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Balaji P, Liulu X, Sivakumar S, Chong JJH, Kizana E, Vandenberg JI, Hill AP, Hau E, Qian PC. Mechanistic insights and knowledge gaps in the effects of radiation therapy on cardiac arrhythmias. Int J Radiat Oncol Biol Phys 2024:S0360-3016(24)03316-9. [PMID: 39222823 DOI: 10.1016/j.ijrobp.2024.08.040] [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: 01/14/2024] [Revised: 08/05/2024] [Accepted: 08/18/2024] [Indexed: 09/04/2024]
Abstract
Stereotactic body radiation therapy (SBRT) is an innovative modality for treatment of refractory ventricular arrhythmias (VA). Phase I/II clinical trials have demonstrated the remarkable efficacy of SBRT at reducing VA burden(by>85%) in patients with good short-term safety. SBRT as an option for VA treatment delivered in an ambulatory, non-sedated patient in a single fraction, during an outpatient session of 15-30 minutes, without added risks of anesthetic or surgery is clinically relevant. However, the underlying mechanism remains unclear. Currently used clinical dosing of SBRT has been derived from preclinical studies aimed to induce transmural fibrosis in the atria. The propitious clinical effects of SBRT appear earlier than the time-course for fibrosis. This review addresses the plausible mechanisms by which radiation alters the electrophysiological properties of myocytes and myocardial conduction to impart an anti-arrhythmic effect to elucidate clinical observations and point the direction for further research in this promising area.
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Affiliation(s)
- Poornima Balaji
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, NSW 2145, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia
| | - Xingzhou Liulu
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, NSW 2145, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Sonaali Sivakumar
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, NSW 2145, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia
| | - James J H Chong
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, NSW 2145, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia; Centre for Heart Research, The Westmead Institute for Medical Research, Westmead, NSW 2145, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Eddy Kizana
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, NSW 2145, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia; Centre for Heart Research, The Westmead Institute for Medical Research, Westmead, NSW 2145, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Jamie I Vandenberg
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW 2010, Australia
| | - Adam P Hill
- Victor Chang Cardiac Research Institute, Darlinghurst, NSW 2010, Australia
| | - Eric Hau
- Translational Radiation Biology and Oncology Laboratory, Centre for Cancer Research, The Westmead Institute for Medical Research, Westmead, NSW 2145, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia; Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, NSW, Westmead, Australia; Blacktown Hematology and Cancer Centre, Blacktown Hospital, NSW, Blacktown, Australia
| | - Pierre C Qian
- Cardiology Department, Westmead Hospital, University of Sydney, Westmead, NSW 2145, Australia; Westmead Applied Research Centre, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia.
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Haberl C, Crean AM, Zelt JGE, Redpath CJ, deKemp RA. Role of Nuclear Imaging in Cardiac Stereotactic Body Radiotherapy for Ablation of Ventricular Tachycardia. Semin Nucl Med 2024; 54:427-437. [PMID: 38658301 DOI: 10.1053/j.semnuclmed.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 04/26/2024]
Abstract
Ventricular tachycardia (VT) is a life-threatening arrhythmia common in patients with structural heart disease or nonischemic cardiomyopathy. Many VTs originate from regions of fibrotic scar tissue, where delayed electrical signals exit scar and re-enter viable myocardium. Cardiac stereotactic body radiotherapy (SBRT) has emerged as a completely noninvasive alternative to catheter ablation for the treatment of recurrent or refractory ventricular tachycardia. While there is no common consensus on the ideal imaging workflow, therapy planning for cardiac SBRT often combines information from a plurality of imaging modalities including MRI, CT, electroanatomic mapping and nuclear imaging. MRI and CT provide detailed anatomic information, and late enhancement contrast imaging can indicate regions of fibrosis. Electroanatomic maps indicate regions of heterogenous conduction voltage or early activation which are indicative of arrhythmogenic tissue. Some early clinical adopters performing cardiac SBRT report the use of myocardial perfusion and viability nuclear imaging to identify regions of scar. Nuclear imaging of hibernating myocardium, inflammation and sympathetic innervation have been studied for ventricular arrhythmia prognosis and in research relating to catheter ablation of VT but have yet to be studied in their potential applications for cardiac SBRT. The integration of information from these many imaging modalities to identify a target for ablation can be challenging. Multimodality image registration and dedicated therapy planning tools may enable higher target accuracy, accelerate therapy planning workflows and improve patient outcomes. Understanding the pathophysiology of ventricular arrhythmias, and localizing the arrhythmogenic tissues, is vital for successful ablation with cardiac SBRT. Nuclear imaging provides an arsenal of imaging strategies to identify regional scar, hibernation, inflammation, and sympathetic denervation with some advantages over alternative imaging strategies.
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Affiliation(s)
- Connor Haberl
- University of Ottawa Heart Institute, Ottawa, ON; Carleton University, Ottawa, ON
| | - Andrew M Crean
- University of Ottawa Heart Institute, Ottawa, ON; North West Heart Center, University of Manchester Foundation NHS Trust, Manchester, UK
| | - Jason G E Zelt
- The Ottawa Hospital, Ottawa, ON; Department of Medicine, University of Ottawa, Ottawa, ON
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Lee JH. Discrimination between ventricular tachycardia and wide-QRS preexcited tachycardia. Ann Noninvasive Electrocardiol 2024; 29:e13112. [PMID: 38491719 PMCID: PMC10943251 DOI: 10.1111/anec.13112] [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: 11/14/2023] [Revised: 02/05/2024] [Accepted: 02/26/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND To develop a new algorithm to differentiate ventricular tachycardia (VT) from preexcited tachycardia (pre-ET) according to left bundle branch block (LBBB) and right bundle branch block (RBBB) patterns. METHODS This study included 67 electrocardiograms (ECGs) with VT and 63 ECGs with pre-ET, collected from our hospital and through PubMed. Of those, 64 were allocated to the derivation cohort and the rest to the validation cohort. The diagnoses of the ECGs were confirmed using an electrophysiological study. Parameters and classifiers from prior algorithms along with the propagation speeds in the early portion of the QRS complex (initial deflection index) in leads V1, V6, aVR, II, and III were manually measured. The performance of the new algorithm was compared with that of prior algorithms. RESULTS The initial deflection index in lead III was the strongest predictor of pre-ET in LBBB-pattern wide-QRS tachycardia (p = 0.003, AUC 0.805). The initial deflection index in lead V1 was the most powerful predictor of pre-ET in RBBB-pattern wide-QRS tachycardia (p = 0.001, AUC 0.848). Compared to earlier algorithms, those using the initial deflection indexes: lead III in LBBB patterns (cutoff value >0.3) and lead V1 in RBBB patterns (cutoff value ≤0.48), demonstrated superior performance in screening VT, with AUC values of 0.828. The initial deflection indexes proved effective as discriminators between VT and pre-ET in the validation cohort. CONCLUSIONS In LBBB-pattern wide-QRS tachycardia, the early propagation speed of pre-ET was faster than that in VT. Conversely, in RBBB-pattern wide-QRS tachycardia, it was slower.
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Affiliation(s)
- Jae Hoon Lee
- Department of Emergency MedicineDong‐A University College of MedicineBusanSouth Korea
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Rao K, Danaila V, Bennett RG, Turnbull S, Campbell T, Kumar S. Correlation of exit sites of inducible ventricular tachycardia post-ST elevation myocardial infarction on electrophysiology study, with region of infarct. Intern Med J 2023; 53:1570-1580. [PMID: 36053941 DOI: 10.1111/imj.15891] [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: 03/30/2022] [Accepted: 07/18/2022] [Indexed: 09/26/2023]
Abstract
BACKGROUND Ventricular arrhythmia (VA) is the most common cause of sudden cardiac death post-ST elevation myocardial infarction (STEMI). Ventricular tachycardia (VT) may be inducible in electrophysiology studies (EPS) early (<40 days) post-STEMI. Whether it originates from the infarct site remains unknown. We examined the correlation between inducible VT and infarct location post-STEMI. AIMS To investigate the correlation between inducible VT and infarct location post-STEMI. METHODS We retrospectively analysed 46 patients from 2005 to 2017 with STEMI who underwent early programmed ventricular stimulation through EPS (>48 h post-STEMI and <40 days from admission). Gated heart pool scans were used to visualise infarct scar regions, and VT exit sites were derived from induction 12-lead electrocardiography. Patients were followed up for primary outcomes of recurrent VA and all-cause mortality. RESULTS Forty-six patients were included for analysis, with 50 uniquely induced VT exit sites. Mean left ventricular ejection fraction was 30 ± 8.7% and 22% had impaired right ventricular ejection fraction. Mean time from presentation to EPS was 16 ± 31.3 days. Of the induced VT, 44 (88%) were from within scar and scar-border regions, whereas 6 (12%) of the induced VT were found to be remote to imaging-derived scar. Over a median follow-up period of 75 months, 6 (13%) patients died, and 7 (15%) patients had recurrent VA. No deaths occurred in patients with remote VT. CONCLUSION The majority of early inducible post-infarct VT arises from acute myocardial scar; however, a small portion arises from sites remote from scars with a possible focal aetiology.
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Affiliation(s)
- Karan Rao
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Vlad Danaila
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Richard G Bennett
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Samual Turnbull
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Timothy Campbell
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
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Bennett RG, Garikapati K, Campbell TG, Kotake Y, Turnbull S, Bhaskaran A, De Silva K, Kanawati J, Zhou J, Wong MS, Kumar S. Mortality after catheter ablation of structural heart disease related ventricular tachycardia. Int J Cardiol 2023:S0167-5273(23)00728-3. [PMID: 37225093 DOI: 10.1016/j.ijcard.2023.05.035] [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: 03/28/2023] [Revised: 05/02/2023] [Accepted: 05/19/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND There is a paucity of data describing mortality after catheter ablation of ventricular tachycardia (VT). OBJECTIVES We describe the causes and predictors of cardiac transplant and/or mortality following catheter ablation of structural heart disease (SHD) related VT. METHODS Over 10-years, 175 SHD patients underwent VT ablation. Clinical characteristics, and outcomes, were compared between patients undergoing transplant and/or dying and those surviving. RESULTS During 2.8 (IQR 1.9-5.0) years follow-up, 37/175 (21%) patients underwent transplant and/or died following VT ablation. Prior to ablation, these patients were older (70.3 ± 11.1 vs. 62.1 ± 13.9 years, P = 0.001), had lower left ventricular ejection fraction ([LVEF] 30 ± 12% vs. 44 ± 14%, P < 0.001), and were more likely to have failed amiodarone (57% vs. 39%, P = 0.050), compared to those that survived. Predictors of transplant and/or mortality included LVEF≤35% (HR 4.71 [95% CI 2.18-10.18], P < 0.001), age ≥ 65 years (HR 2.18 [95% CI 1.01-4.73], P = 0.047), renal impairment (HR 3.73 [95% CI 1.80-7.74], P < 0.001), amiodarone failure (HR 2.67 [95% CI 1.27-5.63], P = 0.010) and malignancy (HR 3.09 [95% CI 1.03-9.26], P = 0.043). Ventricular arrhythmia free survival at 6-months was lower in the transplant and/or deceased, compared to non-deceased group (62% vs. 78%, P = 0.010), but was not independently associated with transplant and/or mortality. The risk score, MORTALITIES-VA, accurately predicted transplant and/or mortality (AUC: 0.872 [95% CI 0.810-0.934]). CONCLUSIONS Cardiac transplant and/or mortality after VT ablation occurred in 21% of patients. Independent predictors included LVEF≤35%, age ≥ 65 years, renal impairment, malignancy, and amiodarone failure. The MORTALITIES-VA score may identify patients at high-risk of transplant and/or dying after VT ablation.
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Affiliation(s)
- Richard G Bennett
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Australia
| | - Kartheek Garikapati
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Australia
| | - Timothy G Campbell
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Australia
| | - Yasuhito Kotake
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Australia
| | - Samual Turnbull
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Australia
| | - Ashwin Bhaskaran
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Australia
| | - Kasun De Silva
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Australia
| | - Juliana Kanawati
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Australia
| | - Julia Zhou
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Australia
| | - Mary S Wong
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Australia.
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Hawson J, Joshi S, Al-Kaisey A, Das SK, Anderson RD, Morton J, Kumar S, Kistler P, Kalman J, Lee G. Utility of cardiac imaging in patients with ventricular tachycardia. Indian Pacing Electrophysiol J 2023; 23:63-76. [PMID: 36958589 PMCID: PMC10160788 DOI: 10.1016/j.ipej.2023.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 02/09/2023] [Accepted: 03/13/2023] [Indexed: 03/25/2023] Open
Abstract
Ventricular tachycardia (VT) is a life-threatening arrhythmia that may be idiopathic or result from structural heart disease. Cardiac imaging is critical in the diagnostic workup and risk stratification of patients with VT. Data gained from cardiac imaging provides information on likely mechanisms and sites of origin, as well as risk of intervention. Pre-procedural imaging can be used to plan access route(s) and identify patients where post-procedural intensive care may be required. Integration of cardiac imaging into electroanatomical mapping systems during catheter ablation procedures can facilitate the optimal approach, reduce radiation dose, and may improve clinical outcomes. Intraprocedural imaging helps guide catheter position, target substrate, and identify complications early. This review summarises the contemporary imaging modalities used in patients with VT, and their uses both pre-procedurally and intra-procedurally.
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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
| | - Subodh Joshi
- Department of Cardiology, Royal Melbourne Hospital, 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
| | - Souvik K Das
- Department of Cardiology, Royal Melbourne Hospital, 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
| | - 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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Kotake Y, Bennett R, Silva KD, Bhaskaran A, Kanawati J, Turnbull S, Zhou J, Kumar S, Campbell T. Correlation of spatial patterns of endocardial pace mapping to underlying scar topography in patients with scar-related ventricular tachycardia. J Cardiovasc Electrophysiol 2023; 34:638-649. [PMID: 36640432 DOI: 10.1111/jce.15811] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 12/16/2022] [Accepted: 12/29/2022] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Endocardial pace mapping (PM) can identify conducting channels for ventricular tachycardia (VT) circuits in patients with structural heart disease (SHD). Recent findings show the temporal and spatial pattern of PM may aid identification of the surface harboring VT isthmii. The specific correlation of PM patterns to scar topography has not been examined. OBJECTIVE To correlate the pattern of endocardial PMs to underlying scar topography in SHD patients with VT. METHODS Data from patients undergoing VT ablation from August 2018 to February 2022 were reviewed. RESULTS Sixty-three patients with SHD-related VT (mean age 65 ± 14 years) with 83 endocardial PM correlation maps were analysed. Two main correlation patterns were identified, an "abrupt-change correlation pattern (AC-pattern)" and "centrifugal-attenuation correlation pattern (CA-pattern)." AC-pattern had lower scar ratio (unipolar/bipolar % scar area; 1.1 vs. 1.5, p < .001), had longer maximal stimulus-QRS intervals (97.5 vs. 68 ms, p = .002), and higher likelihood of endocardial dominant scar (11/21 [52%] vs. 3/38 [8%], p < .001) than CA-pattern seen on intracardiac echocardiography (ICE). In contrast, CA-pattern was more likely to have epicardial dominant scar or mid-intramural scar on ICE (epicardial dominant scar; CA-pattern: 12/38 [32%] vs. AC-pattern: 1/21 [5%], p = .02, mid-intramural scar; CA-pattern: 15/38 [39%] vs. AC-pattern: 1/21 [5%], p = .005). CONCLUSIONS The spatial pattern of endocardial PM in SHD-related VT directly correlates with scar topography. AC-pattern is associated with endocardial dominant scar on ICE with lower scar ratio and longer stimulus-QRS intervals, whereas CA-pattern is strongly associated with epicardial dominant or mid-intramural scar with higher scar ratio and shorter stimulus-QRS intervals.
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Affiliation(s)
- Yasuhito Kotake
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Cardiology, Westmead Applied Research Center, University of Sydney, New South Wales, Sydney, Australia
| | - Richard Bennett
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Cardiology, Westmead Applied Research Center, University of Sydney, New South Wales, Sydney, Australia
| | - Kasun De Silva
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Cardiology, Westmead Applied Research Center, University of Sydney, New South Wales, Sydney, Australia
| | - Ashwin Bhaskaran
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Cardiology, Westmead Applied Research Center, University of Sydney, New South Wales, Sydney, Australia
| | - Juliana Kanawati
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Cardiology, Westmead Applied Research Center, University of Sydney, New South Wales, Sydney, Australia
| | - Samual Turnbull
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Cardiology, Westmead Applied Research Center, University of Sydney, New South Wales, Sydney, Australia
| | - Julia Zhou
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Cardiology, Westmead Applied Research Center, University of Sydney, New South Wales, Sydney, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Cardiology, Westmead Applied Research Center, University of Sydney, New South Wales, Sydney, Australia
| | - Timothy Campbell
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia.,Department of Cardiology, Westmead Applied Research Center, University of Sydney, New South Wales, Sydney, Australia
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Advanced ventricular arrhythmia ablation: step-by-step problem-solving. J Interv Card Electrophysiol 2023; 66:75-77. [PMID: 36645576 DOI: 10.1007/s10840-022-01467-8] [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: 01/17/2023]
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Impact of sex on clinical, procedural characteristics and outcomes of catheter ablation for ventricular arrhythmias according to underlying heart disease. JOURNAL OF INTERVENTIONAL CARDIAC ELECTROPHYSIOLOGY : AN INTERNATIONAL JOURNAL OF ARRHYTHMIAS AND PACING 2023; 66:203-213. [PMID: 35353320 DOI: 10.1007/s10840-022-01188-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 03/20/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Women are under-represented in many key studies and trials examining outcomes of catheter ablation (CA) for ventricular arrhythmias (VA). We compared characteristics between men and women undergoing their first catheter ablation for VA at a single centre over 10 years. METHODS The clinical, procedural characteristics and outcomes of 287 consecutive patients (male = 182, female = 105), undergoing their first CA at our centre over 10 years were compared according to sex and underlying heart disease. RESULTS In the ablation population, women were younger, had fewer co-morbidities, were less likely to have ischemic cardiomyopathy (ICM) and VA storm and were more likely to have idiopathic VA and premature ventricular complexes as the indication for ablation (P < 0.05 for all). Amongst idiopathic and non-ischemic cardiomyopathy (NICM) subgroups, baseline characteristics were similar; amongst ICM, women were younger and had higher numbers of drug failure pre-ablation (P = 0.05). Women were similar to men in all procedural characteristics, acute procedural success and complications, regardless of underlying heart disease. At median follow-up of 666 days, VA-free survival, overall mortality and survival free of death or transplant were comparable in both groups. Sex was not a predictor of these outcomes, after accounting for clinical and procedural characteristics. CONCLUSION Women represented 36% of the real-world population at our centre referred for CA of VA. There are key differences in clinical features of women versus men referred for VA ablation. Despite these differences, VA ablation in women can be accomplished with similar success and complication rates to men, regardless of underlying heart disease.
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Kotake Y, Nalliah CJ, Campbell T, Bennett RG, Turnbull S, Kumar S. Comparison of the arrhythmogenic substrate for ventricular tachycardia in patients with ischemic vs non-ischemic cardiomyopathy - insights from high-density, multi-electrode catheter mapping. JOURNAL OF INTERVENTIONAL CARDIAC ELECTROPHYSIOLOGY : AN INTERNATIONAL JOURNAL OF ARRHYTHMIAS AND PACING 2023; 66:5-14. [PMID: 34787768 DOI: 10.1007/s10840-021-01088-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 11/04/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to compare the differences of arrhythmogenic substrate using high-density mapping in ventricular tachycardia (VT) patients with ischemic (ICM) vs non-ischemic cardiomyopathy (NICM). METHODS Data from patients presenting for VT ablation from December 2016 to December 2020 at Westmead Hospital were reviewed. RESULTS Sixty consecutive patients with structural heart disease (ICM 57%, NICM 43%, mean age 66 years) having catheter ablation of scar-related VT with pre-dominant left ventricular involvement were included. ICM was associated with larger proportion of dense scar area (bipolar; 19 [12-29]% vs 6 [3-10]%, P < 0.001, unipolar; 20 [12-32]% vs 11 [7-19]%, P = 0.01) compared with NICM. However, the scar ratio (unipolar dense scar [%]/bipolar dense scar [%]) was significantly higher in NICM patients (1.2 [0.8-1.7] vs 1.7 [1.3-2.3], P = 0.003). Larger scar area in ICM was paralleled by higher proportion of complex electrograms (6 [2-13] % vs 3 [1-5] %, P = 0.01), longer and wider voltage based conducting channels, higher incidence of late potential-based conducting channels, longer VT cycle-length (399 ± 80 ms vs 359 ± 68 ms, P = 0.04) and greater maximal stimulation-QRS interval among sites with good pace-map correlation (75 [51-99]ms vs 48 [31-73]ms, P = 0.02). Ventricular arrhythmia (VA) storm was more highly prevalent in ICM than NICM (50% vs 23%, P = 0.03). During the follow-up period, NICM had a significantly higher cumulative incidence for the VA recurrence than ICM (P = 0.03). CONCLUSIONS High-density multi-electrode catheter mapping of left ventricular arrhythmogenic substrate of NICM tends to show smaller dense scar area and higher scar ratio, compared with ICM, suggestive the extent of epicardial/intramural substrate, with paucity of substrate targets for ablation, which results in the worse outcomes with ablation.
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Affiliation(s)
- Yasuhito Kotake
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Hawkesbury Road, Westmead, NSW, 2145, Australia
| | - Chrishan J Nalliah
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Hawkesbury Road, Westmead, NSW, 2145, Australia
| | - Timothy Campbell
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Hawkesbury Road, Westmead, NSW, 2145, Australia
| | - Richard G Bennett
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Hawkesbury Road, Westmead, NSW, 2145, Australia
| | - Samual Turnbull
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Hawkesbury Road, Westmead, NSW, 2145, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Hawkesbury Road, Westmead, NSW, 2145, Australia.
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Cetin M, Ornek E, Bastug S, Kara M, Deveci B, Korkmaz A, Ozeke O, Cay S, Ozcan F, Topaloglu S, Aras D. An Incessant Tachycardia with Alternating QRS Complexes: What Is the Mechanism? J Innov Card Rhythm Manag 2022; 13:4900-4904. [PMID: 35251760 PMCID: PMC8887927 DOI: 10.19102/icrm.2022.130203] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 08/02/2021] [Indexed: 11/15/2022] Open
Abstract
We present a patient with ischemic cardiomyopathy who had ventricular tachycardia (VT) with QRS morphology alternans. The electrophysiological findings, in this case, supported the occurrence of antegrade activation of the proximal His–Purkinje system during VT, with the ultimate electrocardiogram morphology dependent on fusion from intramyocardial and His–Purkinje activations.
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Affiliation(s)
- Mustafa Cetin
- Department of Cardiology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Ender Ornek
- Department of Cardiology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Serdal Bastug
- Department of Cardiology, Ankara Yıldırım Beyazıt University School of Medicine, Ankara City Hospital, Ankara, Turkey
| | - Meryem Kara
- Department of Cardiology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Bulent Deveci
- Department of Cardiology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Ahmet Korkmaz
- Department of Cardiology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Ozcan Ozeke
- Department of Cardiology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Serkan Cay
- Department of Cardiology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Firat Ozcan
- Department of Cardiology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Serkan Topaloglu
- Department of Cardiology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
| | - Dursun Aras
- Department of Cardiology, Health Sciences University, Ankara City Hospital, Ankara, Turkey
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Bennett RG, Garikapati K, Anderson RD, Silva KD, Campbell T, Kotake Y, Turnbull S, Tonchev I, Lee G, Kalman J, Kumar S. Clinical, Electroanatomic and Electrophysiologic Characterisation and Outcomes of Catheter Ablation for Ventricular Tachycardia Following Valvular Intervention. J Cardiovasc Electrophysiol 2022; 33:589-604. [PMID: 35107192 DOI: 10.1111/jce.15388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 10/28/2021] [Accepted: 11/18/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Ventricular tachycardia (VT) can occur following valvular interventions. There are limited data describing substrate and ablation approaches in such patients. We sought to describe the clinical, electrophysiologic, electroanatomic features and catheter ablation outcomes of patients with VT following aortic and/or mitral valve intervention. METHODS Over 12-years, consecutive patients with aortic valve replacement (AVR) and/or mitral valve replacement (MVR) or repair, undergoing VT ablation, were identified from 2 centres. Clinical and procedural parameters, and outcomes are described. RESULTS Twenty-three patients (age 66±14years, 78% male, left ventricular ejection fraction 37±16%), with prior AVR (mechanical n=6, bioprosthetic n=2, transcatheter n=1), MVR (mechanical n=5, bioprosthetic n=1), mitral valve repair (n=6) and both mechanical AVR and MVR (n=2), underwent VT ablation. Sixteen had concurrent ischemic cardiomyopathy, 10 with prior bypass surgery. Left ventricular access was obtained in 21/23 (91%) patients (transseptal n=14, retrograde aortic n=5, transapical n=2), with perivalvular scar identified in 17/21 (81%). Re-entrant VT isthmi involved the perivalvular regions in 12/23 (52%) patients, and regions remote from the valve in the remainder; 9% had non-scar related VT. Intramural substrate was ablated from adjacent chambers in 5/23 (22%) patients and with half-normal saline irrigation in 8/23 (35%) patients. There were no instances of catheter entrapment. Following final ablation, VA-free survival was 78% at 13-months. CONCLUSION Only half of VT circuits following valvular interventions involve the valve regions themselves, whilst the remainder involve unrelated regions. Catheter ablation is safe and efficacious at treating VT following valvular intervention, but novel strategies may be required. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Richard G Bennett
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Australia
| | - Kartheek Garikapati
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Australia
| | - Robert D Anderson
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | | | - Timothy Campbell
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Australia
| | - Yasuhito Kotake
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Australia
| | - Samual Turnbull
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Australia
| | - Ivaylo Tonchev
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Jonathan Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Westmead Applied Research Centre, University of Sydney, Australia
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13
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Trivedi SJ, Campbell T, Davey CJ, Stefani L, Thomas L, Kumar S. Longitudinal strain with speckle tracking echocardiography predicts electroanatomic substrate for ventricular tachycardia in non-ischemic cardiomyopathy patients. Heart Rhythm O2 2022; 3:176-185. [PMID: 35496460 PMCID: PMC9043373 DOI: 10.1016/j.hroo.2022.02.002] [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] [Indexed: 11/30/2022] Open
Abstract
Background Longitudinal strain (LS) derived from speckle-tracking echocardiography (STE) corresponds to regions of scar in ischemic cardiomyopathy. Objective We investigated if regional LS abnormalities correlate with scar location and scar burden, identified using high-density electroanatomic mapping (EAM) in nonischemic cardiomyopathy (NICM). Methods Fifty NICM patients with ventricular tachycardia (VT) underwent echocardiography; multilayer (endocardial, midmyocardial, and epicardial) regional LS and global LS (GLS) were evaluated prior to EAM for detection of low-voltage scar. Patients were divided into 3 groups by EAM left ventricular scar location: (1) anteroseptal (group 1, n = 20); (2) inferolateral (group 2, n = 20); and (3) epicardial scar (group 3; n = 10). We correlated (1) location of scar to regional LS and (2) regional strain and GLS to scar percentage. Results Regional LS abnormalities correlated with EAM scar in all groups. Segmental impaired LS and low voltage on EAM demonstrated concordance with scar in ∼75% or its border zone in 25% of segments. In groups 1 and 2, endocardial GLS showed a strong linear correlation with endocardial bipolar scar percentage (r = 0.79, 0.75 for groups 1 and 2, respectively; P < .001), whereas midmyocardial GLS correlated with unipolar scar percentage (r = 0.82, 0.78 for groups 1 and 2, respectively; P < .001). In group 3, epicardial regional LS and GLS correlated with epicardial bipolar scar percentage (r = 0.72, P < .001). Conclusion Regional abnormalities on LS predict scar location on EAM mapping in patients with NICM. Moreover, global and regional LS correlate with scar percentage. STE could be used as a noninvasive tool for localizing and quantifying scar prior to EAM.
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Bennett RG, Campbell T, Sood A, Bhaskaran A, De Silva K, Davis L, Qian P, Sivagangabalan G, Cooper MJ, Chow CK, Thiagalingam A, Denniss AR, Thomas SP, Kizana E, Kumar S. Remote magnetic navigation compared to contemporary manual techniques for the catheter ablation of ventricular arrhythmias in structural heart disease. Heliyon 2021; 7:e08538. [PMID: 34917813 PMCID: PMC8666643 DOI: 10.1016/j.heliyon.2021.e08538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/29/2021] [Accepted: 11/30/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND There are limited data comparing remote magnetic navigation (RMN) to contemporary techniques of manual-guided ventricular arrhythmia (VA) catheter ablation. OBJECTIVES We compared acute and long-term outcomes of VA ablation guided by either RMN or contemporary manual techniques in patients with structural heart disease. METHODS From 2010-2019, 192 consecutive patients, with ischemic cardiomyopathy (ICM) or non-ischemic cardiomyopathy (NICM) underwent catheter ablation for sustained ventricular tachycardia (VT) or premature ventricular complexes (PVCs), using either RMN (n = 60) or manual (n = 132) guided techniques. Acute success and VA-free survival were compared. RESULTS In ICM, acute procedural success was comparable between the 2 techniques (manual 43.5% vs. RMN 29%, P = 0.11), as was VA-free survival (manual 83% vs. RMN 74%, P = 0.88), and survival free from cardiac transplantation and all-cause mortality (manual 88% vs. RMN 87%, P = 0.47), both at 12-months after final ablation. In NICM, manual compared to RMN guided, had superior acute procedural success (manual 46% vs. RMN 19%, P = 0.003) and VA-free survival 12-months after final ablation (manual 79% vs. RMN 41%, P = 0.004), but comparable survival free from cardiac transplantation and all-cause mortality 12-months after final ablation (manual 95% vs. RMN 90%, P = 0.52). Procedural duration was shorter in both subgroups undergoing manual guided ablation, whereas fluoroscopy dose and complication rates were comparable. CONCLUSION RMN provides similar outcomes to manual ablation in patients with ICM. In NICM however, acute success, and long-term VA-free survival was better with manual ablation. Prospective, multi-centre randomised trials comparing contemporary manual and RMN systems for VA catheter ablation are needed.
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Affiliation(s)
- Richard G. Bennett
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Timothy Campbell
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Ashish Sood
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | | | - Kasun De Silva
- Department of Cardiology, Westmead Hospital, Sydney, Australia
| | - Lloyd Davis
- Department of Cardiology, Westmead Hospital, Sydney, Australia
| | - Pierre Qian
- Department of Cardiology, Westmead Hospital, Sydney, Australia
| | | | - Mark J. Cooper
- Department of Cardiology, Westmead Hospital, Sydney, Australia
| | - Clara K. Chow
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | | | | | - Stuart P. Thomas
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Eddy Kizana
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- Westmead Institute of Medical Research, Westmead, Sydney, New South Wales, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Sydney, Australia
- Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
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Abstract
Conduction disorders and arrhythmias remain difficult to treat and are increasingly prevalent owing to the increasing age and body mass of the general population, because both are risk factors for arrhythmia. Many of the underlying conditions that give rise to arrhythmia - including atrial fibrillation and ventricular arrhythmia, which frequently occur in patients with acute myocardial ischaemia or heart failure - can have an inflammatory component. In the past, inflammation was viewed mostly as an epiphenomenon associated with arrhythmia; however, the recently discovered inflammatory and non-canonical functions of cardiac immune cells indicate that leukocytes can be arrhythmogenic either by altering tissue composition or by interacting with cardiomyocytes; for example, by changing their phenotype or perhaps even by directly interfering with conduction. In this Review, we discuss the electrophysiological properties of leukocytes and how these cells relate to conduction in the heart. Given the thematic parallels, we also summarize the interactions between immune cells and neural systems that influence information transfer, extrapolating findings from the field of neuroscience to the heart and defining common themes. We aim to bridge the knowledge gap between electrophysiology and immunology, to promote conceptual connections between these two fields and to explore promising opportunities for future research.
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Bennett R, Turnbull S, Kotake Y, Campbell T, Kumar S. Ventricular Arrhythmia Burden as a Marker of Success Following Catheter Ablation of Ventricular Arrhythmias in Patients with Structural Heart Disease. Korean Circ J 2021; 51:455-468. [PMID: 33764012 PMCID: PMC8112175 DOI: 10.4070/kcj.2020.0415] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 12/09/2020] [Accepted: 01/12/2021] [Indexed: 01/19/2023] Open
Abstract
Background and Objectives There is little emphasis on the efficacy of catheter ablation for ventricular arrhythmia (VA) when using VA burden reduction as a marker for success. We examined the efficacy of catheter ablation using VA burden, rather than VA recurrence as a marker of success, following catheter ablation of structural heart disease (SHD) related VA. Methods Catheter ablation of SHD related VA was performed at a single centre over 4-years. VA episodes and implantable cardioverter defibrillator (ICD) therapies were recorded over the 6-months before and after final ablation. Outcomes were reported in terms of burden reduction and compared to singular VA recurrence. Results Overall, 108 patients were included in the study. Mean age 64.2±13.9 years, 86% male, mean left ventricular ejection fraction (LVEF) 42±16%. Median VA episodes and ICD therapy were significantly reduced after ablation (VA before: 10 [interquartile range, IQR: 2–38] vs. VA after: 0 [IQR: 0–2], p<0.001; anti–tachycardia pacing [ATP] before: 16 (IQR: 1.5–57) vs. ATP after: 0 [IQR: 0–2], p<0.001; shocks before: 1 [IQR: 0–5] vs. shocks after: 0 [IQR: 0–0], p<0.001). Procedural success at 6-months was significantly higher when considering ≥75% reduction in VA burden, rather than a singular VA-free survival (83% vs. 67%, p=0.001). Conclusions The vast majority (>80%) of patients achieve reduction in VA burden (≥75% reduction) after catheter ablation for VA. This data suggests that catheter ablation is highly therapeutic when procedure success is defined as reduction in VA, rather than using a single VA recurrence as a metric for failure.
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Affiliation(s)
- Richard Bennett
- Department of Cardiology, Westmead Hospital, The University of Sydney, Westmead, Australia
| | - Samual Turnbull
- Department of Cardiology, Westmead Hospital, The University of Sydney, Westmead, Australia
| | - Yasuhito Kotake
- Department of Cardiology, Westmead Hospital, The University of Sydney, Westmead, Australia
| | - Timothy Campbell
- Department of Cardiology, Westmead Hospital, The University of Sydney, Westmead, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, The University of Sydney, Westmead, Australia.
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17
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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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18
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Campbell T, Bennett RG, Garikapati K, Turnbull S, Bhaskaran A, De Silva K, Kumar S. Prognostic significance of extensive versus limited induction protocol during catheter ablation of scar-related ventricular tachycardia. J Cardiovasc Electrophysiol 2020; 31:2909-2919. [PMID: 32905634 DOI: 10.1111/jce.14740] [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: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Testing for inducible ventricular tachycardia (VT) pre- and postablation forms the cornerstone of contemporary scar-related VT ablation procedures. There is significant heterogeneity in reported VT induction protocols. We examined the utility of an extensive induction protocol (up to 4 extra-stimuli [ES] ± burst ventricular pacing) compared to the current guideline-recommended protocol (up to 3ES, defined as limited induction protocol) in patients with scar-related VT. METHODS AND RESULTS Sixty-two patients (age: 64 ± 14 years; left ventricular ejection fraction: 37 ± 13%, ischemic cardiomyopathy: 31, nonischemic cardiomyopathy: 31) with at least one inducible VT were included. An extensive testing protocol induced 11%-17% more VTs, compared to the limited induction protocol before, and after the final ablation. VT recurred in 48% of patients during a mean follow up of 566 ± 428 days. Patients who were noninducible for any VT using the limited induction protocol had worse ventricular arrhythmia (VA)-free survival (12 months, 43% vs. 82%; p = .03) and worse survival free of VA, transplantation and mortality (12 months 46% vs. 82%; p = .02), compared to patients who were noninducible for any VT using the extensive induction protocol. CONCLUSIONS Between 11% and 17% of inducible VTs may be missed if 4ES and burst pacing are not performed in induction protocols before and after ablation. Noninducibility for any VT after an extensive induction protocol after the final ablation portends more favorable prognostic outcomes when compared with the current guideline-recommended induction protocol of up to 3ES. This data suggests that the adoption of an extensive induction protocol is of prognostic benefit after VT ablation.
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Affiliation(s)
- Timothy Campbell
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Richard G Bennett
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | | | - Samual Turnbull
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | | | - Kasun De Silva
- Department of Cardiology, Westmead Hospital, Sydney, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Sydney, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
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Chatterjee NA, Tikkanen JT, Albert CM. The electrocardiogram and sudden death: capturing electrical physiology and arrhythmic substrate. Eur Heart J 2020; 41:2911-2912. [PMID: 32609368 DOI: 10.1093/eurheartj/ehaa472] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Neal A Chatterjee
- Division of Cardiology, Department of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195, USA.,Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jani T Tikkanen
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Medicine, Research Unit of Internal Medicine, University Hospital of Oulu and University of Oulu, Oulu, Finland
| | - Christine M Albert
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Cardiology, Smidt Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA
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