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Sipko J, Baranowski B, Bhargava M, Callahan TD, Dresing TJ, Higuchi K, Hussein AA, Kanj M, Lee J, Martin DO, Nakhla S, Rickard JJ, Saliba WI, Taigen T, Wazni OM, Santangeli P, Sroubek J. Acute post-procedural inducibility is a poor predictor of clinical outcomes in high-risk patients (PAINESD > 17) undergoing scar-related ventricular tachycardia ablation. Europace 2024; 26:euae185. [PMID: 39031021 PMCID: PMC11259852 DOI: 10.1093/europace/euae185] [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: 05/07/2024] [Accepted: 06/19/2024] [Indexed: 07/22/2024] Open
Abstract
AIMS Ventricular tachycardia (VT) non-inducibility in response to programmed ventricular stimulation (PVS) is a widely used procedural endpoint for VT ablation despite inconclusive evidence with respect to clinical outcomes in high-risk patients. The aim is to determine the utility of acute post-ablation VT inducibility as a predictor of VT recurrence, mortality, or mortality equivalent in high-risk patients. METHODS AND RESULTS We conducted a retrospective analysis of high-risk patients (defined as PAINESD > 17) who underwent scar-related VT ablation at our institution between July 2010 and July 2022. Patients' response to PVS (post-procedure) was categorized into three groups: Group A, no clinical VT or VT with cycle length > 240 ms inducible; Group B, only non-clinical VT with cycle length > 240 ms induced; and Group C, all other outcomes (including cases where no PVS was performed). The combined primary endpoint included death, durable left ventricular assist device placement, and cardiac transplant (Cox analysis). Ventricular tachycardia recurrence was considered a secondary endpoint (competing risk analysis). Of the 1677 VT ablation cases, 123 cases met the inclusion criteria for analysis. During a 19-month median follow-up time (interquartile range 4-43 months), 82 (66.7%) patients experienced the composite primary endpoint. There was no difference between Groups A and C with respect to the primary [hazard ratio (HR) = 1.21 (0.94-1.57), P = 0.145] or secondary [HR = 1.18 (0.91-1.54), P = 0.210] outcomes. These findings persisted after multivariate adjustments. The size of Group B (n = 13) did not permit meaningful statistical analysis. CONCLUSION The results of post-ablation PVS do not significantly correlate with long-term outcomes in high-risk (PAINESD > 17) VT ablation patients.
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Affiliation(s)
- Joseph Sipko
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Bryan Baranowski
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mandeep Bhargava
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Thomas D Callahan
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Thomas J Dresing
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Koji Higuchi
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ayman A Hussein
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Mohamed Kanj
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Justin Lee
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - David O Martin
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Shady Nakhla
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - John J Rickard
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Walid I Saliba
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Tyler Taigen
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Oussama M Wazni
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Pasquale Santangeli
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jakub Sroubek
- Section of Cardiac Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, OH, USA
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2
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Lambiase PD. Can an S3 Extrastimulus Light the Way for More Targeted VT Substrate Ablation? JACC Clin Electrophysiol 2024; 10:1548-1550. [PMID: 39084735 DOI: 10.1016/j.jacep.2024.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 05/25/2024] [Indexed: 08/02/2024]
Affiliation(s)
- Pier D Lambiase
- Institute of Cardiovascular Science, University College London, Barts Heart Centre, London, United Kingdom.
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3
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Cauti FM, Martini N, Fioravanti F, Tanese N, Magnocavallo M, Rampa L, Calore F, Scalisi G, Peretto G, Barengo A, Hadjis A, Radinovic A, Della Bella P. Analysis of electrogram peak frequency during ventricular tachycardia ablation: Insights into human tridimensional ventricular tachycardia circuits. Heart Rhythm 2024:S1547-5271(24)02697-3. [PMID: 38880202 DOI: 10.1016/j.hrthm.2024.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 05/30/2024] [Accepted: 06/11/2024] [Indexed: 06/18/2024]
Affiliation(s)
| | - Nicolò Martini
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | | | - Nikita Tanese
- Arrhythmology Department IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Lorenzo Rampa
- Arrhythmology Department IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Giulia Scalisi
- University of Medicine, IRCCS San Raffaele Hospital, Milan, Italy
| | - Giovanni Peretto
- Arrhythmology Department IRCCS San Raffaele Hospital, Milan, Italy
| | - Alberto Barengo
- Arrhythmology Department IRCCS San Raffaele Hospital, Milan, Italy
| | - Alexios Hadjis
- Division of Cardiology, Hôpital du Sacrè-Coeur de Montrèal, University of Montreal, Quebec, Canada
| | - Andrea Radinovic
- Arrhythmology Department IRCCS San Raffaele Hospital, Milan, Italy
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Solimene F, Speziale G, Schillaci V, Stabile G, Shopova G, Arestia A, Salito A, D'Auria C, Coltorti F, De Simone A, Scalone A, Tola G, Casula M, Mura E, Bolao IG. An annotation-independent algorithm based on electrogram characteristics to guide the identification of ventricular tachycardia isthmuses in patients with structural heart disease. J Interv Card Electrophysiol 2024; 67:739-750. [PMID: 37775727 DOI: 10.1007/s10840-023-01657-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/20/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND Criteria such as electrograms voltage or late potentials have been largely utilized in the past to help identify areas of substrate maps that are within the ventricular tachycardia (VT) isthmus; yet their specificity and positive predictive value are quite low. The Lumipoint fractionation tool of the Rhythmia system illuminates regions with fractionated electrograms irrespective of their timing and annotation. We aimed to ascertain whether the use of this tool can rapidly identify areas within VT isthmuses from substrate maps. METHODS Thirty patients with structural cardiomyopathy in whom a complete right ventricular-paced substrate map and a full reconstruction of the diastolic isthmus during VT could be obtained were enrolled. The VT isthmus border was projected on each substrate map to verify whether the areas illuminated by Lumipoint fell within those borders. The behavior of the electrograms detected at the illuminated areas of the substrate maps was studied during a right ventricular drive train and extra stimulus protocol: if the near field potentials showed a delayed conduction after a single extra stimulus, defined as a minimum of 10 ms increase of the time interval between the far field and the near field activation measured during the drive train, the electrogram was said to have a "decremental" behavior. RESULTS The logistic analysis showed that areas with fractionated electrograms illuminated by the Lumipoint software and showing the greatest decremental behavior fell within the VT isthmus borders (OR = 1.66, CI: 1.41-1.75, p<0.001; OR=1.57 CI: 1.32-1.72, p<0.001, respectively) with a sensitivity, specificity, and positive predictive value of 87%, 96%, and 97%, respectively. CONCLUSIONS Fractionated electrograms illuminated by the automated Lumipoint software on right ventricular-paced substrate maps showing the greatest decremental behavior fall within the VT isthmus borders with a probability of 0.97, irrespective of their timing, annotation, or voltage, without any need for subjective assessment of their involvement in slow conduction areas.
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Affiliation(s)
- Francesco Solimene
- Clinica Montevergine, Via M. Malzoni 5, 83013, Mercogliano, Avellino, Italy.
| | | | - Vincenzo Schillaci
- Clinica Montevergine, Via M. Malzoni 5, 83013, Mercogliano, Avellino, Italy
| | | | - Gergana Shopova
- Clinica Montevergine, Via M. Malzoni 5, 83013, Mercogliano, Avellino, Italy
| | - Alberto Arestia
- Clinica Montevergine, Via M. Malzoni 5, 83013, Mercogliano, Avellino, Italy
| | - Armando Salito
- Clinica Montevergine, Via M. Malzoni 5, 83013, Mercogliano, Avellino, Italy
| | - Carmela D'Auria
- Clinica Montevergine, Via M. Malzoni 5, 83013, Mercogliano, Avellino, Italy
| | - Fernando Coltorti
- Clinica Montevergine, Via M. Malzoni 5, 83013, Mercogliano, Avellino, Italy
| | | | - Antonio Scalone
- Cardiology and Cardiovascular Intensive Care Unit, ARNAS "G.Brotzu", Cagliari, Italy
| | - Gianfranco Tola
- Cardiology and Cardiovascular Intensive Care Unit, ARNAS "G.Brotzu", Cagliari, Italy
| | - Matteo Casula
- Cardiology and Cardiovascular Intensive Care Unit, ARNAS "G.Brotzu", Cagliari, Italy
| | | | - Ignacio Garcia Bolao
- Department of Cardiology and Cardiovascular Surgery, Clìnica Universidad de Navarra, Pamplona, Spain
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Falzone PV, Vazquez-Calvo S, Roca-Luque I. Catheter Ablation of Ventricular Tachycardia in Ischemic Heart Disease: What Is Known and New Perspectives. Curr Heart Fail Rep 2024; 21:174-185. [PMID: 38536648 DOI: 10.1007/s11897-024-00656-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 05/14/2024]
Abstract
PURPOSE OF THE REVIEW This review aims to evaluate current evidence regarding ventricular tachycardia ablation in patients with ischemic heart disease and explore novel approaches currently developing to improve procedural and long-term outcomes. RECENT FINDINGS Recently published trials (PARTITA, PAUSE-SCD, and SURVIVE-VT) have demonstrated the prognostic benefit of prophylactic ventricular tachycardia ablation compared to current clinical practice. Advanced cardiac imaging provides a valuable pre-procedural evaluation of the arrhythmogenic substrate, identifying ablation targets non-invasively. Advanced cardiac mapping techniques allow to better characterize arrhythmogenic substrate during ablation procedure. Emerging technologies like pulsed field ablation and ultra-low temperature cryoablation show promise in ventricular tachycardia ablation. Advancements in mapping techniques, ablation technologies, and pre-procedural cardiac imaging offer promise for improving ventricular tachycardia ablation outcomes in ischemic heart disease.
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Affiliation(s)
- Pasquale Valerio Falzone
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Carrer de Villaroel 170, 08036, Barcelona, Catalonia, Spain
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Sara Vazquez-Calvo
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Carrer de Villaroel 170, 08036, Barcelona, Catalonia, Spain
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Ivo Roca-Luque
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Carrer de Villaroel 170, 08036, Barcelona, Catalonia, Spain.
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
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6
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Jimenez-Perez G, Acosta J, Bocanegra-Pérez ÁJ, Arana-Rueda E, Frutos-López M, Sánchez-Brotons JA, Llamas-López H, Di Massa Pezzutti R, González de la Portilla Concha C, Camara O, Pedrote A. Delineation of intracavitary electrograms for the automatic quantification of decrement-evoked potentials in the coronary sinus with deep-learning techniques. Front Physiol 2024; 15:1331852. [PMID: 38818521 PMCID: PMC11138951 DOI: 10.3389/fphys.2024.1331852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 04/10/2024] [Indexed: 06/01/2024] Open
Abstract
Cardiac arrhythmias cause depolarization waves to conduct unevenly on the myocardial surface, potentially delaying local components with respect to a previous beat when stimulated at faster frequencies. Despite the diagnostic value of localizing the distinct local electrocardiogram (EGM) components for identifying regions with decrement-evoked potentials (DEEPs), current software solutions do not perform automatic signal quantification. Electrophysiologists must manually measure distances on the EGM signals to assess the existence of DEEPs during pacing or extra-stimuli protocols. In this work, we present a deep learning (DL)-based algorithm to identify decrement in atrial components (measured in the coronary sinus) with respect to their ventricular counterparts from EGM signals, for disambiguating between accessory pathways (APs) and atrioventricular re-entrant tachycardias (AVRTs). Several U-Net and W-Net neural networks with different configurations were trained on a private dataset of signals from the coronary sinus (312 EGM recordings from 77 patients who underwent AP or AVRT ablation). A second, separate dataset was annotated for clinical validation, with clinical labels associated to EGM fragments in which decremental conduction was elucidated. To alleviate data scarcity, a synthetic data augmentation method was developed for generating EGM recordings. Moreover, two novel loss functions were developed to minimize false negatives and delineation errors. Finally, the addition of self-attention mechanisms and their effect on model performance was explored. The best performing model was a W-Net model with 6 levels, optimized solely with the Dice loss. The model obtained precisions of 91.28%, 77.78% and of 100.0%, and recalls of 94.86%, 95.25% and 100.0% for localizing local field, far field activations, and extra-stimuli, respectively. The clinical validation model demonstrated good overall agreement with respect to the evaluation of decremental properties. When compared to the criteria of electrophysiologists, the automatic exclusion step reached a sensitivity of 87.06% and a specificity of 97.03%. Out of the non-excluded signals, a sensitivity of 96.77% and a specificity of 95.24% was obtained for classifying them into decremental and non-decremental potentials. Current results show great promise while being, to the best of our knowledge, the first tool in the literature allowing the delineation of all local components present in an EGM recording. This is of capital importance at advancing processing for cardiac electrophysiological procedures and reducing intervention times, as many diagnosis procedures are performed by comparing segments or late potentials in subsequent cardiac cycles.
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Affiliation(s)
- Guillermo Jimenez-Perez
- PhySense Research Group, BCN MedTech, Universitat Pompeu Fabra, Barcelona, Spain
- Arrhythmia Unit, Department of Cardiology at Virgen Del Rocío University Hospital, Sevilla, Spain
| | - Juan Acosta
- Arrhythmia Unit, Department of Cardiology at Virgen Del Rocío University Hospital, Sevilla, Spain
| | | | - Eduardo Arana-Rueda
- Arrhythmia Unit, Department of Cardiology at Virgen Del Rocío University Hospital, Sevilla, Spain
| | - Manuel Frutos-López
- Arrhythmia Unit, Department of Cardiology at Virgen Del Rocío University Hospital, Sevilla, Spain
| | - Juan A. Sánchez-Brotons
- Arrhythmia Unit, Department of Cardiology at Virgen Del Rocío University Hospital, Sevilla, Spain
| | - Helena Llamas-López
- Arrhythmia Unit, Department of Cardiology at Virgen Del Rocío University Hospital, Sevilla, Spain
| | | | | | - Oscar Camara
- PhySense Research Group, BCN MedTech, Universitat Pompeu Fabra, Barcelona, Spain
| | - Alonso Pedrote
- Arrhythmia Unit, Department of Cardiology at Virgen Del Rocío University Hospital, Sevilla, Spain
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7
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Tonko JB, Lambiase P. Exploring the Full Potential of Radiofrequency Technology: A Practical Guide to Advanced Radiofrequency Ablation for Complex Ventricular Arrhythmias. Curr Cardiol Rep 2024; 26:269-282. [PMID: 38700597 PMCID: PMC11136806 DOI: 10.1007/s11886-024-02048-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE OF REVIEW Percutaneous radiofrequency (RF) catheter ablation is an established strategy to prevent ventricular tachycardia (VT) recurrence and ICD shocks. Yet delivery of durable lesion sets by means of traditional unipolar radiofrequency ablation remains challenging, and left ventricular transmurality is rarely achieved. Failure to ablate and eliminate functionally relevant areas is particularly common in deep intramyocardial substrates, e.g. septal VT and cardiomyopathies. Here, we aim to give a practical-orientated overview of advanced and emerging RF ablation technologies to target these complex VT substrates. We summarize recent evidence in support of these technologies and share experiences from a tertiary VT centre to highlight important "hands-on" considerations for operators new to advanced RF ablation strategies. RECENT FINDINGS A number of innovative and modified radiofrequency ablation approaches have been proposed to increase energy delivery to the myocardium and maximize RF lesion dimensions and depth. These include measures of impedance modulation, combinations of simultaneous unipolar ablations or true bipolar ablation, intramyocardial RF delivery via wires or extendable RF needles and investigational linear or spherical catheter designs. Recent new clinical evidence for the efficacy and safety of these investigational technologies and strategies merits a re-evaluation of their role and clinic application for percutaneous VT ablations. Complexity of substrates targeted with percutaneous VT ablation is increasing and requires detailed preprocedural imaging to characterize the substrate to inform the procedural approach and selection of ablation technology. Depending on local experience, options for additional and/or complementary interventional treatments should be considered upfront in challenging substrates to improve the success rates of index procedures. Advanced RF technologies available for clinical VT ablations include impedance modulation via hypotonic irrigation or additional dispersive patches and simultaneous unipolar as well as true bipolar ablation. Promising investigational RF technologies involve an extendable needle RF catheter, intramyocardial RF delivery over intentionally perforated wires as well as a variety of innovative ablation catheter designs including multipolar linear, spherical and partially insulated ablation catheters.
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Affiliation(s)
- J B Tonko
- Institute of Cardiovascular Science, University College London, 62 Huntley St, London, WC1E 6DD, UK.
- Bartholomew s Hospital, W Smithfield, London, UK.
| | - P Lambiase
- Institute of Cardiovascular Science, University College London, 62 Huntley St, London, WC1E 6DD, UK
- Bartholomew s Hospital, W Smithfield, London, UK
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8
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Vázquez-Calvo S, Mas Casanovas J, Garre P, Sánchez-Somonte P, Falzone PV, Uribe L, Guasch E, Tolosana JM, Borras R, Figueras i Ventura RM, Arbelo E, Ortiz-Pérez JT, Prats S, Perea RJ, Brugada J, Mont L, Porta-Sanchez A, Roca-Luque I. Non-invasive detection of slow conduction with cardiac magnetic resonance imaging for ventricular tachycardia ablation. Europace 2024; 26:euae025. [PMID: 38262674 PMCID: PMC10872668 DOI: 10.1093/europace/euae025] [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: 11/27/2023] [Accepted: 01/11/2024] [Indexed: 01/25/2024] Open
Abstract
AIMS Non-invasive myocardial scar characterization with cardiac magnetic resonance (CMR) has been shown to accurately identify conduction channels and can be an important aid for ventricular tachycardia (VT) ablation. A new mapping method based on targeting deceleration zones (DZs) has become one of the most commonly used strategies for VT ablation procedures. The aim of the study was to analyse the capability of CMR to identify DZs and to find predictors of arrhythmogenicity in CMR channels. METHODS AND RESULTS Forty-four consecutive patients with structural heart disease and VT undergoing ablation after CMR at a single centre (October 2018 to July 2021) were included (mean age, 64.8 ± 11.6 years; 95.5% male; 70.5% with ischaemic heart disease; a mean ejection fraction of 32.3 ± 7.8%). The characteristics of CMR channels were analysed, and correlations with DZs detected during isochronal late activation mapping in both baseline maps and remaps were determined. Overall, 109 automatically detected CMR channels were analysed (2.48 ± 1.15 per patient; length, 57.91 ± 63.07 mm; conducting channel mass, 2.06 ± 2.67 g; protectedness, 21.44 ± 25.39 mm). Overall, 76.1% of CMR channels were associated with a DZ. A univariate analysis showed that channels associated with DZs were longer [67.81 ± 68.45 vs. 26.31 ± 21.25 mm, odds ratio (OR) 1.03, P = 0.010], with a higher border zone (BZ) mass (2.41 ± 2.91 vs. 0.87 ± 0.86 g, OR 2.46, P = 0.011) and greater protectedness (24.97 ± 27.72 vs. 10.19 ± 9.52 mm, OR 1.08, P = 0.021). CONCLUSION Non-invasive detection of targets for VT ablation is possible with CMR. Deceleration zones found during electroanatomical mapping accurately correlate with CMR channels, especially those with increased length, BZ mass, and protectedness.
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Affiliation(s)
- Sara Vázquez-Calvo
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Villarroel, 170, 08036 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Judit Mas Casanovas
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Villarroel, 170, 08036 Barcelona, Spain
| | - Paz Garre
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Villarroel, 170, 08036 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Paula Sánchez-Somonte
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Villarroel, 170, 08036 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Pasquale Valerio Falzone
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Villarroel, 170, 08036 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Laura Uribe
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Villarroel, 170, 08036 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Eduard Guasch
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Villarroel, 170, 08036 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - José Maria Tolosana
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Villarroel, 170, 08036 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Roger Borras
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Villarroel, 170, 08036 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red e Salud Mental, CIBERSAM, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Elena Arbelo
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Villarroel, 170, 08036 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - José T Ortiz-Pérez
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Villarroel, 170, 08036 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Susana Prats
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Villarroel, 170, 08036 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Rosario J Perea
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Villarroel, 170, 08036 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Josep Brugada
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Villarroel, 170, 08036 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Lluís Mont
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Villarroel, 170, 08036 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Andreu Porta-Sanchez
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Villarroel, 170, 08036 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Ivo Roca-Luque
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Villarroel, 170, 08036 Barcelona, Spain
- Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red, Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
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Elewa MG, Altoukhy S, Badran HA, El Damanhoury H, Zarif JK. Ablation targets of scar-related ventricular tachycardia identified by dynamic functional substrate mapping. Egypt Heart J 2023; 75:87. [PMID: 37831212 PMCID: PMC10575820 DOI: 10.1186/s43044-023-00414-w] [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: 07/10/2023] [Accepted: 10/03/2023] [Indexed: 10/14/2023] Open
Abstract
BACKGROUND Dynamic functional substrate mapping of scar-related ventricular tachycardia offers better identification of ablation targets with limited ablation lesions. Several functional substrate mapping approaches have been proposed, including decrement-evoked potential (DEEP) mapping. The aim of our study was to compare the short- and long-term efficacy of a DEEP-guided versus a fixed-substrate-guided strategy for the ablation of scar-related ventricular tachycardia (VT). RESULTS Forty consecutive patients presenting for ablation of scar-related VT were randomized to either DEEP-guided or substrate-guided ablation. Late potentials were tagged and ablated in the non-DEEP group, while those in the DEEP group were subjected to RV extrastimulation after a drive train. Only potentials showing significant delay were ablated. Patients were followed for a median duration of 12 months. Twenty patients were allocated to the DEEP group, while the other 20 were allocated to the non-DEEP group. Twelve patients (60%) in the DEEP group had ischemic cardiomyopathy versus 10 patients (50%) in the non-DEEP group (P-value 0.525). Intraoperatively, the median percentage of points with LPs was 19% in the DEEP group and 20.6% in the non-DEEP group. The procedural time was longer in the DEEP group, approaching but missing statistical significance (P-value 0.059). VT non-inducibility was successfully accomplished in 16 patients (80%) in the DEEP group versus 17 patients (85%) in the non-DEEP group (P value 0.597). After a median follow-up duration of 12 months, the VT recurrence rate was 65% in both groups (P value 0.311), with a dropout rate of 10% in the DEEP group. As for the secondary endpoints, all-cause mortality rates were 20% and 25% in the DEEP and non-DEEP groups, respectively (P-value 0.342). CONCLUSIONS DEEP-assisted ablation of scar-related ventricular tachycardia is a feasible strategy with comparable short- and long-term outcomes to a fixed-substrate-based strategy with more specific ablation targets, albeit relatively longer but non-significant procedural times and higher procedural deaths. The imbalance between the study groups in terms of epicardial versus endocardial mapping, although non-significant, warrants the prudent interpretation of our results. Further large-scale randomized trials are recommended. TRIAL REGISTRATION clinicaltrials.gov, registration number: NCT05086510, registered on 28th September 2021, record https://classic. CLINICALTRIALS gov/ct2/show/NCT05086510.
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Affiliation(s)
- Mohammad Gamal Elewa
- Cardiology Department, Ain Shams University Hospital, Faculty of Medicine, Ain Shams University, 5B - Swiss Project B, PO 11826, Nasr City, Cairo, Egypt.
| | - Sherif Altoukhy
- Cardiology Department, Ain Shams University Hospital, Faculty of Medicine, Ain Shams University, 5B - Swiss Project B, PO 11826, Nasr City, Cairo, Egypt
| | - Haitham Abdelfattah Badran
- Cardiology Department, Ain Shams University Hospital, Faculty of Medicine, Ain Shams University, 5B - Swiss Project B, PO 11826, Nasr City, Cairo, Egypt
| | - Hayam El Damanhoury
- Cardiology Department, Ain Shams University Hospital, Faculty of Medicine, Ain Shams University, 5B - Swiss Project B, PO 11826, Nasr City, Cairo, Egypt
| | - John Kamel Zarif
- Cardiology Department, Ain Shams University Hospital, Faculty of Medicine, Ain Shams University, 5B - Swiss Project B, PO 11826, Nasr City, Cairo, Egypt
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10
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Tonko JB, Sporton S, Sawhney V, Dhinoja M. Mapping the unmappable-Rapid high-density contact mapping in hemodynamically unstable ventricular tachycardia using a novel star-shaped multipolar catheter. HeartRhythm Case Rep 2023; 9:749-754. [PMID: 38047195 PMCID: PMC10691944 DOI: 10.1016/j.hrcr.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2023] Open
Affiliation(s)
- Johanna B. Tonko
- St Bartholomew’s Hospital, London, United Kingdom
- Institute for Cardiovascular Science, University College London, London, United Kingdom
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11
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Salvador Montañés O, Fitzgerald JL, Jackson N, Haldar S, Valli H, Cotton J, Morris GM, Gizurarson S, Cabrera JA, Nanthakumar K, Porta-Sánchez A. Decrement Evoked Potential (DEEP) Mapping of the Atria: Unmasking Atrial Fibrillation Substrate. Heart Lung Circ 2023; 32:1198-1206. [PMID: 37634968 DOI: 10.1016/j.hlc.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 06/26/2023] [Accepted: 07/10/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Atrial myopathy may underlie the progression of atrial fibrillation (AF) from a treatable disease to an irreversible condition with poor ablation outcomes. Electrophysiological methods to unmask areas prone to re-entry initiation could be key to defining latent atrial myopathy. METHODS Consecutive patients referred for AF ablation were prospectively included at four institutions. Decrement evoked potential mapping (DEEP) was performed in eight left atrial sites and five right atrial sites, from two different pacing locations (endocardially from the left atrial appendage, epicardially from the proximal coronary sinus). The electrograms (EGMs) during S1 600 ms drive and after an extra stimulus (S2 at +30 ms above atrial refractoriness) were studied at each location and assessed for decremental properties. Follow-up was 12 months. RESULTS Seventy-four patients were included and 85% had persistent AF. A total of 17,614 EGMs were individually analysed and measured. Nine percent of the EGMs showed DEEP properties (local delay of >10 ms after S2) with a mean decrement of 33±26 ms. DEEPs were more frequent in the left atrium than the right atrium (9.4% vs 8.0%; p<0.001) and more prevalent in persistent AF patients than paroxysmal AF patients (9.8% vs 4.6% p=0.001). Atrial DEEPs were more frequently unmasked in normal bipolar voltage areas and by epicardial pacing than endocardial pacing (9.6% vs 8.4%, respectively; p=0.004). Within the left atrium, the roof had the highest prevalence of DEEP EGMs. CONCLUSIONS DEEP mapping of both atria is useful for highlighting areas with a tendency for unidirectional block and re-entry initiation. Those areas are more easily unmasked by epicardial pacing from the coronary sinus and more prevalent in persistent AF patients than in paroxysmal AF patients.
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Affiliation(s)
- Oscar Salvador Montañés
- Hospital Universitario Quirónsalud Madrid, Spain; Hospital Universitario de Torrejón, Madrid, Spain; Universidad Francisco de Vitoria, Departamento de Medicina, Madrid, Spain
| | | | - Nicholas Jackson
- John Hunter Hospital and the University of Newcastle, Newcastle, Australia
| | | | - Haseeb Valli
- Royal Brompton & Harefield Hospitals, London, UK
| | - Josh Cotton
- Royal Brompton & Harefield Hospitals, London, UK
| | - Gwilym M Morris
- John Hunter Hospital and the University of Newcastle, Newcastle, Australia
| | | | | | | | - Andreu Porta-Sánchez
- Hospital Universitario Quirónsalud Madrid, Spain; Hospital Clinic de Barcelona, Institut d'Investigacions Biomédiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain; Fundación Centro Nacional de Investigaciones Carlos III.
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12
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Kasai Y, Kitai T, Morita J, Okada T, Kasai J, Fujita T. Successful, urgent, single-stage endo-epicardial catheter ablation with a surgically subxiphoid pericardial window for a drug-resistant ventricular tachycardia storm in an extremely old hemodialysis patient with ischemic cardiomyopathy. HeartRhythm Case Rep 2023; 9:736-740. [PMID: 38047188 PMCID: PMC10691947 DOI: 10.1016/j.hrcr.2023.07.018] [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: 12/05/2023] Open
Affiliation(s)
- Yuhei Kasai
- Department of Cardiology, Sapporo Cardiovascular Clinic, Sapporo, Japan
| | - Takayuki Kitai
- Department of Cardiology, Sapporo Cardiovascular Clinic, Sapporo, Japan
| | - Junji Morita
- Department of Cardiology, Sapporo Cardiovascular Clinic, Sapporo, Japan
| | - Takuya Okada
- Department of Clinical Engineering, Sapporo Cardiovascular Clinic, Sapporo, Japan
| | - Jungo Kasai
- Paul G. Allen School of Computer Science & Engineering, University of Washington, Seattle, Washington
| | - Tsutomu Fujita
- Department of Cardiology, Sapporo Cardiovascular Clinic, Sapporo, Japan
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13
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Marashly Q, Najjar SN, Hahn J, Rector GJ, Khawaja M, Chelu MG. Innovations in ventricular tachycardia ablation. J Interv Card Electrophysiol 2023; 66:1499-1518. [PMID: 35879516 DOI: 10.1007/s10840-022-01311-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 07/18/2022] [Indexed: 11/30/2022]
Abstract
Catheter ablation of ventricular arrhythmias (VAs) has evolved significantly over the past decade and is currently a well-established therapeutic option. Technological advances and improved understanding of VA mechanisms have led to tremendous innovations in VA ablation. The purpose of this review article is to provide an overview of current innovations in VA ablation. Mapping techniques, such as ultra-high density mapping, isochronal late activation mapping, and ripple mapping, have provided improved arrhythmogenic substrate delineation and potential procedural success while limiting duration of ablation procedure and potential hemodynamic compromise. Besides, more advanced mapping and ablation techniques such as epicardial and intramyocardial ablation approaches have allowed operators to more precisely target arrhythmogenic substrate. Moreover, advances in alternate energy sources, such as electroporation, as well as stereotactic radiation therapy have been proposed to be effective and safe. New catheters, such as the lattice and the saline-enhanced radiofrequency catheters, have been designed to provide deeper and more durable tissue ablation lesions compared to conventional catheters. Contact force optimization and baseline impedance modulation are important tools to optimize VT radiofrequency ablation and improve procedural success. Furthermore, advances in cardiac imaging, specifically cardiac MRI, have great potential in identifying arrhythmogenic substrate and evaluating ablation success. Overall, VA ablation has undergone significant advances over the past years. Innovations in VA mapping techniques, alternate energy source, new catheters, and utilization of cardiac imaging have great potential to improve overall procedural safety, hemodynamic stability, and procedural success.
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Affiliation(s)
- Qussay Marashly
- Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Salim N Najjar
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA
| | - Joshua Hahn
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA
| | - Graham J Rector
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA
| | - Muzamil Khawaja
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA
| | - Mihail G Chelu
- Division of Cardiology, Baylor College of Medicine, 7200 Cambridge Suite A6.137, MS: BCM621, Houston, TX, 77030, USA.
- Baylor St. Luke's Medical Center, Houston, USA.
- Texas Heart Institute, Houston, USA.
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14
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Evertz R, van der Heijden T, Beukema R, Westra S, Meindersma E, van Deursen C, Vernooy K. Comparison and predictors of implantable cardioverter-defibrillator therapy for primary and secondary prevention. Neth Heart J 2023; 31:348-356. [PMID: 37326801 PMCID: PMC10444702 DOI: 10.1007/s12471-023-01785-0] [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: 03/05/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND Implantable cardioverter-defibrillators (ICDs) are effective in detecting and treating ventricular arrhythmias. Studies on ICD therapy for different indications (primary and secondary prevention) and possible predictors of ICD therapy are limited. In this study, the incidence and type of ICD therapy were related to the indication and the underlying cardiac pathology. METHODS A single-centre, retrospective and observational study was performed of 482 patients who underwent ICD implantation for primary (53.3%) or secondary prevention (46.7%) between 2015 and 2020 at the Radboud University Medical Centre. RESULTS During a median follow-up of 2.4 years (interquartile range 0.2-3.9), the occurrence of appropriate ICD therapy for primary versus secondary prevention was 9.7% and 27.6%, respectively (p < 0.001). Time to appropriate ICD therapy was significantly shorter in the secondary prevention group (p < 0.001). No difference in ICD therapy was seen for different underlying aetiologies. In the majority of cases (70%) ICD therapy was given for ventricular tachycardia (VT). The occurrence of adverse events (16.3% vs 17.3%, p = 0.772), hospitalisation for cardiovascular reasons (29.2% vs 35.1%, p = 0.559) and all-cause mortality (12.5% vs 11.6%, p = 0.763) were similar in both groups. Male gender (3.53, 95% confidence interval (CI) (1.003, 12.403), p = 0.049) and secondary prevention indication (4.90, 95% CI (1.495, 16.066), p = 0.009) were predictors of appropriate ICD therapy. CONCLUSION The risk associated with appropriate ICD therapy is higher in secondary prevention patients, who have their first therapy within a shorter time frame after device implantation. Rates of complications, hospitalisation and all-cause mortality are comparable. Future treatment options should target the prevention of ICD therapy, mainly by preventing the recurrence of VT.
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Affiliation(s)
- Reinder Evertz
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands.
| | - Tessa van der Heijden
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Rypko Beukema
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Sjoerd Westra
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Esther Meindersma
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Caroline van Deursen
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
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15
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Subramanian M, Atreya AR, Saggu DK, Yalagudri S, Calambur N. Catheter ablation of ventricular tachycardia: strategies to improve outcomes. Front Cardiovasc Med 2023; 10:966634. [PMID: 37645526 PMCID: PMC10461400 DOI: 10.3389/fcvm.2023.966634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 04/24/2023] [Indexed: 08/31/2023] Open
Abstract
Catheter ablation of ventricular arrhythmias has evolved considerably since it was first described more than 3 decades ago. Advancements in understanding the underlying substrate, utilizing pre-procedural imaging, and evolving ablation techniques have improved the outcomes of catheter ablation. Ensuring safety and efficacy during catheter ablation requires adequate planning, including analysis of the 12 lead ECG and appropriate pre-procedural imaging. Defining the underlying arrhythmogenic substrate and disease eitology allow for the developed of tailored ablation strategies, especially for patients with non-ischemic cardiomyopathies. During ablation, the type of anesthesia can affect VT induction, the quality of the electro-anatomic map, and the stability of the catheter during ablation. For high risk patients, appropriate selection of hemodynamic support can increase the success of VT ablation. For patients in whom VT is hemodynamically unstable or difficult to induce, substrate modification strategies can aid in safe and successful ablation. Recently, there has been an several advancements in substrate mapping strategies that can be used to identify and differentiate local late potentials. The incorporation of high-definition mapping and contact-sense technologies have both had incremental benefits on the success of ablation procedures. It is crucial to harness newer technology and ablation strategies with the highest level of peri-procedural safety to achieve optimal long-term outcomes in patients undergoing VT ablation.
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Affiliation(s)
- Muthiah Subramanian
- Department of Cardiology, AIG Institute of Cardiac Sciences, Gachibowli, India
| | - Auras R. Atreya
- Department of Cardiology, University of Arkansas Medical Sciences, Little Rock, AR, United States
| | - Daljeet Kaur Saggu
- Department of Cardiology, AIG Institute of Cardiac Sciences, Gachibowli, India
| | - Sachin Yalagudri
- Department of Cardiology, AIG Institute of Cardiac Sciences, Gachibowli, India
| | - Narasimhan Calambur
- Department of Cardiology, AIG Institute of Cardiac Sciences, Gachibowli, India
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16
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Yorgun H, Çöteli C, Kılıç GS, Sezenöz B, Dural M, Ateş AH, Aytemir K. Functional substrate mapping characteristics during sinus rhythm predicts critical isthmus of reentrant atrial tachycardia. J Cardiovasc Electrophysiol 2023; 34:1539-1548. [PMID: 37269230 DOI: 10.1111/jce.15961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 05/05/2023] [Accepted: 05/24/2023] [Indexed: 06/05/2023]
Abstract
BACKGROUND Atrial tachycardia (AT) is a commonly encountered rhythm disorder in patients with underlying atrial scar. The role of atrial late activation mapping during sinus rhythm to predict the critical isthmus (CI) of AT has yet to be systematically evaluated. We aimed to investigate the relationship between the functional substrate mapping (FSM) characteristics and the CI of reentrant ATs in patients with underlying atrial low-voltage areas. METHODS Patients with history of left AT who underwent catheter ablation with 3D mapping using high-density mapping were enrolled. Voltage map and isochronal late activation mapping were created during sinus/paced rhythm to detect deceleration zones (DZ). Electrograms with continuous-fragmented morphology were also tagged. After induction of AT, activation mapping was performed to detect CI of the tachycardia. Atrial tachyarrhythmia (ATa) recurrence was defined as detection of atrial fibrillation or AT (≥30 s) during the follow-up. RESULTS Among 35 patients [mean age: 62 ± 9, gender: 25 (71.5%) female] with left AT, a total of 42 reentrant ATs induced. Voltage mapping during sinus rhythm revealed low-voltage area of 37.1 ± 23.8% of the left atrium. The mean value of bipolar voltage, EGM duration, and conduction velocity during sinus rhythm corresponding to CI of ATs were 0.18 ± 0.12 mV, 133 ± 47 ms, and 0.12 ± 0.09 m/s, respectively. Total number of DZs per chamber was 1.5 ± 0.6, which were located in the low-voltage zone (<0.5 mV) detected by high-density mapping. All CIs of reentry were colocalized with DZs detected during FSM. The positive predictive value of DZs to detect CI of inducible ATs is 80.4%. Freedom from ATa after the index procedure was 74.3% during a mean follow-up of 12.2 ± 7.5 months. CONCLUSION Our findings demonstrated the utility of FSM during sinus rhythm to predict the CI of AT. DZs displayed continuous-fragmented signal morphology with slow conduction which may guide to tailor ablation strategy in case of underlying atrial scar.
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Affiliation(s)
- Hikmet Yorgun
- Department of Cardiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Cem Çöteli
- Department of Cardiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Gül Sinem Kılıç
- Department of Cardiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Burak Sezenöz
- Department of Cardiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
- Department of Cardiology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Muhammet Dural
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Cardiology, Faculty of Medicine, Osmangazi University, Eskişehir, Turkey
| | - Ahmet Hakan Ateş
- Department of Cardiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Kudret Aytemir
- Department of Cardiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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17
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Al-Sheikhli J, Winter J, Luque IR, Lambiase PD, Orini M, Porta-Sánchez A, Dhanjal T. Optimization of decrementing evoked potential mapping for functional substrate identification in ischaemic ventricular tachycardia ablation. Europace 2023; 25:euad092. [PMID: 37032650 PMCID: PMC10228600 DOI: 10.1093/europace/euad092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 03/15/2023] [Indexed: 04/11/2023] Open
Affiliation(s)
- Jaffar Al-Sheikhli
- Department of Cardiology, University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Walsgrave, Coventry, CV2 2DX, UK
| | - James Winter
- Electrophysiology Division, Abbott Laboratories, Solihull, UK
| | - Ivo Roca Luque
- Arrhythmia Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Pier D Lambiase
- Institute of Cardiovascular Science, University College London, London, UK
| | - Michele Orini
- Institute of Cardiovascular Science, University College London, London, UK
| | | | - Tarvinder Dhanjal
- Department of Cardiology, University Hospital Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Walsgrave, Coventry, CV2 2DX, UK
- University of Warwick, Warwick Medical School, Coventry, CV4 7HL, UK
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18
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Baldazzi G, Orrù M, Viola G, Pani D. Computer-aided detection of arrhythmogenic sites in post-ischemic ventricular tachycardia. Sci Rep 2023; 13:6906. [PMID: 37106017 PMCID: PMC10140038 DOI: 10.1038/s41598-023-33866-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 04/20/2023] [Indexed: 04/29/2023] Open
Abstract
Nowadays, catheter-based ablation in patients with post-ischemic ventricular tachycardia (VT) is performed in arrhythmogenic sites identified by electrophysiologists by visual inspection during electroanatomic mapping. This work aims to present the development of machine learning tools aiming at supporting clinicians in the identification of arrhythmogenic sites by exploiting innovative features that belong to different domains. This study included 1584 bipolar electrograms from nine patients affected by post-ischemic VT. Different features were extracted in the time, time scale, frequency, and spatial domains and used to train different supervised classifiers. Classification results showed high performance, revealing robustness across the different classifiers in terms of accuracy, true positive, and false positive rates. The combination of multi-domain features with the ensemble tree is the most effective solution, exhibiting accuracies above 93% in the 10-time 10-fold cross-validation and 84% in the leave-one-subject-out validation. Results confirmed the effectiveness of the proposed features and their potential use in a computer-aided system for the detection of arrhythmogenic sites. This work demonstrates for the first time the usefulness of supervised machine learning for the detection of arrhythmogenic sites in post-ischemic VT patients, thus enabling the development of computer-aided systems to reduce operator dependence and errors, thereby possibly improving clinical outcomes.
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Affiliation(s)
- Giulia Baldazzi
- Medical Devices and Signal Processing (MeDSP) Lab, Department of Electrical and Electronic Engineering (DIEE), University of Cagliari, Cagliari, Italy.
- Department of Informatics, Bioengineering, Robotics and Systems Engineering (DIBRIS), University of Genoa, Genoa, Italy.
| | - Marco Orrù
- Medical Devices and Signal Processing (MeDSP) Lab, Department of Electrical and Electronic Engineering (DIEE), University of Cagliari, Cagliari, Italy
- Department of Informatics, Bioengineering, Robotics and Systems Engineering (DIBRIS), University of Genoa, Genoa, Italy
| | - Graziana Viola
- Department of Cardiology, Santissima Annunziata Hospital, Sassari, Italy
| | - Danilo Pani
- Medical Devices and Signal Processing (MeDSP) Lab, Department of Electrical and Electronic Engineering (DIEE), University of Cagliari, Cagliari, Italy
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19
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Khanra D, Calvert P, Hughes S, Waktare J, Modi S, Hall M, Todd D, Mahida S, Gupta D, Luther V. An approach to help differentiate postinfarct scar from borderzone tissue using Ripple Mapping during ventricular tachycardia ablation. J Cardiovasc Electrophysiol 2023; 34:664-672. [PMID: 36478627 DOI: 10.1111/jce.15766] [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: 09/09/2022] [Revised: 11/15/2022] [Accepted: 11/25/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Ventricular scar is traditionally highlighted on a bipolar voltage (BiVolt) map in areas of myocardium <0.50 mV. We describe an alternative approach using Ripple Mapping (RM) superimposed onto a BiVolt map to differentiate postinfarct scar from conducting borderzone (BZ) during ventricular tachycardia (VT) ablation. METHODS Fifteen consecutive patients (left ventricular ejection fraction 30 ± 7%) underwent endocardial left ventricle pentaray mapping (median 5148 points) and ablation targeting areas of late Ripple activation. BiVolt maps were studied offline at initial voltage of 0.50-0.50 mV to binarize the color display (red and purple). RMs were superimposed, and the BiVolt limits were sequentially reduced until only areas devoid of Ripple bars appeared red, defined as RM-scar. The surrounding area supporting conducting Ripple wavefronts in tissue <0.50 mV defined the RM-BZ. RESULTS RM-scar was significantly smaller than the traditional 0.50 mV cutoff (median 4% vs. 12% shell area, p < .001). 65 ± 16% of tissue <0.50 mV supported Ripple activation within the RM-BZ. The mean BiVolt threshold that differentiated RM-scar from BZ tissue was 0.22 ± 0.07 mV, though this ranged widely (from 0.12 to 0.35 mV). In this study, septal infarcts (7/15) were associated with more rapid VTs (282 vs. 347 ms, p = .001), and had a greater proportion of RM-BZ to RM-scar (median ratio 3.2 vs. 1.2, p = .013) with faster RM-BZ conduction speed (0.72 vs. 0.34 m/s, p = .001). Conversely, scars that supported hemodynamically stable sustained VT (6/15) were slower (367 ± 38 ms), had a smaller proportion of RM-BZ to RM-scar (median ratio 1.2 vs. 3.2, p = .059), and slower RM-BZ conduction speed (0.36 vs. 0.63 m/s, p = .036). RM guided ablation collocated within 66 ± 20% of RM-BZ, most concentrated around the RM-scar perimeter, with significant VT reduction (median 4.0 episodes preablation vs. 0 post, p < .001) at 11 ± 6 months follow-up. CONCLUSION Postinfarct scars appear significantly smaller than traditional 0.50 mV cut-offs suggest, with voltage thresholds unique to each patient.
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Affiliation(s)
| | - Peter Calvert
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | | | | | - Simon Modi
- Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Mark Hall
- Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Derick Todd
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | - Saagar Mahida
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | - Dhiraj Gupta
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
| | - Vishal Luther
- Liverpool Heart & Chest Hospital, Liverpool, UK.,Liverpool Centre of Cardiovascular Sciences, University of Liverpool, Liverpool, UK
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20
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Sung E, Prakosa A, Kyranakis S, Berger RD, Chrispin J, Trayanova NA. Wavefront directionality and decremental stimuli synergistically improve identification of ventricular tachycardia substrate: insights from personalized computational heart models. Europace 2023; 25:223-235. [PMID: 36006658 PMCID: PMC10103576 DOI: 10.1093/europace/euac140] [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: 04/12/2022] [Accepted: 07/16/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS Multiple wavefront pacing (MWP) and decremental pacing (DP) are two electroanatomic mapping (EAM) strategies that have emerged to better characterize the ventricular tachycardia (VT) substrate. The aim of this study was to assess how well MWP, DP, and their combination improve identification of electrophysiological abnormalities on EAM that reflect infarct remodelling and critical VT sites. METHODS AND RESULTS Forty-eight personalized computational heart models were reconstructed using images from post-infarct patients undergoing VT ablation. Paced rhythms were simulated by delivering an initial (S1) and an extra-stimulus (S2) from one of 100 locations throughout each heart model. For each pacing, unipolar signals were computed along the myocardial surface to simulate substrate EAM. Six EAM features were extracted and compared with the infarct remodelling and critical VT sites. Concordance of S1 EAM features between different maps was lower in hearts with smaller amounts of remodelling. Incorporating S1 EAM features from multiple maps greatly improved the detection of remodelling, especially in hearts with less remodelling. Adding S2 EAM features from multiple maps decreased the number of maps required to achieve the same detection accuracy. S1 EAM features from multiple maps poorly identified critical VT sites. However, combining S1 and S2 EAM features from multiple maps paced near VT circuits greatly improved identification of critical VT sites. CONCLUSION Electroanatomic mapping with MWP is more advantageous for characterization of substrate in hearts with less remodelling. During substrate EAM, MWP and DP should be combined and delivered from locations proximal to a suspected VT circuit to optimize identification of the critical VT site.
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Affiliation(s)
- Eric Sung
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21287, USA
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218, USA
| | - Adityo Prakosa
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21287, USA
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218, USA
| | - Stephen Kyranakis
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21287, USA
| | - Ronald D Berger
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218, USA
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Jonathan Chrispin
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218, USA
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Natalia A Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21287, USA
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, 3400 N. Charles Street, Baltimore, MD 21218, USA
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21
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Lima da Silva G, Cortez-Dias N, Nunes Ferreira A, Nakar E, Francisco R, Pereira M, Moreno J, Martins RP, Pinto FJ, de Sousa J. Impact of different activation wavefronts on ischemic myocardial scar electrophysiological properties during high-density ventricular tachycardia mapping and ablation. J Cardiovasc Electrophysiol 2023; 34:389-399. [PMID: 36335623 DOI: 10.1111/jce.15740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/02/2022] [Accepted: 10/12/2022] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Scar-related ventricular tachycardia (VT) usually results from an underlying reentrant circuit facilitated by anatomical and functional barriers. The later are sensitive to the direction of ventricular activation wavefronts. We aim to evaluate the impact of different ventricular activation wavefronts on the functional electrophysiological properties of myocardial tissue. METHODS Patients with ischemic heart disease referred for VT ablation underwent high-density mapping using Carto®3 (Biosense Webster). Maps were generated during sinus rhythm, right and left ventricular pacing, and analyzed using a new late potential map software, which allows to assess local conduction velocities and facilitates the delineation of intra-scar conduction corridors (ISCC); and for all stable VTs. RESULTS In 16 patients, 31 high-resolution substrate maps from different ventricular activation wavefronts and 7 VT activation maps were obtained. Local abnormal ventricular activities (LAVAs) were found in VT isthmus, but also in noncritical areas. The VT isthmus was localized in areas of LAVAs overlapping surface between the different activation wavefronts. The deceleration zone location differed depending on activation wavefronts. Sixty-six percent of ISCCs were similarly identified in all activating wavefronts, but the one acting as VT isthmus was simultaneously identified in all activation wavefronts in all cases. CONCLUSION Functional based substrate mapping may improve the specificity to localize the most arrhythmogenic regions within the scar, making the use of different activation wavefronts unnecessary in most cases.
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Affiliation(s)
- Gustavo Lima da Silva
- Cardiology Department, Santa Maria University Hospital (CHULN), Lisbon Academic Medical Centre, Lisbon, Portugal.,Cardiac Rhythm Abnormalities Unit, Cardiovascular Centre of the University of Lisbon, Lisbon School of Medicine of the Universidade de Lisboa, Lisbon, Portugal
| | - Nuno Cortez-Dias
- Cardiology Department, Santa Maria University Hospital (CHULN), Lisbon Academic Medical Centre, Lisbon, Portugal.,Cardiac Rhythm Abnormalities Unit, Cardiovascular Centre of the University of Lisbon, Lisbon School of Medicine of the Universidade de Lisboa, Lisbon, Portugal
| | - Afonso Nunes Ferreira
- Cardiology Department, Santa Maria University Hospital (CHULN), Lisbon Academic Medical Centre, Lisbon, Portugal.,Cardiac Rhythm Abnormalities Unit, Cardiovascular Centre of the University of Lisbon, Lisbon School of Medicine of the Universidade de Lisboa, Lisbon, Portugal
| | - Elad Nakar
- Research and Development Department, Biosense Webster, Johnson & Johnson, Yokneam, Israel
| | - Raquel Francisco
- Biosense Webster, Johnson & Johnson, EMEA Clinical Development, Diegem, Belgium
| | - Mariana Pereira
- Biosense Webster, Johnson & Johnson, Clinical Support, Porto Salvo, Portugal
| | - Javier Moreno
- Cardiology Department, Arrhythmia Unit, University Hospital Ramón y Cajal and CIBER-CV Madrid, Madrid, Spain
| | - Raphaël P Martins
- Department of Cardiology, Rennes University Hospital, Rennes, France
| | - Fausto J Pinto
- Cardiology Department, Santa Maria University Hospital (CHULN), Lisbon Academic Medical Centre, Lisbon, Portugal.,Cardiac Rhythm Abnormalities Unit, Cardiovascular Centre of the University of Lisbon, Lisbon School of Medicine of the Universidade de Lisboa, Lisbon, Portugal
| | - João de Sousa
- Cardiology Department, Santa Maria University Hospital (CHULN), Lisbon Academic Medical Centre, Lisbon, Portugal.,Cardiac Rhythm Abnormalities Unit, Cardiovascular Centre of the University of Lisbon, Lisbon School of Medicine of the Universidade de Lisboa, Lisbon, Portugal
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22
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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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23
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Zachariah D, Nakajima K, Limite LR, Zweiker D, Spartalis M, Zirolia D, Musto M, D'Angelo G, Paglino G, Baratto F, Cireddu M, Bisceglia C, Radinovic A, Marzi A, Sala S, Peretto G, Vergara P, Gulletta S, Mazzone P, Della Bella P, Frontera A. Significance of abnormal and late ventricular signals in ventricular tachycardia ablation of ischemic and nonischemic cardiomyopathies. Heart Rhythm 2022; 19:2075-2083. [PMID: 35964871 DOI: 10.1016/j.hrthm.2022.08.008] [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: 04/29/2022] [Revised: 08/02/2022] [Accepted: 08/04/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Abnormal ventricular signals (AVS) are the cornerstone of substrate-based ventricular tachycardia (VT) ablation in sinus rhythm. Signal characterization of AVS in ischemic and nonischemic cardiomyopathies has never been performed. OBJECTIVE The purpose of this study was to describe ventricular signal abnormalities in 3 different pathologies and examine their association with the diastolic component of VT circuits. METHODS A total of 45 patients (15 ischemic cardiomyopathy [ICM], 15 arrhythmogenic cardiomyopathy [ACM], 15 dilated cardiomyopathy [DCM]) who had undergone VT ablation with >50% of the diastolic pathway of the VT circuit recorded were studied. AVS were classified into late potentials (LPs) and continuous fractionated ventricular signals (CFVS), and their characteristics and correlation with the diastolic pathway of VT circuits were analyzed. RESULTS Seventy-five VT circuits were analyzed. Bipolar scars were greatest in ICM endocardially (53 cm2 ICM vs 36 cm2 ACM vs 25 cm2 DCM; P = .010) and in ACM epicardially (98 cm2 ACM vs 25 cm2 ICM vs 24 cm2 DCM; P = .005). Location of the VT diastolic interval coincided with AVS location in 54% of VTs in ICM, 89% in ACM, and 72% in DCM (P = .036). There was a trend toward a greater association of diastolic intervals coinciding with LPs than with CFVS (78% vs 57%; P = .052) (69% diastolic intervals in ICM coincided with LPs, 33% with CFVS; P = .063). All patients (100%) with CFVS in ACM had VT diastolic components arising from CFVS (33% ICM, 64% DCM; P = .049). Positive predictive value for LPs vs CFVS was 77.8% vs 56.7%, and sensitivity was 67.3% vs 32.7%, respectively. CONCLUSION The nature of abnormal signals in different cardiomyopathies reflects underlying pathology. LPs rather than CFVS seem to be more linked to diastolic components of VT circuits, especially in ICM. LPs have greater sensitivity and specificity for VT; however, CFVS may be of more relevance in ACM.
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Affiliation(s)
- Donah Zachariah
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy; Department of Cardiology, University Hospitals of North Midlands, Stoke on Trent, United Kingdom.
| | | | | | - David Zweiker
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Michael Spartalis
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Davide Zirolia
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Martina Musto
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Giuseppe D'Angelo
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Gabriele Paglino
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Francesca Baratto
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Manuela Cireddu
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | | | - Andrea Radinovic
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alessandra Marzi
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Simone Sala
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Giovanni Peretto
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Pasquale Vergara
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Simone Gulletta
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Patrizio Mazzone
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Paolo Della Bella
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Antonio Frontera
- Department of Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
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24
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Atreya AR, Yalagudri SD, Subramanian M, Rangaswamy VV, Saggu DK, Narasimhan C. Best Practices for the Catheter Ablation of Ventricular Arrhythmias. Card Electrophysiol Clin 2022; 14:571-607. [PMID: 36396179 DOI: 10.1016/j.ccep.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Techniques for catheter ablation have evolved to effectively treat a range of ventricular arrhythmias. Pre-operative electrocardiographic and cardiac imaging data are very useful in understanding the arrhythmogenic substrate and can guide mapping and ablation. In this review, we focus on best practices for catheter ablation, with emphasis on tailoring ablation strategies, based on the presence or absence of structural heart disease, underlying clinical status, and hemodynamic stability of the ventricular arrhythmia. We discuss steps to make ablation safe and prevent complications, and techniques to improve the efficacy of ablation, including optimal use of electroanatomical mapping algorithms, energy delivery, intracardiac echocardiography, and selective use of mechanical circulatory support.
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Affiliation(s)
- Auras R Atreya
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India; Division of Cardiovascular Medicine, Electrophysiology Section, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sachin D Yalagudri
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India
| | - Muthiah Subramanian
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India
| | | | - Daljeet Kaur Saggu
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India
| | - Calambur Narasimhan
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India.
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25
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Niri A, Shapira E, Massé S, Bar-Tal M, Bar-on T, Hayam G, Ben-Dor A, Bhaskaran A, Ha A, Anter E, Porta-Sanchez A, Jackson N, Nanthakumar K, Nair K. Automated Identification of Ventricular Tachycardia Ablation Targets: Multicenter Validation and Workflow Characterization. J Innov Card Rhythm Manag 2022; 13:5147-5152. [PMID: 36196238 PMCID: PMC9521725 DOI: 10.19102/icrm.2022.130903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 03/09/2022] [Indexed: 11/27/2022] Open
Abstract
Decrement evoked potentials (EPs) (DeEPs) constitute an accepted method to identify physiological ventricular tachycardia (VT) ablation targets without inducing VT. The feasibility of automated software (SW) in the detection of arrhythmogenic VT substrate has been documented. However, multicenter validation of automated SW and workflow has yet to be characterized. The objective of this study was to describe the functionality of a novel DeEP SW (Biosense Webster, Diamond Bar, CA, USA) and evaluate the independent performance of the automated algorithm using multicenter data. VT ablation cases were performed in the catheterization laboratory and retrospectively analyzed using the DeEP SW. The algorithm indicated and mapped DeEPs by first identifying capture in surface electrocardiograms (ECGs). Once capture was confirmed, the EPs of S1 paces were detected. The algorithm checked for the stability of S1 EPs by comparing the last 3 of the 8 morphologies and attributing standard deviation values. The extra-stimulus EP was then detected by comparing it to the S1 EP. Once detected, the DeEP value was computed from the extra-stimulus and displayed as a sphere on a voltage map. A total of 5,885 DeEP signals were extracted from 21 substrate mapping cases conducted at 3 different centers (in Spain, Canada, and Australia). A gold standard was established from ECGs manually marked by subject experts. Once the algorithm was deployed, 91.6% of S2 algorithm markings coincided with the gold standard, 1.9% were false-positives, and 0.1% were false-negatives. Also, 6.4% were non-specific DeEP detections. In conclusion, the automated DeEP algorithm identifies and displays DeEP points, revealing VT substrates in a multicenter validation study. The automation of identification and mapping display is expected to improve efficiency.
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Affiliation(s)
- Ahmed Niri
- The Hull Family Cardiac Fibrillation Management Laboratory, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | | | - Stéphane Massé
- The Hull Family Cardiac Fibrillation Management Laboratory, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | | | | | | | | | - Abishek Bhaskaran
- The Hull Family Cardiac Fibrillation Management Laboratory, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Andrew Ha
- The Hull Family Cardiac Fibrillation Management Laboratory, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Elad Anter
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, USA
| | | | | | - Kumaraswamy Nanthakumar
- The Hull Family Cardiac Fibrillation Management Laboratory, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada,Address correspondence to: Kumaraswamy Nanthakumar, MD, FRCPC, Division of Cardiology, University Health Network, Toronto General Hospital, 150 Gerrard Street West, GW3-526, Toronto, ON, Canada M5G 2C4.
| | - Krishnakumar Nair
- The Hull Family Cardiac Fibrillation Management Laboratory, Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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26
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Vázquez-Calvo S, Roca-Luque I, Porta-Sánchez A. Ventricular Tachycardia Ablation Guided by Functional Substrate Mapping: Practices and Outcomes. J Cardiovasc Dev Dis 2022; 9:jcdd9090288. [PMID: 36135433 PMCID: PMC9501404 DOI: 10.3390/jcdd9090288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 11/16/2022] Open
Abstract
Catheter ablation of ventricular tachycardia has demonstrated its important role in the treatment of ventricular tachycardia in patients with structural cardiomyopathy. Conventional mapping techniques used to define the critical isthmus, such as activation mapping and entrainment, are limited by the non-inducibility of the clinical tachycardia or its poor hemodynamic tolerance. To overcome these limitations, a voltage mapping strategy based on bipolar electrograms peak to peak analysis was developed, but a low specificity (30%) for VT isthmus has been described with this approach. Functional mapping strategy relies on the analysis of the characteristics of the electrograms but also their propagation patterns and their response to extra-stimulus or alternative pacing wavefronts to define the targets for ablation. With this review, we aim to summarize the different functional mapping strategies described to date to identify ventricular arrhythmic substrate in patients with structural heart disease.
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27
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Hawson J, Al-Kaisey A, Anderson RD, Watts T, Morton J, Kumar S, Kistler P, Kalman J, Lee G. Substrate-based approaches in ventricular tachycardia ablation. Indian Pacing Electrophysiol J 2022; 22:273-285. [PMID: 36007824 PMCID: PMC9649336 DOI: 10.1016/j.ipej.2022.08.002] [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: 06/24/2022] [Revised: 07/23/2022] [Accepted: 08/16/2022] [Indexed: 11/30/2022] Open
Abstract
Catheter ablation for ventricular tachycardia (VT) in patients with structural heart disease is now part of standard care. Mapping and ablation of the clinical VT is often limited when the VT is noninducible, nonsustained or not haemodynamically tolerated. Substrate-based ablation strategies have been developed in an aim to treat VT in this setting and, subsequently, have been shown to improve outcomes in VT ablation when compared to focused ablation of mapped VTs. Since the initial description of linear ablation lines targeting ventricular scar, many different approaches to substrate-based VT ablation have been developed. Strategies can broadly be divided into three categories: 1) targeting abnormal electrograms, 2) anatomical targeting of conduction channels between areas of myocardial scar, and 3) targeting areas of slow and/or decremental conduction, identified with “functional” substrate mapping techniques. This review summarises contemporary substrate-based ablation strategies, along with their strengths and weaknesses.
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Affiliation(s)
- Joshua Hawson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Ahmed Al-Kaisey
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Robert D Anderson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Troy Watts
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Joseph Morton
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital and Westmead Applied Research Centre, Westmead, New South Wales, Australia; Western Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Peter Kistler
- Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia; Department of Cardiology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia; Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, Victoria, Australia.
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28
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Wiles BM, Li AC, Waight MC, Saba MM. Contemporary Management of Complex Ventricular Arrhythmias. Arrhythm Electrophysiol Rev 2022; 11:e04. [PMID: 35734144 PMCID: PMC9194914 DOI: 10.15420/aer.2021.66] [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] [Received: 11/29/2021] [Accepted: 02/06/2022] [Indexed: 12/02/2022] Open
Abstract
Percutaneous catheter ablation is an effective and safe therapy that can eliminate ventricular tachycardia, reducing the risks of both recurrent arrhythmia and shock therapies from a defibrillator. Successful ablation requires accurate identification of arrhythmic substrate and the effective delivery of energy to the targeted tissue. A thorough pre-procedural assessment is needed before considered 3D electroanatomical mapping can be performed. In contemporary practice, this must combine traditional electrophysiological techniques, such as activation and entrainment mapping, with more novel physiological mapping techniques for which there is an ever-increasing evidence base. Novel techniques to maximise energy delivery to the tissue must also be considered and balanced against their associated risks of complication. This review provides a comprehensive appraisal of contemporary practice and the evidence base that supports recent developments in mapping and ablation, while also considering potential future developments in the field.
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Affiliation(s)
- Benedict M Wiles
- Advanced Ventricular Arrhythmia Training and Research (AVATAR) Program, St George's University Hospitals NHS Foundation Trust, London, UK.,Cardiology Clinical Academic Group, St George's University of London, London, UK
| | - Anthony C Li
- Advanced Ventricular Arrhythmia Training and Research (AVATAR) Program, St George's University Hospitals NHS Foundation Trust, London, UK.,Cardiology Clinical Academic Group, St George's University of London, London, UK
| | - Michael C Waight
- Advanced Ventricular Arrhythmia Training and Research (AVATAR) Program, St George's University Hospitals NHS Foundation Trust, London, UK.,Cardiology Clinical Academic Group, St George's University of London, London, UK
| | - Magdi M Saba
- Advanced Ventricular Arrhythmia Training and Research (AVATAR) Program, St George's University Hospitals NHS Foundation Trust, London, UK.,Cardiology Clinical Academic Group, St George's University of London, London, UK
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29
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[Update on ablation of ventricular tachyarrhythmias]. Herzschrittmacherther Elektrophysiol 2022; 33:42-48. [PMID: 35157111 DOI: 10.1007/s00399-022-00840-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 01/17/2022] [Indexed: 10/19/2022]
Abstract
Catheter ablation of ventricular tachycardia (VT) is performed with increasing frequency in clinical practice. Whereas the reported success rates of idiopathic VT are high, catheter ablation of VT in patients with structural heart disease with its scar-related re-entry mechanism may remain a challenge especially if deep intramyocardial or epicardial portions exist. The integration of modern cardiac imaging, new functional mapping strategies and catheter technologies allow optimized identification and characterization of the critical arrhythmogenic substrate and hence a more targeted VT ablation. The extent to which these innovations will have the potential to improve VT ablation success rates will be determined by future studies.
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30
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Lima da Silva G, Cortez-Dias N, Carpinteiro L, Pinto FJ, de Sousa J. Outcome of ventricular tachycardia catheter ablation in ischemic heart disease patients using a high-density mapping substrate-based approach: A prospective cohort study. Rev Port Cardiol 2022; 41:325-335. [DOI: 10.1016/j.repc.2021.02.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/25/2021] [Accepted: 02/10/2021] [Indexed: 11/17/2022] Open
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31
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Ciaccio EJ, Anter E, Coromilas J, Wan EY, Yarmohammadi H, Wit AL, Peters NS, Garan H. Structure and function of the ventricular tachycardia isthmus. Heart Rhythm 2022; 19:137-153. [PMID: 34371192 DOI: 10.1016/j.hrthm.2021.08.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/22/2021] [Accepted: 08/01/2021] [Indexed: 12/24/2022]
Abstract
Catheter ablation of postinfarction reentrant ventricular tachycardia (VT) has received renewed interest owing to the increased availability of high-resolution electroanatomic mapping systems that can describe the VT circuits in greater detail, and the emergence and need to target noninvasive external beam radioablation. These recent advancements provide optimism for improving the clinical outcome of VT ablation in patients with postinfarction and potentially other scar-related VTs. The combination of analyses gleaned from studies in swine and canine models of postinfarction reentrant VT, and in human studies, suggests the existence of common electroanatomic properties for reentrant VT circuits. Characterizing these properties may be useful for increasing the specificity of substrate mapping techniques and for noninvasive identification to guide ablation. Herein, we describe properties of reentrant VT circuits that may assist in elucidating the mechanisms of onset and maintenance, as well as a means to localize and delineate optimal catheter ablation targets.
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Affiliation(s)
- Edward J Ciaccio
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York; ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom.
| | - Elad Anter
- Department of Cardiovascular Medicine, Cardiac Electrophysiology, Cleveland Clinic, Cleveland, Ohio
| | - James Coromilas
- Department of Medicine, Division of Cardiovascular Disease and Hypertension, Rutgers University, New Brunswick, New Jersey
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Hirad Yarmohammadi
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Andrew L Wit
- Department of Pharmacology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Nicholas S Peters
- ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom
| | - Hasan Garan
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York
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Kahle AK, Jungen C, Alken FA, Scherschel K, Willems S, Pürerfellner H, Chen S, Eckardt L, Meyer C. Management of ventricular tachycardia in patients with ischaemic cardiomyopathy: contemporary armamentarium. Europace 2021; 24:538-551. [PMID: 34967892 DOI: 10.1093/europace/euab274] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Indexed: 01/10/2023] Open
Abstract
Worldwide, ∼4 million people die from sudden cardiac death every year caused in more than half of the cases by ischaemic cardiomyopathy (ICM). Prevention of sudden cardiac death after myocardial infarction by implantation of a cardioverter-defibrillator (ICD) is the most common, even though not curative, therapy to date. Optimized ICD programming should be strived for in order to decrease the incidence of ICD interventions. Catheter ablation reduces the recurrence of ventricular tachycardias (VTs) and is an important adjunct to sole ICD-based treatment or pharmacological antiarrhythmic therapy in patients with ICM, as conclusively demonstrated by seven randomized controlled trials (RCTs) in the last two decades. However, none of the conducted trials was powered to reveal a survival benefit for ablated patients as compared to controls. Whereas thorough consideration of an early approach is necessary following two recent RCTs (PAUSE-SCD, BERLIN VT), catheter ablation is particularly recommended in patients with recurrent VT after ICD therapy. In this context, novel, pathophysiologically driven ablation strategies referring to deep morphological and functional substrate phenotyping based on high-resolution mapping and three-dimensional visualization of scars appear promising. Emerging concepts like sympathetic cardiac denervation as well as radioablation might expand the therapeutical armamentarium especially in patients with therapy-refractory VT. Randomized controlled trials are warranted and on the way to investigate how these translate into improved patient outcome. This review summarizes therapeutic strategies currently available for the prevention of VT recurrences, the optimal timing of applicability, and highlights future perspectives after a PAUSE in BERLIN.
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Affiliation(s)
- Ann-Kathrin Kahle
- Division of Cardiology, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217 Düsseldorf, Germany.,Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Medical Faculty, Universitätsstrasse 1, 40225 Düsseldorf, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany
| | - Christiane Jungen
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany.,Clinic for Cardiology, University Heart & Vascular Center, University Hospital Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.,Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - Fares-Alexander Alken
- Division of Cardiology, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217 Düsseldorf, Germany.,Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Medical Faculty, Universitätsstrasse 1, 40225 Düsseldorf, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany
| | - Katharina Scherschel
- Division of Cardiology, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217 Düsseldorf, Germany.,Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Medical Faculty, Universitätsstrasse 1, 40225 Düsseldorf, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany
| | - Stephan Willems
- DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany.,Department of Cardiology and Internal Intensive Care Medicine, Asklepios Hospital St. Georg, Lohmühlenstrasse 5, 20099 Hamburg, Germany
| | - Helmut Pürerfellner
- Department of Electrophysiology, Academic Teaching Hospital, Ordensklinikum Linz Elisabethinen, Fadingerstraße 1, 4020 Linz, Austria
| | - Shaojie Chen
- Cardioangiologisches Centrum Bethanien (CCB), Frankfurt Academy For Arrhythmias (FAFA), Kardiologie, Medizinische Klinik III, Agaplesion Markus Krankenhaus, Wilhelm-Epstein Straße 4, 60431 Frankfurt am Main, Germany
| | - Lars Eckardt
- Department for Cardiology II (Electrophysiology), University Hospital Münster, Albert-Schweitzer-Campus 1, 48149 Münster, Germany
| | - Christian Meyer
- Division of Cardiology, EVK Düsseldorf, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Kirchfeldstrasse 40, 40217 Düsseldorf, Germany.,Institute of Neural and Sensory Physiology, cNEP, cardiac Neuro- and Electrophysiology Research Consortium, Heinrich Heine University Düsseldorf, Medical Faculty, Universitätsstrasse 1, 40225 Düsseldorf, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Potsdamer Strasse 58, 10785 Berlin, Germany
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Advances in Mapping of Ventricular Tachycardia. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-021-00951-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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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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Srinivasan NT, Garcia J, Schilling RJ, Ahsan S, Hunter RJ, Lowe M, Chow AW, Lambiase PD. Dynamic spatial dispersion of repolarization is present in regions critical for ischemic ventricular tachycardia ablation. Heart Rhythm O2 2021; 2:280-289. [PMID: 34337579 PMCID: PMC8322930 DOI: 10.1016/j.hroo.2021.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The presence of dynamic substrate changes may facilitate functional block and reentry in ventricular tachycardia (VT). OBJECTIVE We aimed to study dynamic ventricular repolarization changes in critical regions of the VT circuit during sensed single extrastimulus pacing known as the Sense Protocol (SP). METHODS Twenty patients (aged 67 ± 9 years, 17 male) underwent VT ablation. A bipolar voltage map was obtained during sinus rhythm (SR) and right ventricular SP pacing at 20 ms above ventricular effective refractory period. Ventricular repolarization maps were constructed. Ventricular repolarization time (RT) was calculated from unipolar electrogram T waves, using the Wyatt method, as the dV/dtmax of the unipolar T wave. Entrainment or pace mapping confirmed critical sites for ablation. RESULTS The median global repolarization range (max-min RT per patient) was 166 ms (interquartile range [IQR] 143-181 ms) during SR mapping vs 208 ms (IQR 182-234) during SP mapping (P = .0003 vs intrinsic rhythm). Regions of late potentials (LP) had a longer RT during SP mapping compared to regions without LP (mean 394 ± 40 ms vs 342 ± 25 ms, P < .001). In paired regions of normal myocardium there was no significant spatial dispersion of repolarization (SDR)/10 mm2 during SP mapping vs SR mapping (SDR 11 ± 6 ms vs 10 ± 6 ms, P = .54). SDR/10 mm2 was greater in critical areas of the VT circuit during SP mapping 63 ± 29 ms vs SR mapping 16 ± 9 ms (P < .001). CONCLUSION Ventricular repolarization is prolonged in regions of LP and increases dynamically, resulting in dynamic SDR in critical areas of the VT circuit. These dynamic substrate changes may be an important factor that facilitates VT circuits.
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Affiliation(s)
- Neil T. Srinivasan
- Department of Cardiac Electrophysiology, The Essex Cardiothoracic Centre, Basildon, Essex, United Kingdom
- Department of Cardiac Electrophysiology, The Barts Heart Center, St Bartholomew’s Hospital, London, United Kingdom
- Institute of Cardiovascular Science, University College London, London, United Kingdom
- Circulatory Health Research Group, Medical Technology Research Centre, School of Medicine, Anglia Ruskin University, Essex, United Kingdom
| | - Jason Garcia
- Department of Cardiac Electrophysiology, The Barts Heart Center, St Bartholomew’s Hospital, London, United Kingdom
| | - Richard J. Schilling
- Department of Cardiac Electrophysiology, The Barts Heart Center, St Bartholomew’s Hospital, London, United Kingdom
| | - Syed Ahsan
- Department of Cardiac Electrophysiology, The Barts Heart Center, St Bartholomew’s Hospital, London, United Kingdom
| | - Ross J. Hunter
- Department of Cardiac Electrophysiology, The Barts Heart Center, St Bartholomew’s Hospital, London, United Kingdom
| | - Martin Lowe
- Department of Cardiac Electrophysiology, The Barts Heart Center, St Bartholomew’s Hospital, London, United Kingdom
| | - Anthony W. Chow
- Department of Cardiac Electrophysiology, The Barts Heart Center, St Bartholomew’s Hospital, London, United Kingdom
| | - Pier D. Lambiase
- Department of Cardiac Electrophysiology, The Barts Heart Center, St Bartholomew’s Hospital, London, United Kingdom
- Institute of Cardiovascular Science, University College London, London, United Kingdom
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Papageorgiou N, Srinivasan NT. Dynamic High-density Functional Substrate Mapping Improves Outcomes in Ischaemic Ventricular Tachycardia Ablation: Sense Protocol Functional Substrate Mapping and Other Functional Mapping Techniques. Arrhythm Electrophysiol Rev 2021; 10:38-44. [PMID: 33936742 PMCID: PMC8076974 DOI: 10.15420/aer.2020.28] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Post-infarct-related ventricular tachycardia (VT) occurs due to reentry over surviving fibres within ventricular scar tissue. The mapping and ablation of patients in VT remains a challenge when VT is poorly tolerated and in cases in which VT is non-sustained or not inducible. Conventional substrate mapping techniques are limited by the ambiguity of substrate characterisation methods and the variety of mapping tools, which may record signals differently based on their bipolar spacing and electrode size. Real world data suggest that outcomes from VT ablation remain poor in terms of freedom from recurrent therapy using conventional techniques. Functional substrate mapping techniques, such as single extrastimulus protocol mapping, identify regions of unmasked delayed potentials, which, by nature of their dynamic and functional components, may play a critical role in sustaining VT. These methods may improve substrate mapping of VT, potentially making ablation safer and more reproducible, and thereby improving the outcomes. Further large-scale studies are needed.
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Affiliation(s)
- Nikolaos Papageorgiou
- Department of Cardiac Electrophysiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Neil T Srinivasan
- Department of Cardiac Electrophysiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK.,Institute of Cardiovascular Science, University College London, London, UK.,Department of Cardiac Electrophysiology, Essex Cardiothoracic Centre, Basildon, UK
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37
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Dynamic high-density functional substrate mapping to treat ventricular tachycardia-Time for electrophysiology to come home. Heart Rhythm 2021; 18:732-733. [PMID: 33482384 DOI: 10.1016/j.hrthm.2021.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 01/12/2021] [Indexed: 11/23/2022]
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38
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Proietti R, Dowd R, Gee LV, Yusuf S, Panikker S, Hayat S, Osman F, Patel K, Salim H, Aldhoon B, Foster W, Merghani A, Kuehl M, Banerjee P, Lellouche N, Dhanjal T. Impact of a high-density grid catheter on long-term outcomes for structural heart disease ventricular tachycardia ablation. J Interv Card Electrophysiol 2021; 62:519-529. [PMID: 33392856 PMCID: PMC8645535 DOI: 10.1007/s10840-020-00918-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/31/2020] [Indexed: 01/04/2023]
Abstract
Background Substrate mapping has highlighted the importance of targeting diastolic conduction channels and late potentials during ventricular tachycardia (VT) ablation. State-of-the-art multipolar mapping catheters have enhanced mapping capabilities. The purpose of this study was to investigate whether long-term outcomes were improved with the use of a HD Grid mapping catheter combining complementary mapping strategies in patients with structural heart disease VT. Methods Consecutive patients underwent VT ablation assigned to either HD Grid, Pentaray, Duodeca, or point-by-point (PbyP) RF mapping catheters. Clinical endpoints included recurrent anti-tachycardia pacing (ATP), appropriate shock, asymptomatic non-sustained VT, or all-cause death. Results Seventy-three procedures were performed (33 HD Grid, 22 Pentaray, 12 Duodeca, and 6 PbyP) with no significant difference in baseline characteristics. Substrate mapping was performed in 97% of cases. Activation maps were generated in 82% of HD Grid cases (Pentaray 64%; Duodeca 92%; PbyP 33% (p = 0.025)) with similar trends in entrainment and pace mapping. Elimination of all VTs occurred in 79% of HD Grid cases (Pentaray 55%; Duodeca 83%; PbyP 33% (p = 0.04)). With a mean follow-up of 372 ± 234 days, freedom from recurrent ATP and shock was 97% and 100% respectively in the HD Grid group (Pentaray 64%, 82%; Duodeca 58%, 83%; PbyP 33%, 33% (log rank p = 0.0042, p = 0.0002)). Conclusions This study highlights a step-wise improvement in survival free from ICD therapies as the density of mapping capability increases. By using a high-density mapping catheter and combining complementary mapping strategies in a strict procedural workflow, long-term clinical outcomes are improved.
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Affiliation(s)
- Riccardo Proietti
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK.,Department of Cardiac, Thoracic, Vascular Sciences, and University of Padua, Padua, Italy
| | - Rory Dowd
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Lim Ven Gee
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Shamil Yusuf
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Sandeep Panikker
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Sajad Hayat
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Faizel Osman
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK.,University of Warwick (Medical School), Gibbet Hill, Coventry, CV4 7AJ, UK
| | - Kiran Patel
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK.,University of Warwick (Medical School), Gibbet Hill, Coventry, CV4 7AJ, UK
| | - Handi Salim
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Bashar Aldhoon
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Will Foster
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Ahmed Merghani
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Michael Kuehl
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Prithwish Banerjee
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Nicolas Lellouche
- Hopital Henri Mondor Albert Chenevier, University Paris Est Creteil Paris XII, Avenue du Marechal de Lattre de Tassigny, 94000, Creteil, Inserm U955, Paris, France
| | - Tarvinder Dhanjal
- Department of Cardiology, University Hospital Coventry & Warwickshire NHS Trust, Clifford Bridge Road, Coventry, CV2 2DX, UK. .,University of Warwick (Medical School), Gibbet Hill, Coventry, CV4 7AJ, UK.
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Campbell T, Bennett RG, Kotake Y, Kumar S. Updates in Ventricular Tachycardia Ablation. Korean Circ J 2021; 51:15-42. [PMID: 33377327 PMCID: PMC7779814 DOI: 10.4070/kcj.2020.0436] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/27/2020] [Indexed: 02/06/2023] Open
Abstract
Sudden cardiac death (SCD) due to recurrent ventricular tachycardia is an important clinical sequela in patients with structural heart disease. As a result, ventricular tachycardia (VT) has emerged as a major clinical and public health problem. The mechanism of VT is predominantly mediated by re-entry in the presence of arrhythmogenic substrate (scar), though focal mechanisms are also important. Catheter ablation for VT, when compared to standard medical therapy, has been shown to improve VT-free survival and burden of device therapies. Approaches to VT ablation are dependent on the underlying disease process, broadly classified into idiopathic (no structural heart disease) or structural heart disease (ischemic or non-ischemic heart disease). This update aims to review recent advances made for the treatment of VT ablation, with respect to current clinical trials, peri-procedure risk assessments, pre-procedural cardiac imaging, electro-anatomic mapping and advances in catheter and non-catheter based ablation techniques.
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Affiliation(s)
- Timothy Campbell
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- Westmead Applied Research Centre, University of Sydney, New South Wales, Australia
| | - Richard G Bennett
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- Westmead Applied Research Centre, University of Sydney, New South Wales, Australia
| | - Yasuhito Kotake
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- Westmead Applied Research Centre, University of Sydney, New South Wales, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- Westmead Applied Research Centre, University of Sydney, New South Wales, Australia.
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Crinion D, Neira V, Al Hamad N, de Leon A, Bakker D, Korogyi A, Abdollah H, Glover B, Simpson C, Baranchuk A, Chacko S, Enriquez A, Redfearn D. Close-coupled pacing to identify the "functional" substrate of ventricular tachycardia: Long-term outcomes of the paced electrogram feature analysis technique. Heart Rhythm 2020; 18:723-731. [PMID: 33378703 DOI: 10.1016/j.hrthm.2020.12.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 12/09/2020] [Accepted: 12/22/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND The conduction delay and block that compose the critical isthmus of macroreentrant ventricular tachycardia (VT) is partly "functional" in that they only occur at faster cycle lengths. Close-coupled pacing stresses the myocardium's conduction capacity and may reveal late potentials (LPs) and fractionation. Interest has emerged in targeting this functional substrate. OBJECTIVE The purpose of this study was to assess the feasibility and efficacy of a functional substrate VT ablation strategy. METHODS Patients with scar-related VT undergoing their first ablation were recruited. A closely coupled extrastimulus (ventricular effective refractory period + 30 ms) was delivered at the right ventricular apex while mapping with a high-density catheter. Sites of functional impaired conduction exhibited increased electrogram duration due to LPs/fractionation. The time to last deflection was annotated on an electroanatomic map, readily identifying ablation targets. RESULTS A total of 40 patients were recruited (34 [85%] ischemic). Median procedure duration was 330 minutes (interquartile range [IQR] 300-369), and ablation time was 49.4 minutes (IQR 33.8-48.3). Median functional substrate area was 41.9 cm2 (IQR 22.1-73.9). It was similarly distributed across bipolar voltage zones. Noninducibility was achieved in 34 of 40 patients (85%). Median follow-up was 711 days (IQR 255.5-972.8), during which 35 of 39 patients (89.7%) did not have VT recurrence, and 3 of 39 (7.5%) died. Antiarrhythmic drugs were continued in 53.8% (21/39). CONCLUSION Functional substrate ablation resulted in high rates of noninducibility and freedom from VT. Mapping times were increased considerably. Our findings add to the encouraging trend reported by related techniques. Randomized multicenter trials are warranted to assess this next phase of VT ablation.
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Affiliation(s)
- Derek Crinion
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | - Victor Neira
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | - Nasser Al Hamad
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | - Ana de Leon
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | - David Bakker
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | | | - Hoshiar Abdollah
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | - Ben Glover
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | - Christopher Simpson
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | - Adrian Baranchuk
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | - Sanoj Chacko
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | - Andres Enriquez
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada
| | - Damian Redfearn
- Heart Rhythm Service, Queen's University, Kingston Health Sciences, Ontario, Canada.
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Bhaskaran A, Fitzgerald J, Jackson N, Gizurarson S, Nanthakumar K, Porta-Sánchez A. Decrement Evoked Potential Mapping to Guide Ventricular Tachycardia Ablation: Elucidating the Functional Substrate. Arrhythm Electrophysiol Rev 2020; 9:211-218. [PMID: 33437489 PMCID: PMC7788395 DOI: 10.15420/aer.2020.25] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Empirical approaches to targeting the ventricular tachycardia (VT) substrate include mapping of late potentials, local abnormal electrogram, pace-mapping and homogenisation of the abnormal signals. These approaches do not try to differentiate between the passive or active role of local signals as the critical components of the VT circuit. By not considering the functional components, these approaches often view the substrate as a fixed anatomical barrier. Strategies to improve the success of VT ablation need to include the identification of critical functional substrate. Decrement-evoked potential (DeEP) mapping has been developed to elucidate this using an extra-stimulus added to a pacing drive train. With knowledge translation in mind, the authors detail the evolution of the DeEP concept by way of a study of simultaneous panoramic endocardial mapping in VT ablation; an in silico modelling study to demonstrate the factors influencing DeEPs; a multicentre VT ablation validation study; a practical approach to DeEP mapping; the potential utility of DeEPs to identify arrhythmogenic atrial substrate; and, finally, other functional mapping strategies.
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Affiliation(s)
| | | | | | | | | | - Andreu Porta-Sánchez
- Hospital Universitario Quirónsalud Madrid, Molecular Cardiology Laboratory, Centro Nacional de Investigaciones Cardiovasculares, Spain
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Halbfaß P, Foldyna B, Lehmkuhl L, Nentwich K, Sonne K, Ene E, Berkovitz A, Deneke T. CT- und MRT-Bildgebung in der Rhythmologie. AKTUELLE KARDIOLOGIE 2020. [DOI: 10.1055/a-1283-5785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
ZusammenfassungDie Anwendung bildgebender Verfahren gewinnt in der interventionellen Elektrophysiologie entgegen der geringen Beachtung in den aktuell geltenden nationalen und internationalen Leitlinien zur Behandlung von Patienten mit Vorhofflimmern und ventrikulären Tachykardien auch über die reine Diagnostik zugrunde liegender struktureller Herzerkrankungen hinaus immer mehr an Bedeutung. Die breite Anwendung der Computertomografie (CT) und der Magnetresonanztomografie (MRT) ergibt sich aus den spezifischen Möglichkeiten dieser bildgebenden Techniken heraus: Gewebecharakterisierung des Myokards auf Vorhof- und Kammerebene mit präziser Darstellung von Infarktnarben, Grenzzonen und vitalem Myokard (MRT inklusive Late-Gadolinium-Enhancement-Darstellung); hochauflösende Darstellung wichtiger anatomischer Strukturen inklusive der Koronararterien und präzise Identifizierung von kritischer ventrikulärer Wandausdünnung im Infarktareal (CT); Identifizierung potenzieller Komplikationen nach
Vorhofflimmerablation (Pulmonalvenenstenosen, Ösophagusruptur oder -fistel). Stärken und Schwächen sowie mögliche relative und absolute Kontraindikationen bei der Anwendung dieser beiden Methoden müssen jedoch berücksichtigt werden. Generell kann die Anwendung bildgebender Verfahren insbesondere für die Therapieplanung und -steuerung als wertvolle Ergänzung mit der Möglichkeit der Steigerung von Effektivität und Sicherheit gesehen werden. Prospektive randomisierte Studien liegen jedoch zu wichtigen aktuellen Anwendungsbereichen der CT und MRT noch nicht vor. Wichtigste Grundlage der interventionellen Elektrophysiologie in der Therapie supraventrikulärer und ventrikulärer Arrhythmien wird noch auf lange Sicht die Anwendung klassischer elektrophysiologischer Manöver und Strategien sowie die Verwendung sich immer weiter entwickelnder elektroanatomischer Mappingsysteme bleiben.
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Affiliation(s)
- Philipp Halbfaß
- Klinik für Kardiologie II, Rhythmologie und interventionelle Elektrophysiologie, Rhön Klinikum Campus Bad Neustadt, Deutschland
| | - Borek Foldyna
- Klinik für diagnostische und interventionelle Radiologie, Rhön Klinikum Campus Bad Neustadt, Deutschland
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Lukas Lehmkuhl
- Klinik für diagnostische und interventionelle Radiologie, Rhön Klinikum Campus Bad Neustadt, Deutschland
| | - Karin Nentwich
- Klinik für Kardiologie II, Rhythmologie und interventionelle Elektrophysiologie, Rhön Klinikum Campus Bad Neustadt, Deutschland
| | - Kai Sonne
- Klinik für Kardiologie II, Rhythmologie und interventionelle Elektrophysiologie, Rhön Klinikum Campus Bad Neustadt, Deutschland
| | - Elena Ene
- Klinik für Kardiologie II, Rhythmologie und interventionelle Elektrophysiologie, Rhön Klinikum Campus Bad Neustadt, Deutschland
| | - Artur Berkovitz
- Klinik für Kardiologie II, Rhythmologie und interventionelle Elektrophysiologie, Rhön Klinikum Campus Bad Neustadt, Deutschland
| | - Thomas Deneke
- Klinik für Kardiologie II, Rhythmologie und interventionelle Elektrophysiologie, Rhön Klinikum Campus Bad Neustadt, Deutschland
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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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Matsunaga-Lee Y, Egami Y, Ukita K, Kawamura A, Nakamura H, Matsuhiro Y, Yasumoto K, Tsuda M, Tanaka A, Okamoto N, Yano M, Shutta R, Sakata Y, Nishino M, Tanouchi J. Electrophysiological identification of superior vena cava: Novel insight into slow conduction or conduction block. J Cardiovasc Electrophysiol 2020; 32:58-66. [PMID: 33210777 DOI: 10.1111/jce.14820] [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: 08/29/2020] [Revised: 10/23/2020] [Accepted: 10/28/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION It has not been clarified how to identify the electrophysiological junction between right atrium (RA) and superior vena cava (SVC). The aim of this study was to identify the electrophysiological RA-SVC junction according to slow conduction or conduction bock and to examine the electrophysiological SVC isolation procedure. METHODS Seventy-three consecutive atrial fibrillation patients who underwent SVC mapping using a CARTO 3 system were enrolled in this study. Slow conduction or conduction block between the RA and SVC was identified by adjusting the lower threshold criteria of the early meets late function and was described as a white line. The SVC isolation was performed along the white line and with pacing maneuvers to confirm direct SVC capture. RESULTS Activation mapping (1296 ± 631 points) was obtained in 66 patients (90%) in 4.6 ± 1.8 min. Slow conduction or conduction block was observed in all patients. The threshold for detecting slow conduction or conduction block was 24 ± 8 ms. The location of the electrophysiological RA-SVC junction was higher in the anterior portion (anterior-septal, anterior, and anterior-lateral) than in the posterior portion (posterior-septal, posterior, and posterior-lateral) (-2.3 ± 6.2 mm vs. 7.1 ± 6.3 mm, p < .001). The SVC isolation at the electrophysiological RA-SVC junction was successful in all patients without any injury to the sinus node function. Asymptomatic phrenic nerve injury was observed in three patients (4.5%). CONCLUSION In all patients, the electrophysiological RA-SVC junction determined by slow conduction or conduction block was identified and the electrophysiological SVC isolation was performed successfully and safely.
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Affiliation(s)
| | - Yasuyuki Egami
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
| | - Kohei Ukita
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
| | - Akito Kawamura
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
| | | | | | - Koji Yasumoto
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
| | - Masaki Tsuda
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
| | - Akihiro Tanaka
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
| | | | - Masamichi Yano
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
| | - Ryu Shutta
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masami Nishino
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
| | - Jun Tanouchi
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
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Berte B, Zeppenfeld K, Tung R. Impact of Micro-, Mini- and Multi-Electrode Mapping on Ventricular Substrate Characterisation. Arrhythm Electrophysiol Rev 2020; 9:128-135. [PMID: 33240508 PMCID: PMC7675146 DOI: 10.15420/aer.2020.24] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/23/2020] [Indexed: 12/29/2022] Open
Abstract
Accurate substrate characterisation may improve the evolving understanding and treatment of cardiac arrhythmias. During substrate-based ablation techniques, wide practice variations exist with mapping via dedicated multi-electrode catheter or conventional ablation catheters. Recently, newer ablation catheter technology with embedded mapping electrodes have been introduced. This article focuses on the general misconceptions of voltage mapping and more specific differences in unipolar and bipolar signal morphology, field of view, signal-to-noise ratio, mapping capabilities (density and resolution), catheter-specific voltage thresholds and impact of micro-, mini- and multi-electrodes for substrate mapping. Efficiency and cost-effectiveness of different catheter types are discussed. Increasing sampling density with smaller electrodes allows for higher resolution with a greater likelihood to record near-field electrical information. These advances may help to further improve our mechanistic understanding of the correlation between substrate and ventricular tachycardia, as well as macro-reentry arrhythmia in humans.
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Affiliation(s)
- Benjamin Berte
- Heart Center, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Roderick Tung
- Center for Arrhythmia Care, Pritzker School of Medicine University of Chicago Medicine, Chicago, IL, US
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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. J Interv Card Electrophysiol 2020; 59:81-133. [PMID: 31960344 PMCID: PMC7508755 DOI: 10.1007/s10840-019-00664-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, IN, USA
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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Acosta J, Soto-Iglesias D, Jáuregui B, Armenta JF, Penela D, Frutos-López M, Arana-Rueda E, Pedrote A, Mont L, Berruezo A. Long-term outcomes of ventricular tachycardia substrate ablation incorporating hidden slow conduction analysis. Heart Rhythm 2020; 17:1696-1703. [DOI: 10.1016/j.hrthm.2020.05.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 04/30/2020] [Accepted: 05/04/2020] [Indexed: 11/16/2022]
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48
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Bella PD, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. J Interv Card Electrophysiol 2020; 59:145-298. [PMID: 31984466 PMCID: PMC7223859 DOI: 10.1007/s10840-019-00663-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, IN, USA
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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Radiofrequency catheter ablation of ventricular tachycardia in ischemic heart disease in light of current practice: a systematic review and meta-analysis of randomized controlled trials. J Interv Card Electrophysiol 2020; 59:603-616. [PMID: 32948937 DOI: 10.1007/s10840-020-00870-3] [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: 06/21/2020] [Accepted: 09/10/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Ventricular tachycardia (VT) is a frequent cause of mortality and morbidity in patients with ischemic heart disease (IHD). We aim to perform a systematic review and meta-analysis of randomized controlled trials (RCT) of radiofrequency catheter ablation (RCA) of VT in patients with IHD and to discuss its appropriate timing and limitations. METHODS Literature searches of MEDLINE, CENTRAL, the Cochrane Database of Systematic Reviews, Health Technology Assessment, and PsycINFO were performed in February 2020. RCTs comparing RCA vs conventional management for VT in patients with IHD and previous or planned implantable cardioverter defibrillator (ICD) were identified. Clinical outcomes included all-cause mortality, cardiovascular mortality, cardiovascular hospitalization, VT storm, recurrent VT/ventricular fibrillation (VF), appropriate ICD therapies, and appropriate ICD shocks. Using a random-effects model, relative risk (RR) and 95% confidence intervals (CI) were calculated for each outcome. RESULTS A total of 6 RCTs (N = 791) met inclusion criteria. RCA was associated with significantly lower VT storm (RR 0.70; CI95% 0.51 to 0.94, p = 0.02) and appropriate ICD therapies (RR 0.69; CI95% 0.54 to 0.88, p = 0.003), including appropriate ICD shocks (RR 0.66; CI95% 0.47 to 0.92, p = 0.02). There was no significant difference in all-cause or cardiovascular mortality, cardiovascular hospitalization, and recurrent VT/VF. CONCLUSIONS Radiofrequency catheter ablation for VT in patients with IHD was associated with a reduced risk of VT storm, ICD therapies, and ICD shocks. There is a need for future carefully designed RCTs that incorporate improved RCA procedural aspects.
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50
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Srinivasan NT, Garcia J, Schilling RJ, Ahsan S, Babu GG, Ang R, Dhinoja MB, Hunter RJ, Lowe M, Chow AW, Lambiase PD. Multicenter Study of Dynamic High-Density Functional Substrate Mapping Improves Identification of Substrate Targets for Ischemic Ventricular Tachycardia Ablation. JACC Clin Electrophysiol 2020; 6:1783-1793. [PMID: 33357574 PMCID: PMC7769061 DOI: 10.1016/j.jacep.2020.06.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 06/26/2020] [Accepted: 06/29/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVES The goal of this study was to evaluate the role of dynamic substrate changes in facilitating conduction delay and re-entry in ventricular tachycardia (VT) circuits. BACKGROUND The presence of dynamic substrate changes facilitate functional block and re-entry in VT but are rarely studied as part of clinical VT mapping. METHODS Thirty patients (age 67 ± 9 years; 27 male subjects) underwent ablation. Mapping was performed with the Advisor HD Grid multipolar catheter. A bipolar voltage map was obtained during sinus rhythm (SR) and right ventricular sense protocol (SP) single extra pacing. SR and SP maps of late potentials (LP) and local abnormal ventricular activity (LAVA) were made and compared with critical sites for ablation, defined as sites of best entrainment or pace mapping. Ablation was then performed to critical sites, and LP/LAVA identified by the SP. RESULTS At a median follow-up of 12 months, 90% of patients were free from antitachycardia pacing (ATP) or implantable cardioverter-defibrillator shocks. SP pacing resulted in a larger area of LP identified for ablation (19.3 mm2 vs. 6.4 mm2) during SR mapping (p = 0.001), with a sensitivity of 87% and a specificity of 96%, compared with 78% and 65%, respectively, in SR. CONCLUSIONS LP and LAVA observed during the SP were able to identify regions critical for ablation in VT with a greater accuracy than SR mapping. This may improve substrate characterization in VT ablation. The combination of ablation to critical sites and SP-derived LP/LAVA requires further assessment in a randomized comparator study.
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Affiliation(s)
- Neil T Srinivasan
- Department of Cardiac Electrophysiology, The Barts Heart Center, St. Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom.
| | - Jason Garcia
- Department of Cardiac Electrophysiology, The Barts Heart Center, St. Bartholomew's Hospital, London, United Kingdom
| | - Richard J Schilling
- Department of Cardiac Electrophysiology, The Barts Heart Center, St. Bartholomew's Hospital, London, United Kingdom
| | - Syed Ahsan
- Department of Cardiac Electrophysiology, The Barts Heart Center, St. Bartholomew's Hospital, London, United Kingdom
| | - Girish G Babu
- Royal Bournemouth and Christchurch Hospitals, Bournemouth, United Kingdom
| | - Richard Ang
- Department of Cardiac Electrophysiology, The Barts Heart Center, St. Bartholomew's Hospital, London, United Kingdom
| | - Mehul B Dhinoja
- Department of Cardiac Electrophysiology, The Barts Heart Center, St. Bartholomew's Hospital, London, United Kingdom
| | - Ross J Hunter
- Department of Cardiac Electrophysiology, The Barts Heart Center, St. Bartholomew's Hospital, London, United Kingdom
| | - Martin Lowe
- Department of Cardiac Electrophysiology, The Barts Heart Center, St. Bartholomew's Hospital, London, United Kingdom
| | - Anthony W Chow
- Department of Cardiac Electrophysiology, The Barts Heart Center, St. Bartholomew's Hospital, London, United Kingdom
| | - Pier D Lambiase
- Department of Cardiac Electrophysiology, The Barts Heart Center, St. Bartholomew's Hospital, London, United Kingdom; Institute of Cardiovascular Science, University College London, London, United Kingdom
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