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Kany S, Alken FA, Schleberger R, Baran J, Luik A, Haas A, Ene E, Deneke T, Dinshaw L, Rillig A, Metzner A, Reissmann B, Makimoto H, Reents T, Popa MA, Deisenhofer I, Piotrowski R, Kulakowski P, Kirchhof P, Scherschel K, Meyer C. Bipolar ablation of therapy-refractory ventricular arrhythmias: application of a dedicated approach. Europace 2022; 24:959-969. [PMID: 34922350 PMCID: PMC9282917 DOI: 10.1093/europace/euab304] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Accepted: 11/18/2021] [Indexed: 12/29/2022] Open
Abstract
AIMS Bipolar radiofrequency ablation (B-RFA) has been reported as a bail-out strategy for the treatment of therapy refractory ventricular arrhythmias (VA). Currently, existing setups have not been standardized for B-RFA, while the impact of conventional B-RFA approaches on lesion formation remains unclear. METHODS AND RESULTS (i) In a multicentre observational study, patients undergoing B-RFA for previously therapy-refractory VA using a dedicated B-RFA setup were retrospectively analysed. (ii) Additionally, in an ex vivo model lesion formation during B-RFA was evaluated using porcine hearts. In a total of 26 procedures (24 patients), acute success was achieved in all 14 ventricular tachycardia (VT) procedures and 7/12 procedures with premature ventricular contractions (PVC), with major complications occurring in 1 procedure (atrioventricular block). During a median follow-up of 211 days in 21 patients, 6/11 patients (VT) and 5/10 patients (PVC) remained arrhythmia-free. Lesion formation in the ex vivo model during energy titration from 30 to 50 W led to similar lesion volumes compared with initial high-power 50 W B-RFA. Lesion size significantly increased when combining sequential unipolar and B-RFA (1429 mm3 vs. titration 501 mm3 vs. B-RFA 50 W 423 mm3, P < 0.001), an approach used in overall 58% of procedures and more frequently applied in procedures without VA recurrence (92% vs. 36%, P = 0.009). Adipose tissue severely limited lesion formation during B-RFA. CONCLUSION Using a dedicated device for B-RFA for therapy-refractory VA appears feasible and safe. While some patients need repeat ablation, success rates were encouraging. Sequential unipolar and B-RFA may be favourable for lesion formation.
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Affiliation(s)
- Shinwan Kany
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251 Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
| | - Fares Alexander Alken
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
- Division of Cardiology/Angiology/Intensive Care, EVK Düsseldorf, Cardiac Neuro- and Electrophysiology Research Consortium (cNEP), Kirchfeldstr. 40, 40217 Düsseldorf, Germany
| | - Ruben Schleberger
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251 Hamburg, Germany
| | - Jakub Baran
- Division of Clinical Electrophysiology, Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland
| | - Armin Luik
- Department of Medicine IV, Hospital Karlsruhe GmbH, Karlsruhe, Germany
| | - Annika Haas
- Department of Medicine IV, Hospital Karlsruhe GmbH, Karlsruhe, Germany
| | - Elena Ene
- Division of Cardiology II, Röhn Hospital, Campus Bad Neustadt, Bad Neustadt/Saale, Germany
| | - Thomas Deneke
- Division of Cardiology II, Röhn Hospital, Campus Bad Neustadt, Bad Neustadt/Saale, Germany
| | - L Dinshaw
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251 Hamburg, Germany
| | - Andreas Rillig
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251 Hamburg, Germany
| | - Andreas Metzner
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251 Hamburg, Germany
| | - Bruno Reissmann
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251 Hamburg, Germany
| | - Hisaki Makimoto
- Division of Cardiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Tilko Reents
- Division of Cardiology, German Heart Center Munich, Munich, Germany
| | | | | | - Roman Piotrowski
- Division of Clinical Electrophysiology, Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland
| | - Piotr Kulakowski
- Division of Clinical Electrophysiology, Department of Cardiology, Centre of Postgraduate Medical Education, Grochowski Hospital, Warsaw, Poland
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251 Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Katharina Scherschel
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
- Division of Cardiology/Angiology/Intensive Care, EVK Düsseldorf, Cardiac Neuro- and Electrophysiology Research Consortium (cNEP), Kirchfeldstr. 40, 40217 Düsseldorf, Germany
- Institute for Neural and Sensory Physiology, Cardiac Neuro- and Electrophysiology Research Consortium (cNEP), Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Christian Meyer
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
- Division of Cardiology/Angiology/Intensive Care, EVK Düsseldorf, Cardiac Neuro- and Electrophysiology Research Consortium (cNEP), Kirchfeldstr. 40, 40217 Düsseldorf, Germany
- Institute for Neural and Sensory Physiology, Cardiac Neuro- and Electrophysiology Research Consortium (cNEP), Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Restrepo AJ, Dickfeld TM. Perioperative Imaging to Guide Epicardial Mapping and Ablation. Card Electrophysiol Clin 2020; 12:281-293. [PMID: 32771183 DOI: 10.1016/j.ccep.2020.06.001] [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: 11/17/2022]
Abstract
Accessing the epicardial space without a sternotomy or a surgical pericardial window to treat ventricular arrhythmias in Chagas disease became a medical necessity in South America. Since the introduction of the dry percutaneous epicardial access approach, epicardial access has been standard procedure for management of ventricular arrhythmias in ischemic and nonischemic cardiomyopathies and atrioventricular accessory pathways after failed conventional endocardial ablation. Understanding the epicardial space and neighboring structures has become an important subject of teachings in electrophysiology. The evolution of complex ablation procedures to treat atrial and ventricular arrhythmias and device interventions to prevent cardioembolic stroke requires thorough understanding of pericardial anatomy.
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Affiliation(s)
- Alejandro Jimenez Restrepo
- Section of Cardiology, Marshfield Clinic Health System, 1000 North Oak Avenue, Marshfield, WI 54449, USA.
| | - Timm Michael Dickfeld
- Section of Cardiac Electrophysiology and the Maryland Arrhythmia and Cardiac Imaging Group (MACIG), University of Maryland School of Medicine, 22 South Greene Street, Room N3W77, Baltimore, MD 21201, USA
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Edward JA, Nguyen DT. Patient Selection for Epicardial Ablation-Part II: The Epicardial Approach and Current Challenges Associated with Epicardial Ablation. J Innov Card Rhythm Manag 2020; 10:3906-3912. [PMID: 32477711 PMCID: PMC7252684 DOI: 10.19102/icrm.2019.101105] [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: 03/04/2019] [Accepted: 03/29/2019] [Indexed: 12/03/2022] Open
Abstract
Since their inception, percutaneous epicardial approaches have become increasingly common in clinical practice with the advent of new technology and the growth of catheter ablation for both ventricular and supraventricular arrhythmias. In addition to identifying the arrhythmogenic foci, there remain challenges to successful epicardial ablation such as the choice of energy source, optimizing irrigation during ablation, and anatomic barriers such as epicardial fat and coronary vessels. The performance of continued translational studies to understand how each of these factors contribute to lesion formation will be essential to guide future advances in the field of epicardial ablation.
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Affiliation(s)
- Justin A Edward
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado Denver, Aurora, CO, USA
| | - Duy T Nguyen
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado Denver, Aurora, CO, USA
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Zipse MM, Edward JA, Zheng L, Tzou WS, Borne RT, Sauer WH, Nguyen DT. Impact of epicardial adipose tissue and catheter ablation strategy on biophysical parameters and ablation lesion characteristics. J Cardiovasc Electrophysiol 2020; 31:1114-1124. [PMID: 32031304 DOI: 10.1111/jce.14383] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 11/29/2019] [Accepted: 12/15/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Epicardial adipose (EA) tissue may limit effective radiofrequency ablation (RFA). OBJECTIVES We sought to evaluate the lesion formation of different ablation strategies on ventricular myocardium with overlying EA. METHODS Bovine myocardium with EA was placed in a circulating saline bath in an ex vivo model. Open-irrigated (OI) RFA was performed, parallel to the myocardium, over fat at 50 W for variable RF durations, variable contact force, catheter configurations (unipolar RF vs bipolar RF), and catheter irrigants (normal saline vs half-normal saline). Ablation was also performed with a needle-tipped ablation catheter (NTAC), perpendicular to the myocardium. RESULTS Increasingly thick EA attenuated lesion size regardless of ablation strategy. RF applied with longer durations and increasing CF produced larger lesion volumes and deeper lesions with ablation over EA more than 3 mm but was unable to produce measurable lesions when EA less than 3 mm. Similarly, ablation with half normal saline irrigant created slightly deeper lesions than bipolar RF and unipolar RF with normal saline as EA thickness increased, but was unable to produce measurable lesions when EA more than 3 mm. Of all ablation strategies, only NTAC produced effective lesion volumes when ablating over thick (>3 mm) EA. CONCLUSIONS While EA attenuates lesion depth and size, relatively larger, and deeper lesions can be achieved with longer RFA duration, higher CF, half normal saline irrigant, and, to a greater extent, by utilizing bipolar RF or NTAC, but only over thin adipose (<3 mm). Of those catheters/strategies tested, only NTAC was able to effectively deliver RF over thick (>3 mm) EA with this model.
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Affiliation(s)
- Matthew M Zipse
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado, Aurora, Colorado
| | - Justin A Edward
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado, Aurora, Colorado
| | - Lijun Zheng
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado, Aurora, Colorado
| | - Wendy S Tzou
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado, Aurora, Colorado
| | - Ryan T Borne
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado, Aurora, Colorado
| | - William H Sauer
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado, Aurora, Colorado
| | - Duy T Nguyen
- Section of Cardiac Electrophysiology, Division of Cardiology, Stanford University, Palo Alto, California
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