R Lindner
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Sáenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Europace 2020; 21:1143-1144. [PMID: 31075787 DOI: 10.1093/europace/euz132] [Citation(s) in RCA: 222] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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50
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Chronic Ablation Lesions on CMR: Is Black a Red Herring? JACC Cardiovasc Imaging 2020; 14:599-601. [PMID: 33248955 DOI: 10.1016/j.jcmg.2020.09.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 09/28/2020] [Indexed: 11/21/2022]
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