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Ghannam M, Liang JJ, Latchamsetty R, Crawford T, Jongnarangsin K, Morady F, Bogun F. Importance of Right Ventricular Mapping and Ablation for Ventricular Tachycardia in Postinfarction Patients. JACC Clin Electrophysiol 2023; 9:17-25. [PMID: 36697197 DOI: 10.1016/j.jacep.2022.08.034] [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: 05/17/2022] [Revised: 08/08/2022] [Accepted: 08/22/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The characteristics of patients with post-myocardial infarction (PMI) ventricular tachycardia (VT) who require right ventricular (RV) ablation are underreported. OBJECTIVES The aims of this study were to examine the characteristics and outcomes of patients undergoing PMI VT ablation who have target sites in the right ventricle and to compare patient and VT characteristics between patients with free wall vs septal RV target sites. METHODS Consecutive patients undergoing ablation for PMI VT with target sites located within the right ventricle were included. Patients were stratified on the basis of the presence of free wall vs septal RV target sites. RESULTS Among 277 consecutive patient undergoing PMI VT ablation, 30 (11%) had RV target sites (mean age 68.71 ± 9.5 years, 29 men [97%], mean left ventricular ejection fraction [LVEF] 28.7% ± 16.7%). Twenty patients had only septal VTs, and 10 patients had only free wall VTs. Fifty-seven VTs with RV targets (1.9 ± 1.4 per patient, mean cycle length 338 ± 90 ms, 53 left bundle branch, 36 superior axis) were induced. Patients with RV free wall VTs had greater rates of RV dysfunction (80% vs 30%; P = 0.023) but had greater LVEFs (38.3% ± 21.06% vs 23.9% ± 11.93%; P = 0.02). Over a mean follow-up period of 3.4 ± 3.2 years, patients with RV septal target sites had worse survival free of VT, transplantation, or left ventricular assist device placement after ablation (log-rank P < 0.05). CONCLUSIONS The arrhythmogenic substrate in PMI patients often involves the right ventricle, including the septum and free wall. The presence of RV dysfunction and greater LVEF were associated with the presence of RV free wall target sites. Patients with only RV septal target sites had worse postablation outcomes.
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Affiliation(s)
| | | | | | | | | | - Fred Morady
- University of Michigan, Ann Arbor, Michigan, USA
| | - Frank Bogun
- University of Michigan, Ann Arbor, Michigan, USA.
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Hoogendoorn JC, Sramko M, Venlet J, Siontis KC, Kumar S, Singh R, Nakajima I, Piers SR, de Riva Silva M, Glashan CA, Crawford T, Tedrow UB, Stevenson WG, Bogun F, Zeppenfeld K. Electroanatomical Voltage Mapping to Distinguish Right-Sided Cardiac Sarcoidosis From Arrhythmogenic Right Ventricular Cardiomyopathy. JACC Clin Electrophysiol 2020; 6:696-707. [DOI: 10.1016/j.jacep.2020.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 01/13/2020] [Accepted: 02/20/2020] [Indexed: 12/21/2022]
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Kuo L, Liang JJ, Nazarian S, Marchlinski FE. Multimodality Imaging to Guide Ventricular Tachycardia Ablation in Patients with Non-ischaemic Cardiomyopathy. Arrhythm Electrophysiol Rev 2020; 8:255-264. [PMID: 32685156 PMCID: PMC7358957 DOI: 10.15420/aer.2019.37.3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Catheter ablation is an effective treatment option for ventricular tachycardia (VT) in patients with non-ischaemic cardiomyopathy (NICM). The heterogeneous nature of NICM aetiologies and VT substrate in patients with NICM play a role in long-term ablation outcomes in this population. Over the past decades, more precise identification of NICM aetiologies and better characterisation of various substrates have been made. Application of multimodal imaging has greatly contributed to the accurate diagnosis of NICM subtypes and improved VT ablation strategies. This article summarises the current knowledge of multimodal imaging used in the characterisation of non-ischaemic NICM substrates, procedural planning and image integration for the optimisation of VT ablation.
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Affiliation(s)
- Ling Kuo
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jackson J Liang
- Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
| | - Saman Nazarian
- Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
| | - Francis E Marchlinski
- Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
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Briceño DF, Liang JJ, Shirai Y, Markman TM, Chahal A, Tschabrunn C, Zado E, Hyman MC, Kumareswaran R, Arkles JS, Santangeli P, Schaller RD, Supple GE, Frankel DS, Deo R, Riley MP, Nazarian S, Lin D, Epstein AE, Garcia FC, Dixit S, Callans DJ, Marchlinski FE. Characterization of Structural Changes in Arrhythmogenic Right Ventricular Cardiomyopathy With Recurrent Ventricular Tachycardia After Ablation: Insights From Repeat Electroanatomic Voltage Mapping. Circ Arrhythm Electrophysiol 2020; 13:e007611. [PMID: 31922914 DOI: 10.1161/circep.119.007611] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Data characterizing structural changes of arrhythmogenic right ventricular (RV) cardiomyopathy are limited. METHODS Patients presenting with left bundle branch block ventricular tachycardia in the setting of arrhythmogenic RV cardiomyopathy with procedures separated by at least 9 months were included. RESULTS Nineteen consecutive patients (84% males; mean age 39±15 years [range, 20-76 years]) were included. All 19 patients underwent 2 detailed sinus rhythm electroanatomic endocardial voltage maps (average 385±177 points per map; range, 93-847 points). Time interval between the initial and repeat ablation procedures was mean 50±37 months (range, 9-162). No significant progression of voltage was observed (bipolar: 38 cm2 [interquartile range (IQR), 25-54] versus 53 cm2 [IQR, 25-65], P=0.09; unipolar: 116 cm2 [IQR, 61-209] versus 159 cm2 [IQR, 73-204], P=0.36) for the entire study group. There was a significant increase in RV volumes (percentage increase, 28%; 206 mL [IQR, 170-253] versus 263 mL [IQR, 204-294], P<0.001) for the entire study population. Larger scars at baseline but not changes over time were associated with a significant increase in RV volume (bipolar: Spearman ρ, 0.6965, P=0.006; unipolar: Spearman ρ, 0.5743, P=0.03). Most patients with progressive RV dilatation (8/14, 57%) had moderate (2 patients) or severe (6 patients) tricuspid regurgitation recorded at either initial or repeat ablation procedure. CONCLUSIONS In patients with arrhythmogenic RV cardiomyopathy presenting with recurrent ventricular tachycardia, >10% increase in RV endocardial surface area of bipolar voltage consistent with scar is uncommon during the intermediate term. Most recurrent ventricular tachycardias are localized to regions of prior defined scar. Voltage indexed scar area at baseline but not changes in scar over time is associated with progressive increase in RV size and is consistent with adverse remodeling but not scar progression. Marked tricuspid regurgitation is frequently present in patients with arrhythmogenic RV cardiomyopathy who have progressive RV dilation.
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Affiliation(s)
- David F Briceño
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Jackson J Liang
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Yasuhiro Shirai
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Timothy M Markman
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Anwar Chahal
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Cory Tschabrunn
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Erica Zado
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Mathew C Hyman
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Ramanan Kumareswaran
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Jeffery S Arkles
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Pasquale Santangeli
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Robert D Schaller
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Gregory E Supple
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - David S Frankel
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Rajat Deo
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Michael P Riley
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Saman Nazarian
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - David Lin
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Andrew E Epstein
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Fermin C Garcia
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Sanjay Dixit
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - David J Callans
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Francis E Marchlinski
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
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Bazan V, Frankel DS, Santangeli P, Garcia FC, Tschabrunn CM, Marchlinski FE. Three-dimensional myocardial scar characterization from the endocardium: Usefulness of endocardial unipolar electroanatomic mapping. J Cardiovasc Electrophysiol 2019; 30:427-437. [PMID: 30614100 DOI: 10.1111/jce.13842] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/26/2018] [Accepted: 12/30/2018] [Indexed: 11/29/2022]
Abstract
Epicardial ablation may be required to eliminate ventricular tachycardia (VT) in patients with underlying structural heart disease. The decision to gain epicardial access is frequently based on the suspicion of an epicardial origin for the VT and/or presence of an arrhythmogenic substrate. Epicardial pathology and VT is frequently present in patients with nonischemic right and/or left cardiomyopathies even in the setting of modest or no endocardial bipolar voltage substrate. In this setting, unipolar voltage mapping from the endocardium serves to help identify midmyocardial and/or epicardial VT substrate. The additional value of endocardial unipolar mapping includes its usefulness to predict the clinical outcome after VT ablation, to determine the irreversibility of myocardial disease, and to guide endomyocardial biopsy procedures to specific areas of intramural scarring. In this review, we aim to provide a guide to the use of endocardial unipolar mapping and its appropriate interpretation in a variety of clinical situations.
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Affiliation(s)
| | - David S Frankel
- Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pasquale Santangeli
- Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fermin C Garcia
- Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cory M Tschabrunn
- Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis E Marchlinski
- Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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