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Maher T, Clarke JR, Virk Z, d'Avila A. Patient Selection, Techniques, and Complication Mitigation for Epicardial Ventricular Tachycardia Ablation. Card Electrophysiol Clin 2022; 14:657-677. [PMID: 36396183 DOI: 10.1016/j.ccep.2022.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Percutaneous epicardial ventricular tachycardia ablation can decrease implanted cardioverter defibrillator shocks and hospitalizations; proper patient selection and procedural technique are imperative to maximize the benefit-risk ratio. The best candidates for epicardial ventricular tachycardia will depend on history of prior ablation, type of cardiomyopathy, and specific electrocardiogram and cardiac imaging findings. Complications include hemopericardium, hemoperitoneum, coronary vessel injury, and phrenic nerve injury. Modern epicardial mapping techniques provide new understandings of the 3-dimensional nature of reentrant ventricular tachycardia circuits across cardiomyopathy etiologies. Where epicardial access is not feasible, alternative techniques to reach epicardial ventricular tachycardia sources may be necessary.
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Affiliation(s)
- Timothy Maher
- Harvard Thorndike Electrophysiology Institute and Arrhythmia Service, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA
| | - John-Ross Clarke
- Harvard Thorndike Electrophysiology Institute and Arrhythmia Service, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA
| | - Zain Virk
- Harvard Medical School, Boston, MA, USA; Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN, USA
| | - Andre d'Avila
- Harvard Thorndike Electrophysiology Institute and Arrhythmia Service, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA.
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Atabekov TA, Batalov RE, Sazonova SI, Krivolapov SN, Khlynin MS, Mishkina AI, Zavadovsky KV, Curnis A, Popov SV. How to get the optimal defibrillation lead parameters using myocardial perfusion scintigraphy in patients with coronary artery disease. Int J Cardiovasc Imaging 2021; 37:3323-3333. [PMID: 34100141 DOI: 10.1007/s10554-021-02308-x] [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: 05/03/2021] [Accepted: 06/01/2021] [Indexed: 11/26/2022]
Abstract
The conventional criteria for a defibrillation lead (DL) implantation don't take into account presence of scar or deep ischemia in the myocardium. This may impair a proper functioning of the DL. We sought to optimize the DL implantation placement using rest myocardial perfusion scintigraphy (MPS), which allow detecting areas of myocardial hypoperfusion (MH). To study the influence of MH and scarring, detected by MPS, on the DL parameters in patients with coronary artery disease (CAD). 69 patients (male-65, age 64.8 ± 7.7 years) with CAD and indications for ICD implantation were enrolled. Two days before ICD implantation all patients underwent MPS at rest. Then patients were divided in 2 groups. In the 1st group DL was implanted considering MPS results: to the septal position, if the most significant MH were detected in the apical segments, and to the apical position, if MH were in the septal segments. In the 2nd group DL was implanted using the conventional approach without considering MPS results. Clinical 12 months follow-up was performed with ICD interrogation. Patients of both groups were comparable by clinical and scintigraphic parameters. In the same time, in the 1st group pacing threshold was lower (p < 0.0001) and ventricle signal amplitude was higher (p < 0.0001) comparing with the 2nd group at all control points. The presence of MH detected by MPS in the area of the DL placement worsens its parameters. The results of MPS in patients with CAD can be useful for optimization of DL placement.
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Affiliation(s)
- Tariel A Atabekov
- Department of Surgical Arrhythmology and Cardiac Pacing, Cardiology Research Institute, Tomsk National Research Medical Centre, Russian Academy of Sciences, Kievskaya st., 111a, Tomsk, Russian Federation, 634012.
| | - Roman E Batalov
- Department of Surgical Arrhythmology and Cardiac Pacing, Cardiology Research Institute, Tomsk National Research Medical Centre, Russian Academy of Sciences, Kievskaya st., 111a, Tomsk, Russian Federation, 634012
| | - Svetlana I Sazonova
- Nuclear Medicine Department, Cardiology Research Institute, Tomsk National Research Medical Centre, Russian Academy of Sciences, Kievskaya street, 111a, Tomsk, Russian Federation
| | - Sergey N Krivolapov
- Department of Surgical Arrhythmology and Cardiac Pacing, Cardiology Research Institute, Tomsk National Research Medical Centre, Russian Academy of Sciences, Kievskaya st., 111a, Tomsk, Russian Federation, 634012
| | - Mikhail S Khlynin
- Department of Surgical Arrhythmology and Cardiac Pacing, Cardiology Research Institute, Tomsk National Research Medical Centre, Russian Academy of Sciences, Kievskaya st., 111a, Tomsk, Russian Federation, 634012
| | - Anna I Mishkina
- Nuclear Medicine Department, Cardiology Research Institute, Tomsk National Research Medical Centre, Russian Academy of Sciences, Kievskaya street, 111a, Tomsk, Russian Federation
| | - Konstantin V Zavadovsky
- Nuclear Medicine Department, Cardiology Research Institute, Tomsk National Research Medical Centre, Russian Academy of Sciences, Kievskaya street, 111a, Tomsk, Russian Federation
| | - Antonio Curnis
- Department of Clinical and Experimental Sciences, Università Degli Studi di Brescia, via san Faustino 74b, 25122, Brescia, Italy
| | - Sergey V Popov
- Department of Surgical Arrhythmology and Cardiac Pacing, Cardiology Research Institute, Tomsk National Research Medical Centre, Russian Academy of Sciences, Kievskaya st., 111a, Tomsk, Russian Federation, 634012
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Kamat I, Cohn WE. Pericardial Access Through the Right Atrium in a Porcine Model. Tex Heart Inst J 2021; 48:464399. [PMID: 33915571 DOI: 10.14503/thij-20-7244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
As procedures such as epicardial ventricular ablation and left atrial appendage occlusion become more commonplace, the need grows for safer techniques to access the physiologic pericardial space. Because this space contains minimal fluid for lubrication, prevailing methods of pericardial access pose considerable periprocedural risk to cardiac structures. Therefore, we devised a novel method of pericardial access in which carbon dioxide (CO2) is insufflated through a right atrial puncture under fluoroscopic guidance, enabling clear visualization of the cardiac silhouette separating from the chest wall. We performed the procedure in 8 Landrace pigs, after which transthoracic percutaneous pericardial access was obtained by conventional means. All of the animals remained hemodynamically stable during the procedure, and none showed evidence of epicardial or coronary injury. The protective layer of CO2 in the pericardial space anterior to the heart facilitated percutaneous access in our porcine model, and the absence of complications supports the potential safety of this method.
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Affiliation(s)
- Ishan Kamat
- Department of Internal Medicine, Baylor College of Medicine, Houston, Texas.,Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Transplantation and Circulatory Support, Baylor College of Medicine, Houston, Texas
| | - William E Cohn
- Center for Preclinical Surgical and Interventional Research, Texas Heart Institute, Houston, Texas.,Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Transplantation and Circulatory Support, Baylor College of Medicine, Houston, Texas
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Hale Z, Howard A, Yang Y, Mathuria N. Techniques for Percutaneous Access. Card Electrophysiol Clin 2020; 12:271-280. [PMID: 32771182 DOI: 10.1016/j.ccep.2020.04.004] [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: 11/18/2022]
Abstract
Percutaneous epicardial access continues to have a growing role within cardiac electrophysiology. The classic approach has typically been with a Tuohy needle via a subxiphoid approach guided by fluoroscopic landmarks and tactile feedback. Recent developments have highlighted the role of the micropuncture needle, electroanatomic mapping, and real-time pressure sensors to reduce complications. Further, different access sites, such as the right atrial appendage, have been described and may offer a novel approach to percutaneous epicardial access. In addition, future directions of percutaneous access may involve direct visualization, near-field impedance monitoring, and real-time virtual imaging.
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Affiliation(s)
- Zachary Hale
- Division of Cardiac Electrophysiology, Texas Heart Institute, Houston, TX, USA
| | - Austin Howard
- Division of Cardiac Electrophysiology, Texas Heart Institute, Houston, TX, USA
| | - Yang Yang
- Division of Cardiology, Baylor College of Medicine, 6620 Main Street, 11th Floor, Houston, TX 77030, USA
| | - Nilesh Mathuria
- Division of Cardiac Electrophysiology, Texas Heart Institute, Houston, TX, USA.
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John M, Post A, Burkland DA, Greet BD, Chaisson J, Heberton GA, Saeed M, Rasekh A, Razavi M. Confirming pericardial access by using impedance measurements from a micropuncture needle. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:593-601. [PMID: 32333406 DOI: 10.1111/pace.13927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/03/2020] [Accepted: 04/19/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pericardial access is complicated by two difficulties: confirming when the needle tip is in the pericardial space, and avoiding complications during access, such as inadvertently puncturing other organs. Conventional imaging tools are inadequate for addressing these difficulties, as they lack soft-tissue markers that could be used as guidance during access. A system that can both confirm access and avoid inadvertent organ injury is needed. METHODS A 21G micropuncture needle was modified to include two small electrodes at the needle tip. With continuous bioimpedance monitoring from the electrodes, the needle was used to access the pericardium in porcine models (n = 4). The needle was also visualized in vivo by using an electroanatomical map (n = 2). Bioimpedance data from different tissues were analyzed retrospectively. RESULTS Bioimpedance data collected from the subcutaneous space (992.8 ± 13.1 Ω), anterior mediastinum (972.2 ± 14.2 Ω), pericardial space (323.2 ± 17.1 Ω), mid-myocardium (349.7 ± 87.6 Ω), right ventricular cavity (235.0 ± 9.7 Ω), lung (1142.0 ± 172.0 Ω), liver (575.0 ± 52.6 Ω), and blood (177.5 ± 1.9 Ω) differed significantly by tissue type (P < .01). Phase data in the frequency domain correlated well with the needle being in the pericardial space. A simple threshold analysis effectively separated lung (threshold = 1120.0 Ω) and blood (threshold = 305.9 Ω) tissues from the other tissue types. CONCLUSIONS Continuous bioimpedance monitoring from a modified micropuncture needle during pericardial access can be used to clearly differentiate tissues. Combined with traditional imaging modalities, this system allows for confirming access to the pericardial space while avoiding inadvertent puncture of other organs, creating a safer and more efficient needle-access procedure.
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Affiliation(s)
- Mathews John
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas
| | - Allison Post
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas
| | - David A Burkland
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas.,Department of Internal Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Brian D Greet
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas.,Department of Internal Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Jordan Chaisson
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas.,Department of Internal Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - George A Heberton
- Department of Internal Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Mohammad Saeed
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas.,Department of Internal Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Abdi Rasekh
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas.,Department of Internal Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Mehdi Razavi
- Electrophysiology Clinical Research and Innovations, Texas Heart Institute, Houston, Texas.,Department of Internal Medicine, Section of Cardiology, Baylor College of Medicine, Houston, Texas
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Zecchin M, Solimene F, D'Onofrio A, Zanotto G, Iacopino S, Pignalberi C, Calvi V, Maglia G, Della Bella P, Quartieri F, Curnis A, Biffi M, Capucci A, Caravati F, Senatore G, Santamaria M, Lissoni F, Manzo M, Marini M, Giammaria M, Rapacciuolo A, Sinagra G, Giacopelli D, Gargaro A, Pisanò EC. Atrial signal amplitude predicts atrial high-rate episodes in implantable cardioverter defibrillator patients: Insights from a large database of remote monitoring transmissions. J Arrhythm 2020; 36:353-362. [PMID: 32256887 PMCID: PMC7132187 DOI: 10.1002/joa3.12319] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 02/07/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Parameters measured during implantable cardioverter defibrillator (ICD) implant also depend on bioelectrical properties of the myocardium. We aimed to explore their potential association with clinical outcomes in patients with single/dual-chamber ICD and cardiac resynchronization therapy defibrillator (CRT-D). METHODS In the framework of the Home Monitoring Expert Alliance, baseline electrical parameters for all implanted leads were compared by the occurrence of all-cause mortality, adjudicated ventricular arrhythmia (VA), and atrial high-rate episode lasting ≥24 hours (24 h AHRE). RESULTS In a cohort of 2976 patients (58.1% ICD) with a median follow-up of 25 months, event rates were 3.1/100 patient-years for all-cause mortality, 18.1/100 patient-years for VA, and 9.3/100 patient-years for 24 h AHRE. At univariate analysis, baseline shock impedance was consistently lower in groups with events than without, with a 40 Ω cutoff that better identified high-risk patients. However, at multivariable analysis, the adjusted-hazard ratios (HRs) lost statistical significance for any endpoint. Baseline atrial sensing amplitude during sinus rhythm was lower in patients with 24 h AHRE than in those without (2.45 [IQR: 1.65-3.85] vs 3.51 [IQR: 2.37-4.67] mV, P < .01). The adjusted HR for 24 h AHRE in patients with atrial sensing >1.5 mV vs those with values ≤1.5 mV was 0.52 (95% CI: 0.33-0.83), P = .006. CONCLUSIONS Although lower baseline shock impedance was observed in patients with events, the association lost statistical significance at multivariable analysis. Conversely, low sinus rhythm atrial sensing (≤1.5 mV) measured with standard transvenous leads could identify subjects at high risk of atrial arrhythmia.
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Affiliation(s)
| | | | | | | | | | | | - Valeria Calvi
- Policlinico G. Rodolico, Az. O.U. Policlinico ‐ V. EmanueleCataniaItaly
| | | | | | | | | | - Mauro Biffi
- Policlinico Sant'Orsola‐MalpighiBolognaItaly
| | | | | | | | | | | | - Michele Manzo
- Azienda Ospedaliera Universitaria S.Giovanni di Dio e Ruggi D'AragonaSalernoItaly
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