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Kwaśniewski W, Filipecki A, Orszulak M, Orszulak W, Urbańczyk D, Roczniok R, Trusz-Gluza M, Mizia-Stec K. Risk factors and prognostic role of an electrical storm in patients after myocardial infarction with an implanted ICD for secondary prevention. Arch Med Sci 2018; 14:500-509. [PMID: 29765434 PMCID: PMC5949907 DOI: 10.5114/aoms.2016.59702] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 03/26/2016] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION The aim of our study was to determine the risk factors for electrical storm (ES) and to assess the impact of ES on the long-term prognosis in patients after myocardial infarction (MI) with an implantable cardioverter-defibrillator (ICD) for secondary prevention of sudden cardiac death (SCD). MATERIAL AND METHODS We retrospectively analyzed 416 patients with coronary artery disease after MI who had an implanted ICD for secondary prevention of SCD. Fifty (12%) patients had one or more incidents of an electrical storm - the ES (+) group. We matched the reference group of 47 patients from 366 ES (-) patients. RESULTS We analyzed 3,408 episodes of ventricular arrhythmias: 3,148 ventricular tachyarrhythmic episodes in the ES (+) group (including 187 episodes of ES) and 260 in the ES (-) group. Multivariate logistic regression showed that inferior wall MI (RR = 3.98, 95% CI: 1.52-10.41) and the absence of coronary revascularization (RR = 2.92, 95% CI: 1.18-7.21) were independent predictors of ES (p = 0.0014). During 6-year observation of 97 patients, there were 39 (40%) deaths: 25 (50%) subjects in the ES (+) group and 14 (30%) in the ES (-) group (p = 0.036). Independent predictors of death were: the occurrence of ES (HR = 1.93), older age (HR = 1.06), and lower left ventricular ejection fraction (HR = 0.95) (for all p < 0.001). CONCLUSIONS Electrical storm in patients after MI with ICD for secondary prevention is a relatively common phenomenon and has a negative prognostic significance. Myocardial infarction of the inferior wall and the absence of coronary revascularization are predisposing factors for the occurrence of an ES.
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Affiliation(s)
| | - Artur Filipecki
- First Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Michał Orszulak
- First Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Witold Orszulak
- First Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Dagmara Urbańczyk
- First Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Robert Roczniok
- Department of Statistics and Methodology, Jerzy Kukuczka Academy of Physical Education, Katowice, Poland
| | - Maria Trusz-Gluza
- First Department of Cardiology, Medical University of Silesia, Katowice, Poland
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Lin CH, Lo LW, Lin YJ, Chang SL, Hu YF, Tuan TC, Huang HK, Chiang CH, Allamsetty S, Liao JN, Chung FP, Chang YT, Lin CY, Te ALD, Yamada S, Walia R, Hung Y, Chen SA. Ventricular arrhythmias originating from the cardiac crux and the basal inferior segment of the interventricular septum in the patients with structural heart diseases: characteristics, mapping, and electrophysiological properties. J Interv Card Electrophysiol 2018; 52:225-236. [PMID: 29572717 DOI: 10.1007/s10840-018-0350-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 03/01/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE There are few reports describing ventricular arrhythmias (VAs) from the crux and the corresponding endocardial site, i.e., the basal inferior segment of the interventricular septum (IVS). We aimed to investigate a distinct clinical group of VAs arising from the endocardium at this area in patients with structural heart diseases (SHD). METHODS We included 17 patients with SHD and clinically documented VAs. Thirteen patients underwent endocardial mapping only. Three patients underwent both epicardial and endocardial approaches and one had only epicardial mapping. Eighteen VAs were identified, 14 focal and 4 reentrant VAs, confirmed by entrainment. RESULTS There were 2 VAs from the crux, 5 VAs from the corresponding endocardial site in the right ventricle (RV), and 11 from the site in the left ventricle (LV). Compared with the VAs from RV endocardium, VAs from LV endocardium had a higher R wave in V3 than V2 (V2R/V3R ratio, 1.83 ± 0.84 vs. 0.86 ± 0.38, P = 0.008) and a higher V3 transition ratio percentage (2.16 ± 2.07 vs. 0.58 ± 0.62, P = 0.008). Combining all 16 patients with endocardial mapping, there were also lower bipolar voltages (1.21 ± 1.05 vs. 3.10 ± 2.65 mv, P < 0.0001), lower unipolar voltages (4.05 ± 1.92 vs. 5.75 ± 2.90 mv, P < 0.0001), and longer local electrocardiogram (EGM) lateness (157.6 ± 47.9 vs.140.3 ± 52.5 ms, P = 0.0001) in the dominant chambers. CONCLUSIONS In VAs from the crux and the corresponding endocardial site, the complete ECG V2R/V3R ratio and V3 transition ratio percentage could differentiate the VAs from the RV or LV endocardium. The lower unipolar, bipolar voltage mapping, and longer EGM lateness are helpful to identify the abnormal substrate in the endocardium in these patients.
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Affiliation(s)
- Chung-Hsing Lin
- Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Medical University, Shuang Ho Hospital, Taipei, Taiwan
| | - Li-Wei Lo
- Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Lin Chang
- Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Feng Hu
- Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Ta-Chuan Tuan
- Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Hung-Kai Huang
- Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Cheng-Hung Chiang
- Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan.,Division of Cardiology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Suresh Allamsetty
- Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan.,Apollo Hospital, Visakhapatnam, Andhra Pradesh, India
| | - Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Fa-Po Chung
- Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Yao-Ting Chang
- Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Chin-Yu Lin
- Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan.,Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan
| | - Abigail Louise D Te
- Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shinya Yamada
- Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Rohit Walia
- Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan.,Bhagat Phool Singh Government Medical College, Sonipat, Haryana, India
| | - Yuan Hung
- Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan.,Division of Cardiology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Heart Rhythm Center, Taipei Veterans General Hospital, Taipei, Taiwan. .,Faculty of Medicine, Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan.
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Yoshida N, Yamada T. Successful percutaneous epicardial catheter ablation of ventricular tachycardia arising from the crux of the heart in a patient with prior coronary artery bypass grafting. J Arrhythm 2017; 33:66-68. [PMID: 28217232 PMCID: PMC5300846 DOI: 10.1016/j.joa.2016.04.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 04/16/2016] [Accepted: 04/21/2016] [Indexed: 11/29/2022] Open
Abstract
A 63-year-old man with a history of remote inferior myocardial infarction and coronary artery bypass grafting (CABG) underwent catheter ablation of ventricular tachycardia (VT). Epicardial catheter ablation of the VT was successful at the crux of the heart despite limited mapping within the pericardial space due to pericardial adhesion. Percutaneous subxiphoidal pericardial approach is usually impossible in patients with a history of open heart surgery due to pericardial adhesions. This report suggested that epicardial VT arising from the crux of the heart could be successfully treated by catheter ablation via subxiphoidal pericardial approach despite pericardial adhesions complicated by prior CABG.
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Affiliation(s)
- Naoki Yoshida
- Division of Cardiovascular Disease, University of Alabama at Birmingham, FOT 930A, 510 20th Street South, 1530 3rd AVE S, Birmingham, AL 35294-0019, USA
| | - Takumi Yamada
- Division of Cardiovascular Disease, University of Alabama at Birmingham, FOT 930A, 510 20th Street South, 1530 3rd AVE S, Birmingham, AL 35294-0019, USA
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Kawamura M, Gerstenfeld EP, Vedantham V, Rodrigues DM, Burkhardt JD, Kobayashi Y, Hsia HH, Marcus GM, Marchlinski FE, Scheinman MM, Badhwar N. Idiopathic Ventricular Arrhythmia Originating From the Cardiac Crux or Inferior Septum. Circ Arrhythm Electrophysiol 2014; 7:1152-8. [DOI: 10.1161/circep.114.001704] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Idiopathic ventricular arrhythmia (VA) can arise from the epicardium near the posteroseptal region (cardiac crux). There are only 2 prior reports describing idiopathic VA from the cardiac crux. The purpose of this study was to characterize the clinical and the electrocardiographic features of idiopathic crux VA.
Methods and Results—
Crux VA was identified in 18 patients undergoing catheter ablation. We divided patients into 2 groups, those with VA originating from the apical crux (n=9) and the basal crux (n=9). We described the clinical and electrocardiographic characteristics of crux VA as well as the ablation results. Furthermore, we compared clinical features of crux VA with other sites of idiopathic VA. Fifteen crux VA patients (83%) had sustained ventricular tachycardia and 3 patients required implantable cardioverter defibrillator implantation because of syncope. All patients had a left superior axis and 16 patients had R>S wave in V2. In apical crux VA, all patients had a deep S wave in V6 and 8 patients (89%) had R>S wave in aVR. All apical crux patients underwent attempted ablation in the middle cardiac vein without success. In 4 of these patients, epicardial ablation with subxiphoid approach was performed successfully. All basal crux VA patients had either negative or isoelectric pattern in V1 and had R>S in V6. Patients had successful ablation within the middle cardiac vein.
Conclusions—
Apical versus basal crux VA is identified as a new category of idiopathic VA with distinctive electrocardiographic characteristics; ablation via the middle cardiac vein is effective for eliminating basal crux VA, whereas apical crux VA often requires a subxiphoid epicardial approach.
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Affiliation(s)
- Mitsuharu Kawamura
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
| | - Edward P. Gerstenfeld
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
| | - Vasanth Vedantham
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
| | - Derek M. Rodrigues
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
| | - J. David Burkhardt
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
| | - Youichi Kobayashi
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
| | - Henry H. Hsia
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
| | - Gregory M. Marcus
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
| | - Francis E. Marchlinski
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
| | - Melvin M. Scheinman
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
| | - Nitish Badhwar
- From the Division of Cardiac Electrophysiology, University of California, San Francisco (M.K., E.P.G., V.V., H.H.H., G.M.M., M.M.S., N.B.); Overlake Medical Center, Bellevue, WA (D.M.R.); Texas Cardiac Arrhythmia Institute, Austin (J.D.B.); Division of Cardiology, Showa University School of Medicine, Tokyo, Japan (Y.K.); and Cardiovascular Division, University of Pennsylvania, Philadelphia (F.E.M.)
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Fernandez-Armenta J, Berruezo A. How to recognize epicardial origin of ventricular tachycardias? Curr Cardiol Rev 2014; 10:246-56. [PMID: 24827797 PMCID: PMC4040876 DOI: 10.2174/1573403x10666140514103047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 06/10/2013] [Accepted: 01/28/2014] [Indexed: 01/18/2023] Open
Abstract
Percutaneous pericardial access for epicardial mapping and ablation of ventricular arrhythmias has expanded considerably in recent years. After its description in patients with Chagas disease, the technique has provided relevant in-formation on the arrhythmia substrate in other cardiomyopathies and has improved the results of ablation procedures in various clinical settings. Electrocardiographic criteria proposed for the recognition of the epicardial origin of ventricular tachycardias are mainly based on analysis of the first QRS components. Ventricular activation at the epicardium has a slow initial component reflecting the transmural activation and influenced by the absence of Purkinje system in the epicardium. Various parameters (pseudodelta wave, intrinsicoid deflection and shortest RS interval) of these initial intervals predict an epicardial origin in patients with scar-related ventricular tachycardias with right bundle branch block morphology. Using the same concept, the maximum deflection index was defined for the location of idiopathic epicardial tachycardias remote from the aortic root. Electrocardiogram criteria based on the morphology of the first component of the QRS (q wave in lead I) have been proposed in patients with nonischemic cardiomyopathy. All these criteria seem to be substrate-specific and have several limitations. Other information, including type of underlying heart disease, previous failed endocardial ablation, and evidence of epicardial scar on magnetic resonance imaging, can help to plan the ablation procedure and decide on an epicardial approach.
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Affiliation(s)
| | - Antonio Berruezo
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clinic, C/ Villarroel 170, 08036 Barcelona, Spain.
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Takaoka H, Funabashi N, Daimon M, Nakamura K, Uehara M, Kobayashi Y. Progressive massive and linear fat replacement on computed-tomography and inflammation on positron emission tomography observed in a young male with interventricular septum-originated critical ventricular tachycardia. Int J Cardiol 2013; 166:e25-7. [DOI: 10.1016/j.ijcard.2013.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 01/13/2013] [Indexed: 10/27/2022]
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PARK KYOUNGMIN, KIM YOUHO, MARCHLINSKI FRANCISE. Using the Surface Electrocardiogram to Localize the Origin of Idiopathic Ventricular Tachycardia. Pacing Clin Electrophysiol 2012; 35:1516-27. [DOI: 10.1111/j.1540-8159.2012.03488.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Doppalapudi H, Yamada T, Ramaswamy K, Ahn J, Kay GN. Idiopathic focal epicardial ventricular tachycardia originating from the crux of the heart. Heart Rhythm 2009; 6:44-50. [PMID: 19121799 DOI: 10.1016/j.hrthm.2008.09.029] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2008] [Accepted: 09/24/2008] [Indexed: 12/01/2022]
Affiliation(s)
- Harish Doppalapudi
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama 35294, USA.
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Cesario DA, Vaseghi M, Boyle NG, Fishbein MC, Valderrábano M, Narasimhan C, Wiener I, Shivkumar K. Value of high-density endocardial and epicardial mapping for catheter ablation of hemodynamically unstable ventricular tachycardia. Heart Rhythm 2006; 3:1-10. [PMID: 16399044 DOI: 10.1016/j.hrthm.2005.10.015] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2005] [Accepted: 10/06/2005] [Indexed: 11/23/2022]
Abstract
BACKGROUND Percutaneous epicardial mapping has been used for ablation of recurrent ventricular tachycardia (VT). OBJECTIVES The purpose of this study was to use a combined epicardial and endocardial mapping strategy to delineate the myocardial substrate for recurrent VT in both ischemic (n = 12) and nonischemic cardiomyopathy (n = 8), and to define the role of epicardial ablation. METHODS Electroanatomic mapping was performed in 20 patients. High-density voltage maps were obtained by acquiring both endocardial and epicardial electrograms. Electrograms derived from six patients with structurally normal hearts were used as controls. A total of 26 VTs were targeted in the 20 patients. RESULTS Most VTs (23/26 [88.5%]) were hemodynamically unstable. In patients with ischemic cardiomyopathy, the extent of endocardial scar was greater than epicardial scar. A definable pattern of scar could not be demonstrated in nonischemic cardiomyopathy. Pathologic examination of explanted hearts in two patients with nonischemic cardiomyopathy demonstrated that low-voltage areas were not always predictive of scarred myocardium. A substrate-based approach was used for catheter ablation. Catheter ablation was performed on the endocardium in all patients; additional epicardial delivery of radiofrequency energy was required in 8 (40%) of 20 patients for successful ablation. During follow-up (12 +/- 4 months), 15 (75%) of 20 patients have been arrhythmia-free. CONCLUSION Patients with ischemic cardiomyopathy tend to have a larger endocardial than epicardial scar. Use of epicardial and endocardial electroanatomic mapping to define the full extent of myocardial scars allows successful catheter ablation in patients with hemodynamically unstable VTs.
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Affiliation(s)
- David A Cesario
- UCLA Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California 90095, USA
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Brugada J, Berruezo A, Cuesta A, Osca J, Chueca E, Fosch X, Wayar L, Mont L. Nonsurgical transthoracic epicardial radiofrequency ablation: an alternative in incessant ventricular tachycardia. J Am Coll Cardiol 2003; 41:2036-43. [PMID: 12798578 DOI: 10.1016/s0735-1097(03)00398-x] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The purpose of this study was to analyze the feasibility, efficacy, and safety of epicardial radiofrequency (RF) ablation in patients with incessant ventricular tachycardia (VT). BACKGROUND Management of patients with incessant VT is a difficult clinical problem. Drugs and RF catheter ablation are not always effective. A nonsurgical transthoracic epicardial RF ablation can be an alternative in patients refractory to conventional therapy. METHODS Epicardial RF ablation was performed in 10 patients who presented with incessant VT despite the use of two or more intravenous antiarrhythmic drugs. RESULTS In eight patients, endocardial ablation (EdA) failed to control the tachycardia. In the remaining two patients, epicardial ablation (EpA) was first attempted because of left ventricular thrombus and severe artery disease, respectively. Eight patients had a diagnosis of coronary artery disease with healed myocardial infarction. One patient had dilated cardiomyopathy, and one patient had idiopathic, incessant VT. In patients with structural heart disease, the mean ejection fraction was 0.28 +/- 0.10%. Four patients previously received an implantable defibrillator. The EpA effectively terminated the incessant tachycardia in eight patients, which represents a success rate of 80%. In them, after a follow-up of 18 +/- 18 months, a single episode of a different VT was documented in one patient. No significant complications occurred related to the procedure. CONCLUSIONS In patients with incessant VT despite the use of drugs or standard EdA, the epicardial approach was very effective and should be considered as an alternative in this life-threatening situation.
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Affiliation(s)
- Josep Brugada
- Arrhythmia Section, Cardiovascular Institute, Hospital Clinic, University of Barcelona, Villaroel 170, 08036 Barcelona, Spain.
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