1
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Dos Santos Sousa IB, Chokr MO, Melo SL, Pisani CF, Hardy CA, de Moura LG, Sacilotto L, Wu TC, Darrieux FCC, Scanavacca MI. Comparison between cryotherapy and radiofrequency energy sources for parahisian accessory pathway percutaneous ablation. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01841-8. [PMID: 38833098 DOI: 10.1007/s10840-024-01841-8] [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: 02/29/2024] [Accepted: 05/28/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Catheter ablation of parahisian accessory pathways (PHAP) are challenging due to their proximity to the normal conduction system. Retrospective studies suggest that cryoablation has a better safety profile but a higher recurrence rate when compared to radiofrequency ablation (RFCA). The objective of this study was to compare the results of parahisian AP ablation performed by electrophysiologists with experience in both technologies. METHODS Prospective single-center, non-blinded and 1:1 model was used. Patients included had parahisian AP confirmed by an electrophysiological study and referred for radiofrequency or cryotherapy ablation according to current guidelines, under fluoroscopic guidance. No electroanatomic mapping was used. RESULTS A total of 30 patients (mean age of 25±9.4 years; 90% male) were enrolled between Oct/2018 to Feb/2020. Acute success rate between RFCA and CRYO were similar (93% vs. 87%, p = 0.54). A nonsignificant reduction in short-term recurrence rate for RFCA (14% vs. 30%, p = 0.3) and mechanical trauma (6% vs. 20%; p = 0.28) was observed. Long-term recurrence rate and event-free survival time were similar in both groups after 1-year follow-up (p = 0.286). No persistent complete AV block or conduction disturbance was also observed. CONCLUSION Considering the limitation of a small sample size and the lack of use of electroanatomic mapping for RFCA, the efficacy and safety profile of parahisian AP ablation with RFCA was not different from CRYO, when performed by experienced electrophysiologists. No cases of permanent complete AV block were reported with either energy modalities.
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Affiliation(s)
- Italo Bruno Dos Santos Sousa
- Cardiac Arrhythmia Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, SP, Brazil.
| | - Muhieddine Omar Chokr
- Cardiac Arrhythmia Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | - Sissy Lara Melo
- Cardiac Arrhythmia Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | - Cristiano Faria Pisani
- Cardiac Arrhythmia Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | - Carina Abigail Hardy
- Cardiac Arrhythmia Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | - Lucas Goyanna de Moura
- Cardiac Arrhythmia Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | - Luciana Sacilotto
- Cardiac Arrhythmia Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | - Tan Chen Wu
- Cardiac Arrhythmia Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
| | | | - Mauricio Ibrahim Scanavacca
- Cardiac Arrhythmia Unit, Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, SP, Brazil
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2
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Bocanegra-Pérez ÁJ, Piella G, Sebastian R, Jimenez-Perez G, Falasconi G, Saglietto A, Soto-Iglesias D, Berruezo A, Penela D, Camara O. Automatic and interpretable prediction of the site of origin in outflow tract ventricular arrhythmias: machine learning integrating electrocardiograms and clinical data. Front Cardiovasc Med 2024; 11:1353096. [PMID: 38572307 PMCID: PMC10987867 DOI: 10.3389/fcvm.2024.1353096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 03/07/2024] [Indexed: 04/05/2024] Open
Abstract
The treatment of outflow tract ventricular arrhythmias (OTVA) through radiofrequency ablation requires the precise identification of the site of origin (SOO). Pinpointing the SOO enhances the likelihood of a successful procedure, reducing intervention times and recurrence rates. Current clinical methods to identify the SOO are based on qualitative analysis of pre-operative electrocardiograms (ECG), heavily relying on physician's expertise. Although computational models and machine learning (ML) approaches have been proposed to assist OTVA procedures, they either consume substantial time, lack interpretability or do not use clinical information. Here, we propose an alternative strategy for automatically predicting the ventricular origin of OTVA patients using ML. Our objective was to classify ventricular (left/right) origin in the outflow tracts (LVOT and RVOT, respectively), integrating ECG and clinical data from each patient. Extending beyond differentiating ventricle origin, we explored specific SOO characterization. Utilizing four databases, we also trained supervised learning models on the QRS complexes of the ECGs, clinical data, and their combinations. The best model achieved an accuracy of 89%, highlighting the significance of precordial leads V1-V4, especially in the R/S transition and initiation of the QRS complex in V2. Unsupervised analysis revealed that some origins tended to group closer than others, e.g., right coronary cusp (RCC) with a less sparse group than the aortic cusp origins, suggesting identifiable patterns for specific SOOs.
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Affiliation(s)
- Álvaro J. Bocanegra-Pérez
- Physense, BCN Medtech, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain
| | - Gemma Piella
- Physense, BCN Medtech, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain
| | - Rafael Sebastian
- Computational Multiscale Simulation Lab (CoMMLab), Department of Computer Science, Universitat de Valencia, Valencia, Spain
| | - Guillermo Jimenez-Perez
- Physense, BCN Medtech, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain
| | - Giulio Falasconi
- Cardiology Department, Heart Institute, Teknon Medical Center, Barcelona, Spain
| | - Andrea Saglietto
- Division of Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - David Soto-Iglesias
- Cardiology Department, Heart Institute, Teknon Medical Center, Barcelona, Spain
| | - Antonio Berruezo
- Cardiology Department, Heart Institute, Teknon Medical Center, Barcelona, Spain
| | - Diego Penela
- Department of Arrhythmology, Humanitas Research Hospital, Milan, Italy
| | - Oscar Camara
- Physense, BCN Medtech, Department of Information and Communication Technologies, Universitat Pompeu Fabra, Barcelona, Spain
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3
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Gorbaty B, Arango S, Buyck D, James RC, Porter ST, Iaizzo P, Perry TE, Seslar S. Virtual Reality-based Methods for Training Novice Electrophysiology Trainees-A Pilot Study. J Innov Card Rhythm Manag 2023; 14:5583-5599. [PMID: 37781721 PMCID: PMC10540881 DOI: 10.19102/icrm.2023.14091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 04/25/2023] [Indexed: 10/03/2023] Open
Abstract
Developing an accurate and detailed 3-dimensional (3D) mental model of cardiac anatomy is critical for electrophysiology (EP) trainees. Due to its immersive nature, virtual reality (VR) may provide a better learning environment than traditional teaching methods for assimilating 3D cardiac anatomy. The purpose of this pilot study was to evaluate the technical feasibility of an interactive, remote VR-based method for teaching cardiac anatomy to novice EP trainees. We created a shared, remote VR environment that allows the shared viewing of high-resolution 3D cardiac models. Eighteen trainees accepted for pediatric and adult EP fellowships were recruited. We performed a cohort study comparing the traditional teaching methods with the VR learning environment. Participants completed a demographic questionnaire and a satisfaction survey. The adult EP trainees were given a multiple-choice pre- and post-test exam to assess their anatomical knowledge. Both the adult and pediatric EP trainee cohorts rated the VR experience positively and preferred the VR environment to the more traditional teaching method. All the participants expressed interest in incorporating the VR learning environment into the EP fellowship curriculum. The usability of the system was relatively low, with approximately one-third of participants rating the system as hard to use. The impact of the VR session on exam performance was mixed among the adult cohort. We demonstrated the feasibility of gathering geographically dispersed EP fellows in training with a shared VR-based environment to teach cardiac anatomy. Although we were not able to demonstrate a learning benefit over the traditional lecture format in the adult cohort, the training environment was favorably received by all the participants.
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Affiliation(s)
- Benjamin Gorbaty
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, University of Minnesota, Minneapolis, MN, USA
| | - Susana Arango
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, University of Minnesota, Minneapolis, MN, USA
- Department of Surgery, The Visible Heart Laboratories and the Institute for Engineering in Medicine, University of Minnesota, Minneapolis, MN, USA
| | - David Buyck
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, University of Minnesota, Minneapolis, MN, USA
- Liberal Arts Technologies and Innovation Services, University of Minnesota, Minneapolis, MN, USA
| | | | - Samantha T Porter
- Liberal Arts Technologies and Innovation Services, University of Minnesota, Minneapolis, MN, USA
| | - Paul Iaizzo
- Department of Surgery, The Visible Heart Laboratories and the Institute for Engineering in Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Tjörvi E Perry
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, University of Minnesota, Minneapolis, MN, USA
| | - Stephen Seslar
- Division of Pediatric Cardiology, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
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4
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Karki R, Raina A, Ezzeddine FM, Bois MC, Asirvatham SJ. Anatomy and Pathology of the Cardiac Conduction System. Cardiol Clin 2023; 41:277-292. [PMID: 37321681 DOI: 10.1016/j.ccl.2023.03.016] [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] [Indexed: 06/17/2023]
Abstract
The cardiac conduction system is formed of histologically and electrophysiologically distinct specialized tissues uniquely located in the human heart. Understanding the anatomy and pathology of the cardiac conduction system is imperative to an interventional electrophysiologist to perform safe ablation and device therapy for the management of cardiac arrhythmias and heart failure. The current review summarizes the normal and developmental anatomy of the cardiac conduction system, its variation in the normal heart and congenital anomalies, and its pathology and discusses important clinical pearls for the proceduralist.
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Affiliation(s)
- Roshan Karki
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | - Anvi Raina
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | - Fatima M Ezzeddine
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | - Melanie C Bois
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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5
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Restrepo AJ, Saenz Morales LC. Preventing Complications During Mapping and Ablation of Left Ventricular Summit Arrhythmias. Card Electrophysiol Clin 2023; 15:93-109. [PMID: 36774142 DOI: 10.1016/j.ccep.2022.07.004] [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: 12/15/2022]
Abstract
The left ventricular summit is a site of origin for idiopathic ventricular arrhythmias. With advancements in mapping and ablation techniques, sites previously considered inaccessible can now be approached. Anatomical knowledge of the 3-dimensional landmarks of this space is important, as critical structures reside within its boundaries and are potentially liable to collateral injury during ablation. This article reviews reported complications from ablation of ventricular arrhythmias arising from the left ventricular summit and its vicinity and discusses the pros and cons of different ablation technique and the role of an individualized anatomical approach to reduce procedural related complications and improve outcomes.
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Affiliation(s)
- Alejandro Jimenez Restrepo
- Marshfield Clinic Health System, 1000 North Oak Avenue, Marshfield, WI 54449, USA; University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Luis Carlos Saenz Morales
- International Arrhythmia Center, Fundacion CardioInfantil, Bogota, Colombia; Fundacion CardioInfantil, Instituto de Cardiologia, Calle 163 #13b-60, Bogota, Colombia
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6
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Mountris KA, Pueyo E. A meshless fragile points method for rule-based definition of myocardial fiber orientation. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 226:107164. [PMID: 36265289 DOI: 10.1016/j.cmpb.2022.107164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 09/18/2022] [Accepted: 09/27/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND AND OBJECTIVE Rule-based methods are commonly used to estimate the arrangement of myocardial fibers by solving the Laplace problem with appropriate Dirichlet boundary conditions. Existing algorithms are using the Finite Element Method (FEM) to solve the Laplace-Dirichlet problem. However, meshless methods are under development for cardiac electrophysiology simulation. The objective of this work is to propose a meshless rule based method for the determination of myocardial fiber arrangement without requiring a mesh discretization as it is required by FEM. METHODS The proposed method employs the Fragile Points Method (FPM) for the solution of the Laplace-Dirichlet problem. FPM uses simple discontinuous trial functions and single-point exact integration for linear trial functions that set it as a promising alternative to the Finite Element Method. We derive the FPM formulation of the Laplace-Dirichlet and we estimate ventricular and atrial fiber arrangements according to rules based on histology findings for four different geometries. The obtained fiber arrangements from FPM are compared with the ones obtained from FEM by calculating the angle between the fiber vector fields of the two methods for three different directions (i.e., longitudinal, sheet, transverse). RESULTS The fiber arrangements that were generated with FPM were in close agreement with the generated arrangements from FEM for all three directions. The mean angle difference between the FPM and FEM vector fields were lower than 0.030∘ for the ventricular fiber arrangements and lower than 0.036∘ for the atrial fiber arrangements. DISCUSSION The proposed meshless rule-based method was proven to generate myocardial fiber arrangements with very close agreement with FEM while alleviates the requirement for a mesh of the latter. This is of great value for cardiac electrophysiology solvers that are based on meshless methods since they require a well defined myocardial fiber arrangement to simulate accurately the propagation of electrical signals in the heart. Combining a meshless solution for both the determination of the fibers and the electrical signal propagation can allow for solution that do not require the definition of a mesh. To our knowledge, this work is the first one to propose a meshless rule-based method for myocardial fiber arrangement determination.
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Affiliation(s)
- Konstantinos A Mountris
- Aragón Institute for Engineering Research, University of Zaragoza, IIS Aragón, Zaragoza, Spain; CIBER in Bioengineering, Biomaterials & Nanomedicine (CIBER-BBN), Spain.
| | - Esther Pueyo
- Aragón Institute for Engineering Research, University of Zaragoza, IIS Aragón, Zaragoza, Spain; CIBER in Bioengineering, Biomaterials & Nanomedicine (CIBER-BBN), Spain.
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7
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Soto N, Datino T, Gonzalez-Casal D, González-Panizo J, Sánchez-Quintana D, Macias Y, Cabrera JÁ. Anatomical knowledge for the ablation of left and right atrial flutter. Herzschrittmacherther Elektrophysiol 2022; 33:124-132. [PMID: 35579706 DOI: 10.1007/s00399-022-00865-9] [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: 03/24/2022] [Accepted: 05/05/2022] [Indexed: 06/15/2023]
Abstract
The different forms of atrial flutter (AFL) and atrial macroreentrant tachycardias are strongly related to the atrial anatomy in structurally normal atria, and even more so in patients with dilated chambers or with previous interventions. Atrial anatomy, macro- and microscopic tissue disposition including myocardial fibers, conduction system and connective tissue is complex. This review summarizes knowledge of atrial anatomy for the interventional electrophysiologist to better understand the pathophysiology of and ablation options for these complex arrhythmias, as well as to perform catheter ablation procedures safely and effectively.
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Affiliation(s)
- Nina Soto
- Unidad de Arritmias, Departamento de Cardiología, Hospital Universitario Quirón-Salud Madrid and Complejo Hospitalario Ruber Juan Bravo, Universidad Europea de Madrid, 1 Diego de Velázquez, Madrid, Pozuelo de Alarcón, Spain
| | - Tomás Datino
- Unidad de Arritmias, Departamento de Cardiología, Hospital Universitario Quirón-Salud Madrid and Complejo Hospitalario Ruber Juan Bravo, Universidad Europea de Madrid, 1 Diego de Velázquez, Madrid, Pozuelo de Alarcón, Spain
| | - David Gonzalez-Casal
- Unidad de Arritmias, Departamento de Cardiología, Hospital Universitario Quirón-Salud Madrid and Complejo Hospitalario Ruber Juan Bravo, Universidad Europea de Madrid, 1 Diego de Velázquez, Madrid, Pozuelo de Alarcón, Spain
| | - Jorge González-Panizo
- Unidad de Arritmias, Departamento de Cardiología, Hospital Universitario Quirón-Salud Madrid and Complejo Hospitalario Ruber Juan Bravo, Universidad Europea de Madrid, 1 Diego de Velázquez, Madrid, Pozuelo de Alarcón, Spain
| | - Damián Sánchez-Quintana
- Departamento de Anatomía Humana y Biología Celular, Facultad de Medicina, Universidad de Extremadura, Badajoz, Spain
| | - Yolanda Macias
- Departamento de Terapéutica Médica y Quirúrgica, Facultad de Veterinaria, Universidad de Extremadura, Cáceres, Spain
| | - José-Ángel Cabrera
- Unidad de Arritmias, Departamento de Cardiología, Hospital Universitario Quirón-Salud Madrid and Complejo Hospitalario Ruber Juan Bravo, Universidad Europea de Madrid, 1 Diego de Velázquez, Madrid, Pozuelo de Alarcón, Spain.
- CIBER Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
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8
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Wolfes J, Ellermann C, Köbe J, Lange PS, Leitz P, Rath B, Willy K, Güner F, Frommeyer G, Eckardt L. [Anatomy of the left ventricle for endocardial ablation]. Herzschrittmacherther Elektrophysiol 2022; 33:161-174. [PMID: 35556156 DOI: 10.1007/s00399-022-00859-7] [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: 02/25/2022] [Accepted: 04/15/2022] [Indexed: 06/15/2023]
Abstract
As with all cardiac interventions, performing left ventricular ablation requires profound knowledge of cardiac anatomy. The aim of this article is to provide an overview of left ventricular anatomy and to characterize complex and clinically relevant structures from an electrophysiologist-centered perspective. In addition to the different access routes, the trabecular network, the left ventricular outflow tract, and the left ventricular conduction system, complex anatomical structures such as the aortomitral continuity and the left ventricular summit are also explained. In addition, this article offers multiple clinical examples that combine ECG, anatomy, and electrophysiologic study.
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Affiliation(s)
- Julian Wolfes
- Klinik für Kardiologie II-Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland.
| | - Christian Ellermann
- Klinik für Kardiologie II-Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - Julia Köbe
- Klinik für Kardiologie II-Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - Philipp S Lange
- Klinik für Kardiologie II-Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - Patrick Leitz
- Klinik für Kardiologie II-Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - Benjamin Rath
- Klinik für Kardiologie II-Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - Kevin Willy
- Klinik für Kardiologie II-Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - Fatih Güner
- Klinik für Kardiologie II-Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - Gerrit Frommeyer
- Klinik für Kardiologie II-Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
| | - Lars Eckardt
- Klinik für Kardiologie II-Rhythmologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Deutschland
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9
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Three-Dimensional Echocardiography Assessment of Right Ventricular Volumes and Function: Technological Perspective and Clinical Application. Diagnostics (Basel) 2022; 12:diagnostics12040806. [PMID: 35453854 PMCID: PMC9031180 DOI: 10.3390/diagnostics12040806] [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] [Received: 02/23/2022] [Revised: 03/12/2022] [Accepted: 03/15/2022] [Indexed: 12/10/2022] Open
Abstract
Right ventricular (RV) function has important prognostic value in a variety of cardiovascular diseases. Due to complex anatomy and mode of contractility, conventional two-dimensional echocardiography does not provide sufficient and accurate RV function assessment. Currently, three-dimensional echocardiography (3DE) allows for an excellent and reproducible assessment of RV function owing to overcoming these limitations of traditional echocardiography. This review focused on 3DE and discussed the following points: (i) acquisition of RV dataset for 3DE images, (ii) reliability, feasibility, and reproducibility of RV volumes and function measured by 3DE with different modalities, (iii) the clinical application of 3DE for RV function quantification.
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10
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Rodriguez Padilla J, Petras A, Magat J, Bayer J, Bihan-Poudec Y, El-Hamrani D, Ramlugun G, Neic A, Augustin C, Vaillant F, Constantin M, Benoist D, Pourtau L, Dubes V, Rogier J, Labrousse L, Bernus O, Quesson B, Haissaguerre M, Gsell M, Plank G, Ozenne V, Vigmond E. Impact of Intraventricular Septal Fiber Orientation on Cardiac Electromechanical Function. Am J Physiol Heart Circ Physiol 2022; 322:H936-H952. [PMID: 35302879 PMCID: PMC9109800 DOI: 10.1152/ajpheart.00050.2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Cardiac fiber direction is an important factor determining the propagation of electrical activity, as well as the development of mechanical force. In this article, we imaged the ventricles of several species with special attention to the intraventricular septum to determine the functional consequences of septal fiber organization. First, we identified a dual-layer organization of the fiber orientation in the intraventricular septum of ex vivo sheep hearts using diffusion tensor imaging at high field MRI. To expand the scope of the results, we investigated the presence of a similar fiber organization in five mammalian species (rat, canine, pig, sheep, and human) and highlighted the continuity of the layer with the moderator band in large mammalian species. We implemented the measured septal fiber fields in three-dimensional electromechanical computer models to assess the impact of the fiber orientation. The downward fibers produced a diamond activation pattern superficially in the right ventricle. Electromechanically, there was very little change in pressure volume loops although the stress distribution was altered. In conclusion, we clarified that the right ventricular septum has a downwardly directed superficial layer in larger mammalian species, which can have modest effects on stress distribution. NEW & NOTEWORTHY A dual-layer organization of the fiber orientation in the intraventricular septum was identified in ex vivo hearts of large mammals. The RV septum has a downwardly directed superficial layer that is continuous with the moderator band. Electrically, it produced a diamond activation pattern. Electromechanically, little change in pressure volume loops were noticed but stress distribution was altered. Fiber distribution derived from diffusion tensor imaging should be considered for an accurate strain and stress analysis.
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Affiliation(s)
| | - Argyrios Petras
- Johann Radon Institute for Computational and Applied Mathematics (RICAM), Austrian Academy of Sciences, Linz, Austria
| | - Julie Magat
- Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Univ. Bordeaux, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Jason Bayer
- Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Univ. Bordeaux, IMB, UMR 5251, Talence, France
| | - Yann Bihan-Poudec
- Centre de Neuroscience Cognitive, CNRS UMR 5229, Université Claude Bernard Lyon I, France
| | - Dounia El-Hamrani
- Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Univ. Bordeaux, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Girish Ramlugun
- Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Univ. Bordeaux, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Aurel Neic
- Gottfried Schatz Research Center, Division of Biophysics, Medical University of Graz, Graz, Austria
| | - Christoph Augustin
- Gottfried Schatz Research Center, Division of Biophysics, Medical University of Graz, Graz, Austria.,BioTechMed-Graz, Graz, Austria
| | - Fanny Vaillant
- Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Univ. Bordeaux, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Marion Constantin
- Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Univ. Bordeaux, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - David Benoist
- Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Univ. Bordeaux, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Line Pourtau
- Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Univ. Bordeaux, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Virginie Dubes
- Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Univ. Bordeaux, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | | | | | - Olivier Bernus
- Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Univ. Bordeaux, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | - Bruno Quesson
- Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Univ. Bordeaux, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France.,INSERM, Centre de recherche Cardio-Thoracique de Bordeaux, Bordeaux, France
| | | | - Matthias Gsell
- Gottfried Schatz Research Center, Division of Biophysics, Medical University of Graz, Graz, Austria
| | - Gernot Plank
- Gottfried Schatz Research Center, Division of Biophysics, Medical University of Graz, Graz, Austria.,BioTechMed-Graz, Graz, Austria
| | - Valéry Ozenne
- Centre de Résonance Magnétique des Systèmes Biologiques, UMR 5536, CNRS/Université de Bordeaux, Bordeaux, France
| | - Edward Vigmond
- Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Univ. Bordeaux, IMB, UMR 5251, Talence, France
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11
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Arnold R, Hofer E, Haas J, Sanchez-Quintana D, Plank G. Diversity and complexity of the cavotricuspid isthmus in rabbits: A novel scheme for classification and geometrical transformation of anatomical structures. PLoS One 2022; 17:e0264625. [PMID: 35231058 PMCID: PMC8887761 DOI: 10.1371/journal.pone.0264625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 02/14/2022] [Indexed: 11/18/2022] Open
Abstract
The aim of this study was to describe the morphology of the cavotricuspid isthmus (CTI) in detail and introduce a comprehensive scheme to describe the topology of this region based on functional considerations. This may lead to a better understanding of isthmus-dependent flutter and fibrillation and to improved intervention strategies. We used images of the cavotricuspid isthmus from 52 rabbits of both sexes with a median weight of 3.40 ± 0.93 kg. The area of the CTI was 124.25 ± 42.14 mm2 with 53.28 ± 21.13 mm2 covered by pectinate muscles connecting the terminal crest and the vestibule. Isthmus length decreased from inferolateral (13.09 ±2.14 mm) to central (9.85 ± 2.14 mm) to paraseptal (4.88 ± 1.96 mm) resembling the overall human geometry. Ramification sites of pectinate muscles were identified and six levels dividing the CTI from posterior to anterior were introduced. This allowed the classification of pectinate muscle segments based on the connected ramification level. To account for the high inter-individual variations in size and shape, the CTI was projected onto a normalized reference frame using bilinear transformation. Furthermore, two measures of complexity were introduced: (i) the ramification index, which reflects the total number of muscle segments connected to a ramification site and (ii) the complexity index, which reflects the type of ramification (branching or merging site). Topological analysis showed that the complexity of the pectinate muscle network decreases from inferolateral to paraseptal and that the number of electrically uncoupled parallel pathways increases in the central section between the terminal crest and the vestibule which introduces potential reentry pathways.
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Affiliation(s)
- Robert Arnold
- Division of Biophysics, Gottfried-Schatz-Research-Center, Medical University of Graz, Graz, Austria
- * E-mail:
| | - Ernst Hofer
- Division of Biophysics, Gottfried-Schatz-Research-Center, Medical University of Graz, Graz, Austria
| | - Josef Haas
- Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Damian Sanchez-Quintana
- Department of Anatomy and Cell Biology, Faculty of Medicine, University of Extremadura, Badajoz, Spain
| | - Gernot Plank
- Division of Biophysics, Gottfried-Schatz-Research-Center, Medical University of Graz, Graz, Austria
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12
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Cabrera JÁ, Anderson RH, Porta-Sánchez A, Macías Y, Cano Ó, Spicer DE, Sánchez-Quintana D. The Atrioventricular Conduction Axis and its Implications for Permanent Pacing. Arrhythm Electrophysiol Rev 2021; 10:181-189. [PMID: 34777823 PMCID: PMC8576516 DOI: 10.15420/aer.2021.32] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/04/2021] [Indexed: 01/13/2023] Open
Abstract
Extensive knowledge of the anatomy of the atrioventricular conduction axis, and its branches, is key to the success of permanent physiological pacing, either by capturing the His bundle, the left bundle branch or the adjacent septal regions. The inter-individual variability of the axis plays an important role in underscoring the technical difficulties known to exist in achieving a stable position of the stimulating leads. In this review, the key anatomical features of the location of the axis relative to the triangle of Koch, the aortic root, the inferior pyramidal space and the inferoseptal recess are summarised. In keeping with the increasing number of implants aimed at targeting the environs of the left bundle branch, an extensive review of the known variability in the pattern of ramification of the left bundle branch from the axis is included. This permits the authors to summarise in a pragmatic fashion the most relevant aspects to be taken into account when seeking to successfully deploy a permanent pacing lead.
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Affiliation(s)
- José-Ángel Cabrera
- Unidad de Arritmias, Departamento de Cardiología, Hospital Universitario Quirón-Salud Madrid and Complejo Hospitalario Ruber Juan Bravo, Universidad Europea de Madrid, Spain
| | - Robert H Anderson
- Institute of Genetic Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Andreu Porta-Sánchez
- Unidad de Arritmias, Departamento de Cardiología, Hospital Universitario Quirón-Salud Madrid and Complejo Hospitalario Ruber Juan Bravo, Universidad Europea de Madrid, Spain.,Fundación Centro Nacional de Investigaciones Cardiovasculares Carlos III (CNIC), Madrid, Spain
| | - Yolanda Macías
- Department of Medical and Surgical Therapeutics, Faculty of Veterinary, University of Extremadura, Cáceres, Spain
| | - Óscar Cano
- Unidad de Arritmias, Servicio de Cardiología, Hospital Universitari i Politècnic La Fe, Centro de Investigaciones Biomédicas en RED en Enfermedades Cardiovasculares (CIBERCV), Valencia, Spain
| | - Diane E Spicer
- Congenital Heart Centre, University of Florida, Gainesville, Florida, US
| | - Damián Sánchez-Quintana
- Departamento de Anatomía Humana y Biología Celular, Facultad de Medicina, Universidad de Extremadura, Badajoz, Spain
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13
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Karki R, Raina A, Ezzeddine FM, Bois MC, Asirvatham SJ. Anatomy and Pathology of the Cardiac Conduction System. Card Electrophysiol Clin 2021; 13:569-584. [PMID: 34689887 DOI: 10.1016/j.ccep.2021.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The cardiac conduction system is formed of histologically and electrophysiologically distinct specialized tissues uniquely located in the human heart. Understanding the anatomy and pathology of the cardiac conduction system is imperative to an interventional electrophysiologist to perform safe ablation and device therapy for the management of cardiac arrhythmias and heart failure. The current review summarizes the normal and developmental anatomy of the cardiac conduction system, its variation in the normal heart and congenital anomalies, and its pathology and discusses important clinical pearls for the proceduralist.
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Affiliation(s)
- Roshan Karki
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | - Anvi Raina
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | - Fatima M Ezzeddine
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
| | - Melanie C Bois
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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14
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Gabriels JK, Abdelrahman M, Nambiar L, Kim J, Ip JE, Thomas G, Liu CF, Markowitz SM, Lerman BB, Cheung JW. Reappraisal of electrocardiographic criteria for localization of idiopathic outflow region ventricular arrhythmias. Heart Rhythm 2021; 18:1959-1965. [PMID: 34375724 DOI: 10.1016/j.hrthm.2021.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/20/2021] [Accepted: 08/01/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Electrocardiographic (ECG) criteria have been proposed to localize the site of origin of outflow region ventricular arrhythmias (VAs). Many factors influence the QRS morphology of VAs and may limit the accuracy of these criteria. OBJECTIVE The purpose of this study was to assess the accuracy of ECG criteria that differentiate right from left outflow region VAs and localize VAs within the aortic sinus of Valsalva (ASV). METHODS One hundred one patients (mean age 52 ± 16 years; 55 [54%] women) undergoing catheter ablation of right ventricular outflow tract (RVOT) or ASV VAs with a left bundle branch block, inferior axis morphology were studied. ECG measurements including V2 transition ratio, transition zone index, R-wave duration index, R/S amplitude index, V2S/V3R index, V1-3 QRS morphology, R-wave amplitude in the inferior leads were tabulated for all VAs. Comparisons were made between the predicted site of origin using these criteria and the successful ablation site. RESULTS Patients had successful ablation of 71 RVOT and 38 ASV VAs. For the differentiation of RVOT from ASV VAs, the positive predictive values and negative predictive values for all tested ECG criteria ranged from 42% to 75% and from 71% to 82%, respectively, with the V2S/V3R index having the largest area under the curve of 0.852. Morphological QRS criteria in leads V1 through V3 did not localize ASV VAs. The maximum R-wave amplitude in the inferior leads was the sole criterion demonstrating a significant difference between right ASV, right-left ASV commissure, and left ASV sites. CONCLUSION ECG criteria for differentiating right from left ventricular outflow region VAs and for localizing ASV VAs have a limited accuracy.
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Affiliation(s)
- James K Gabriels
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - Mohamed Abdelrahman
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - Lakshmi Nambiar
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - Jiwon Kim
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - James E Ip
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - George Thomas
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - Christopher F Liu
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - Steven M Markowitz
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - Bruce B Lerman
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - Jim W Cheung
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York.
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15
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Whiteman S, Alimi Y, Carrasco M, Gielecki J, Zurada A, Loukas M. Anatomy of the cardiac chambers: A review of the left ventricle. TRANSLATIONAL RESEARCH IN ANATOMY 2021. [DOI: 10.1016/j.tria.2020.100095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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16
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Hanson M, Enriquez A. Intracardiac Echocardiography to Guide Catheter Ablation of Idiopathic Ventricular Arrythmias. Card Electrophysiol Clin 2021; 13:325-335. [PMID: 33990271 DOI: 10.1016/j.ccep.2021.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Catheter ablation is the most effective treatment option for idiopathic ventricular arrhythmias. Intracardiac echocardiography (ICE) has been increasingly used during ablation procedures, allowing real-time visualization of cardiac anatomy, and improving our understanding of the relationships between different cardiac structures. In this article we review the adjuvant role of ICE to guide mapping and ablation of ventricular arrhythmias in the structurally normal heart.
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Affiliation(s)
- Matthew Hanson
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Andres Enriquez
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada.
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17
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Multimodality Imaging of the Anatomy of the Aortic Root. J Cardiovasc Dev Dis 2021; 8:jcdd8050051. [PMID: 34064421 PMCID: PMC8147821 DOI: 10.3390/jcdd8050051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/22/2021] [Accepted: 05/01/2021] [Indexed: 12/14/2022] Open
Abstract
The aortic root has long been considered an inert unidirectional conduit between the left ventricle and the ascending aorta. In the classical definition, the aortic valve leaflets (similar to what is perceived for the atrioventricular valves) have also been considered inactive structures, and their motion was thought to be entirely passive—just driven by the fluctuations of ventricular–aortic gradients. It was not until the advent of aortic valve–sparing surgery and of transcatheter aortic valve implantation that the interest on the anatomy of the aortic root again took momentum. These new procedures require a systematic and thorough analysis of the fine anatomical details of the components of the so-called aortic valve apparatus. Although holding and dissecting cadaveric heart specimens remains an excellent method to appreciate the complex “three-dimensional” nature of the aortic root, nowadays, echocardiography, computed tomography, and cardiac magnetic resonance provide excellent images of cardiac anatomy both in two- and three-dimensional format. Indeed, modern imaging techniques depict the aortic root as it is properly situated within the thorax in an attitudinally correct cardiac orientation, showing a sort of “dynamic anatomy”, which admirably joins structure and function. Finally, they are extensively used before, during, and after percutaneous structural heart disease interventions. This review focuses on the anatomy of the aortic root as revealed by non-invasive imaging techniques.
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18
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Allen JW, Phipps KL, Llamas AA, Barrett KA. Left atrial decompression as a palliative minimally invasive treatment for congestive heart failure caused by myxomatous mitral valve disease in dogs: 17 cases (2018-2019). J Am Vet Med Assoc 2021; 258:638-647. [PMID: 33683957 DOI: 10.2460/javma.258.6.638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine whether left atrial decompression (LAD) would reduce left atrial pressure (LAP) in dogs with advanced myxomatous mitral valve disease (MMVD) and left-sided congestive heart failure (CHF) and to describe the LAD procedure and hemodynamic alterations and complications. ANIMALS 17 dogs with advanced MMVD and left-sided CHF that underwent LAD. PROCEDURES The medical record database was retrospectively reviewed for all LAD procedures attempted in dogs with MMVD and left-sided CHF between October 2018 and June 2019. Data were collected regarding signalment (age, breed, weight, and sex), clinical signs, treatment, physical examination findings, and diagnostic testing before and after LAD. Procedural data were also collected including approach, technique, hemodynamic data, complications, and outcome. RESULTS 18 LAD procedures performed in 17 patients were identified. Dogs ranged in age from 7.5 to 16 years old (median, 11 years) and ranged in body weight from 2.9 to 11.6 kg (6.4 to 25.5 lb) with a median body weight of 7.0 kg (15.4 lb). Minimally invasive creation of an atrial septal defect for the purpose of LAD was successful in all dogs without any intraoperative deaths. Before LAD, mean LAP was elevated and ranged from 8 to 32 mm Hg with a median value of 14 mm Hg (reference value, < 10 mm Hg). Following LAD, there was a significant decrease in mean LAP (median decrease of 6 mm Hg [range, 1 to 15 mm Hg]). Survival time following LAD ranged from 0 to 478 days (median, 195 days). CONCLUSIONS AND CLINICAL RELEVANCE For dogs with advanced MMVD and left-sided CHF, LAD resulted in an immediate and substantial reduction in LAP.
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19
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Peltzer B, Lerman BB, Cheung JW. Practical Approaches to Catheter Ablation of Idiopathic Ventricular Arrhythmias. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-020-00894-y] [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: 11/30/2022]
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20
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De Almeida MC, Mori S, Anderson RH. Three-dimensional visualization of the bovine cardiac conduction system and surrounding structures compared to the arrangements in the human heart. J Anat 2021; 238:1359-1370. [PMID: 33491213 DOI: 10.1111/joa.13397] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/10/2020] [Accepted: 01/05/2021] [Indexed: 12/14/2022] Open
Abstract
In the human heart, the atrioventricular node is located toward the apex of the triangle of Koch, which is also at the apex of the inferior pyramidal space. It is adjacent to the atrioventricular portion of the membranous septum, through which it penetrates to become the atrioventricular bundle. Subsequent to its penetration, the conduction axis is located on the crest of the ventricular septum, sandwiched between the muscular septum and ventricular component of the membranous septum, where it gives rise to the ramifications of the left bundle branch. In contrast, the bovine conduction axis has a long non-branching component, which penetrates into a thick muscular atrioventricular septum having skirted the main cardiac bone and the rightward half of the non-coronary sinus of the aortic root. It commonly gives rise to both right and left bundle branches within the muscular ventricular septum. Unlike the situation in man, the left bundle branch is long and thin before it branches into its fascicles. These differences from the human heart, however, have yet to be shown in three-dimensions relative to the surrounding structures. We have now achieved this goal by injecting contrast material into the insulating sheaths that surround the conduction network, evaluating the results by subsequent computed tomography. The fibrous atrioventricular membranous septum of the human heart is replaced in the ox by the main cardiac bone and the muscular atrioventricular septum. The apex of the inferior pyramidal space, which in the bovine, as in the human, is related to the atrioventricular node, is placed inferiorly relative to the left ventricular outflow tract. The bovine atrioventricular conduction axis, therefore, originates from a node itself located inferiorly compared to the human arrangement. The axis must then skirt the non-coronary sinus of the aortic root prior to penetrating the thicker muscular ventricular septum, thus accounting for its long non-branching course. We envisage that our findings will further enhance comparative anatomical research.
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Affiliation(s)
- Marcos C De Almeida
- Department of Genetics and Morphology, Brasilia's University, Brasilia, Brazil
| | - Shumpei Mori
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Robert H Anderson
- Biosciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
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21
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Jiménez Restrepo A, Mesa JE, Sánchez-Quintana D, Cabrera JÁ. Da Vinci Anatomy Card #1: The Eustachian Valve and its Implications in Invasive Cardiology and Cardiac Surgery. JACC Case Rep 2021; 3:87-90. [PMID: 34317475 PMCID: PMC8305677 DOI: 10.1016/j.jaccas.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
| | - Juan E. Mesa
- Division of Cardiovascular Medicine, Marshfield Clinic Health System, Marshfield, Wisconsin, USA
| | | | - José Ángel Cabrera
- Division of Cardiology, Hospital Universitario Quirón Salud, European University of Madrid, Madrid, Spain
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22
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De Ponti R, Marazzato J. Transseptal Catheterization With a New Septal Device Implanted: A Paradoxically Complex Procedure When the Door Is Wide Open? JACC Case Rep 2021; 3:141-143. [PMID: 34317488 PMCID: PMC8305084 DOI: 10.1016/j.jaccas.2020.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Roberto De Ponti
- Department of Heart and Vessels, Ospedale di Circolo-University of Insubria, Varese, Italy
| | - Jacopo Marazzato
- Department of Heart and Vessels, Ospedale di Circolo-University of Insubria, Varese, Italy
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23
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Mercado M, Leung L, Gallagher M, Shah S, Kulstad E. Modeling esophageal protection from radiofrequency ablation via a cooling device: an analysis of the effects of ablation power and heart wall dimensions. Biomed Eng Online 2020; 19:77. [PMID: 33046057 PMCID: PMC7552446 DOI: 10.1186/s12938-020-00821-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 09/24/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Esophageal thermal injury can occur after radiofrequency (RF) ablation in the left atrium to treat atrial fibrillation. Existing methods to prevent esophageal injury have various limitations in deployment and uncertainty in efficacy. A new esophageal heat transfer device currently available for whole-body cooling or warming may offer an additional option to prevent esophageal injury. We sought to develop a mathematical model of this process to guide further studies and clinical investigations and compare results to real-world clinical data. RESULTS The model predicts that the esophageal cooling device, even with body-temperature water flow (37 °C) provides a reduction in esophageal thermal injury compared to the case of the non-protected esophagus, with a non-linear direct relationship between lesion depth and the cooling water temperature. Ablation power and cooling water temperature have a significant influence on the peak temperature and the esophageal lesion depth, but even at high RF power up to 50 W, over durations up to 20 s, the cooling device can reduce thermal impact on the esophagus. The model concurs with recent clinical data showing an 83% reduction in transmural thermal injury when using typical operating parameters. CONCLUSIONS An esophageal cooling device appears effective for esophageal protection during atrial fibrillation, with model output supporting clinical data. Analysis of the impact of ablation power and heart wall dimensions suggests that cooling water temperature can be adjusted for specific ablation parameters to assure the desired myocardial tissue ablation while keeping the esophagus protected.
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Affiliation(s)
- Marcela Mercado
- Bioengineering Department, Engineering Faculty, Universidad de Antioquia UdeA, Calle 70 No. 52-21, Medellin, Colombia.
| | - Lisa Leung
- St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, Cranmer Terrace, Tooting, London, SW17 0RE, UK
| | - Mark Gallagher
- St. George's University Hospitals NHS Foundation Trust, St. George's, University of London, Cranmer Terrace, Tooting, London, SW17 0RE, UK
| | | | - Erik Kulstad
- Southwestern Medical Center, University of Texas, Dallas, TX, USA
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24
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Hołda J, Słodowska K, Tyrak K, Bolechała F, Jasińska KA, Koziej M, Hołda MK, Walocha JA. Topographical anatomy of the right atrial appendage vestibule and its isthmuses. J Cardiovasc Electrophysiol 2020; 31:3199-3206. [PMID: 33010077 DOI: 10.1111/jce.14767] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/23/2020] [Accepted: 09/30/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The right atrial appendage (RAA) vestibule is an area located in the right atrium between the RAA orifice and the right atrioventricular valve annulus and may be a target for invasive transcatheter procedures. METHODS AND RESULTS We examined 200 autopsied human hearts. Three isthmuses (an inferior, a middle, and a superior isthmus) were detected. The average length of the vestibule was 67.4 ± 10.1 mm. Crevices and diverticula were observed within the vestibule in 15.3% of specimens. The isthmuses had varying heights: superior: 14.0 ± 3.4 mm, middle: 11.2 ± 3.1 mm, and inferior: 10.1 ± 2.7 mm (p < .001). The superior isthmus had the thickest atrial wall (at midlevel: 16.7 ± 5.6 mm), the middle isthmus had the second thickest wall (13.5 ± 4.2 mm), and the inferior isthmus had the thinnest wall (9.3 ± 3.0 mm; p < .001). This same pattern was observed when analyzing the thickness of the adipose layer (superior isthmus had a thickness of 15.4 ± 5.6 mm, middle: 11.7 ± 4.1 mm and inferior: 7.1 ± 3.1 mm; p < .001). The average myocardial thickness did not vary between isthmuses (superior isthmus: 1.3 ± 0.5 mm, middle isthmus: 1.8 ± 0.8 mm, inferior isthmus: 1.6 ± 0.5 mm; p > .05). Within each isthmus, there were variations in the thickness of the entire atrial wall and of the adipose layer. These were thickest near the valve annulus and thinnest near the RAA orifice (p < .001). The thickness of the myocardial layer followed an inverse trend (p < .001). CONCLUSIONS This study was the first to describe the detailed topographical anatomy of the RAA vestibule and that of its adjoining isthmuses. The substantial variability in the structure and dimensions of the RAA isthmuses may play a role in planning interventions within this anatomic region.
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Affiliation(s)
- Jakub Hołda
- HEART-Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
| | - Katarzyna Słodowska
- HEART-Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
| | - Kamil Tyrak
- HEART-Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
| | - Filip Bolechała
- Department of Forensic Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Katarzyna A Jasińska
- HEART-Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
| | - Mateusz Koziej
- HEART-Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
| | - Mateusz K Hołda
- HEART-Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland.,Department of Forensic Medicine, Jagiellonian University Medical College, Cracow, Poland.,Department of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Jerzy A Walocha
- HEART-Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
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25
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Key factors behind autofluorescence changes caused by ablation of cardiac tissue. Sci Rep 2020; 10:15369. [PMID: 32958843 PMCID: PMC7506017 DOI: 10.1038/s41598-020-72351-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 08/25/2020] [Indexed: 11/30/2022] Open
Abstract
Radiofrequency ablation is a commonly used clinical procedure that destroys arrhythmogenic sources in patients suffering from atrial fibrillation and other types of cardiac arrhythmias. To improve the success of this procedure, new approaches for real-time visualization of ablation sites are being developed. One of these promising methods is hyperspectral imaging, an approach that detects lesions based on changes in the endogenous tissue autofluorescence profile. To facilitate the clinical implementation of this approach, we examined the key variables that can influence ablation-induced spectral changes, including the drop in myocardial NADH levels, the release of lipofuscin-like pigments, and the increase in diffuse reflectance of the cardiac muscle beneath the endocardial layer. Insights from these experiments suggested simpler algorithms that can be used to acquire and post-process the spectral information required to reveal the lesion sites. Our study is relevant to a growing number of multilayered clinical targets to which spectral approaches are being applied.
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Karagodin I, Addetia K, Singh A, Dow A, Rivera L, DeCara JM, Soulat-Dufour L, Yamat M, Kruse E, Shah AP, Mor-Avi V, Lang RM. Improved Delineation of Cardiac Pathology Using a Novel Three-Dimensional Echocardiographic Tissue Transparency Tool. J Am Soc Echocardiogr 2020; 33:1316-1323. [PMID: 32972777 DOI: 10.1016/j.echo.2020.08.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/01/2020] [Accepted: 08/03/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Accurate visualization of cardiac valves and lesions by three-dimensional (3D) echocardiography is integral for optimal guidance of structural procedures and appropriate selection of closure devices. A new 3D rendering tool known as transillumination (TI), which integrates a virtual light source into the data set, was recently reported to effectively enhance depth perception and orifice definition. We hypothesized that adding the ability to adjust transparency to this tool would result in improved visualization and delineation of anatomy and pathology and improved localization of regurgitant jets compared with TI without transparency and standard 3D rendering. METHODS We prospectively studied 30 patients with a spectrum of structural heart disease who underwent 3D transesophageal imaging (EPIQ system, Philips) with standard acquisition and TI with and without the transparency feature. Six experienced cardiologists and sonographers were shown randomized images of all three display types in a blinded fashion. Each image was scored independently by all experts using a Likert scale from 1 to 5, while assessing each of the following aspects: (1) ability to recognize anatomy, (2) ability to identify pathology, including regurgitant jet origin, (3) depth perception, and (4) quality of border delineation. RESULTS TI images with transparency were successfully obtained in all cases. All experts perceived an incremental value of the transparency mode, compared with TI without transparency and standard 3D rendering, in terms of ability to recognize anatomy (respective scores: 4.5 ± 1.1 vs 4.1 ± 1.1 vs 3.6 ± 1.1, P < .05), ability to identify pathology (4.1 ± 1.1 vs 3.9 ± 1.2 vs 3.3 ± 1, P < .05), depth perception (4.6 ± 0.7 vs 4.1 ± 0.8 vs 3.2 ± 1.0, P < .05), and border delineation (4.6 ± 0.8 vs 4.1 ± 1.0 vs 3.1 ± 1.1, P < .05). CONCLUSIONS The addition of the transparency mode to TI rendering significantly improves the diagnostic and clinical utility of 3D echocardiography and has the potential to markedly enhance echocardiographic guidance of cardiac structural interventions.
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Affiliation(s)
- Ilya Karagodin
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Karima Addetia
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Amita Singh
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | | | | | - Jeanne M DeCara
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Laurie Soulat-Dufour
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois; Sorbonne University, APHP, Paris, France
| | - Megan Yamat
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Eric Kruse
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Atman P Shah
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Victor Mor-Avi
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois
| | - Roberto M Lang
- Section of Cardiology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois.
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Right ventricular three-dimensional echocardiography: the current status and future perspectives. J Echocardiogr 2020; 18:149-159. [PMID: 32239383 DOI: 10.1007/s12574-020-00468-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 03/23/2020] [Indexed: 12/18/2022]
Abstract
This review focused on right ventricular (RV) three-dimensional echocardiography (3DE) and discussed the following agenda. First, we summarized the clinical RV anatomy and function-related RV3DE use followed by the explanations about 3DSTE image acquisition, including pitfall. Next, we reviewed the reliability and feasibility of RV volume and RV ejection fraction measurements during the last decade. Besides, we described the techniques that might overcome the dropout images at RV anterior and out tract including the current limitations. Finally, speckle tracking echocardiography by RV3DE and novel RV shape assessment were reviewed. This review will help you get comprehensive information on the current status and future perspectives of RV3DE.
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Mehra N, Asirvatham SJ. Expecting failure yet obtaining success. J Cardiovasc Electrophysiol 2019; 30:2995-2997. [PMID: 31642149 DOI: 10.1111/jce.14225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 10/03/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Nandini Mehra
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota.,Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
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Dong X, Sun Q, Tang M, Zhang S. Catheter ablation of ventricular arrhythmias originating from the junction of the pulmonary sinus cusp via a nonreversed U curve approach. Heart Rhythm 2019; 16:1513-1520. [PMID: 30959204 DOI: 10.1016/j.hrthm.2019.04.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ventricular arrhythmias (VAs) can originate from the pulmonary sinus cusp, and reversed U curve ablation has been highly efficient treatment. OBJECTIVE The purpose of this study was to clarify the characteristics of VAs originating from the pulmonary sinus junction (PSJ): left cusp-anterior cusp (LC-AC), right cusp-left cusp (RC-LC), and right cusp-anterior cusp (RC-AC). METHODS One hundred twenty-five consecutive patients with right ventricular outflow (RVOT)-type VAs were enrolled in the study and analyzed. RESULTS Seventeen RVOT-type VAs (13.6%) had an anatomic origin at the PSJ (9 at LC-AC, 6 at RC-LC, 4 at RC-AC). For PSJ-VA patients, the earliest activation site was identified at the PSJ 22.65 ± 2.47 mm above the pulmonary sinus base and preceded QRS onset by 35.7 ± 12.7 ms (P <.001). Fourteen of the 17 PSJ-VA patients underwent successful ablation via a nonreversed U curve after failed reversed U curve ablation. The bipolar proximal potential was earlier, equal to, or later than the distal potential when the reversed U curve catheter tip was positioned at the bottom, middle, or junction region of individual sinus. Electrocardiographic analysis revealed a lower amplitude of RC-AC than LC-AC and RC-LC VAs (P <.001). CONCLUSION The PSJ is a nonrare but distinct origin of RVOT-type VAs. The nonreversed U curve approach is a more feasible alternative for PSJ-VAs than the reversed U curve approach.
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Affiliation(s)
- Xiaonan Dong
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing, China
| | - Qi Sun
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing, China
| | - Min Tang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing, China.
| | - Shu Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing, China
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Doste R, Soto-Iglesias D, Bernardino G, Alcaine A, Sebastian R, Giffard-Roisin S, Sermesant M, Berruezo A, Sanchez-Quintana D, Camara O. A rule-based method to model myocardial fiber orientation in cardiac biventricular geometries with outflow tracts. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2019; 35:e3185. [PMID: 30721579 DOI: 10.1002/cnm.3185] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 10/23/2018] [Accepted: 01/05/2019] [Indexed: 06/09/2023]
Abstract
Rule-based methods are often used for assigning fiber orientation to cardiac anatomical models. However, existing methods have been developed using data mostly from the left ventricle. As a consequence, fiber information obtained from rule-based methods often does not match histological data in other areas of the heart such as the right ventricle, having a negative impact in cardiac simulations beyond the left ventricle. In this work, we present a rule-based method where fiber orientation is separately modeled in each ventricle following observations from histology. This allows to create detailed fiber orientation in specific regions such as the endocardium of the right ventricle, the interventricular septum, and the outflow tracts. We also carried out electrophysiological simulations involving these structures and with different fiber configurations. In particular, we built a modeling pipeline for creating patient-specific volumetric meshes of biventricular geometries, including the outflow tracts, and subsequently simulate the electrical wavefront propagation in outflow tract ventricular arrhythmias with different origins for the ectopic focus. The resulting simulations with the proposed rule-based method showed a very good agreement with clinical parameters such as the 10 ms isochrone ratio in a cohort of nine patients suffering from this type of arrhythmia. The developed modeling pipeline confirms its potential for an in silico identification of the site of origin in outflow tract ventricular arrhythmias before clinical intervention.
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Affiliation(s)
- Ruben Doste
- Physense, ETIC, Universitat Pompeu Fabra, Barcelona, Spain
| | | | | | | | - Rafael Sebastian
- Computational Multiscale Simulation Lab (CoMMLab), Department of Computer Science, Universitat de Valencia, Valencia, Spain
| | | | | | - Antonio Berruezo
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Damian Sanchez-Quintana
- Department of Anatomy and Cell Biology, Faculty of Medicine, University of Extremadura, Badajoz, Spain
| | - Oscar Camara
- Physense, ETIC, Universitat Pompeu Fabra, Barcelona, Spain
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De Almeida MC, Spicer DE, Anderson RH. Why do we break one of the first rules of anatomy when describing the components of the heart? Clin Anat 2019; 32:585-596. [DOI: 10.1002/ca.23356] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/31/2019] [Accepted: 02/18/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Marcos C. De Almeida
- Instituto de Biologia‐Genetica e MorfologiaCampus Universitario Darcy Ribeiro, Universidade de Brasılia Brasılia Distrito Federal Brazil
| | - Diane E. Spicer
- Department of Pediatric CardiologyUniversity of Florida College of Medicine Gainesville Florida
| | - Robert H. Anderson
- Institute of Genetic MedicineNewcastle University Newcastle‐upon‐Tyne United Kingdom
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32
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Molenaar MMD, Timmermans CC, Hesselink T, Scholten MF, Ter Bekke RMA, Luermans JGLM, Brusse-Keizer M, Kraaier K, Ten Haken B, Grandjean JG, Vernooy K, van Opstal JM. Shorter cryoballoon applications times do effect efficacy but result in less phrenic nerve injury: Results of the randomized 123 study. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:508-514. [PMID: 30756393 PMCID: PMC6850154 DOI: 10.1111/pace.13626] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 02/02/2019] [Accepted: 02/08/2019] [Indexed: 12/18/2022]
Abstract
Background The second‐generation cryoballoon significantly improves outcome of pulmonary vein isolation (PVI) but may cause more complications than the first generation. Currently, no consensus regarding optimal cryoballoon application time exists. The 123‐study aimed to assess the minimal cryoballoon application duration necessary to achieve PVI (primary endpoint) and the effect of application duration on prevention of phrenic nerve injury (PNI). Methods Patients <75 years of age with paroxysmal atrial fibrillation, normal PV anatomy, and left atrial size <40 cc/m² or <50 mm were randomized to two applications of different duration: “short,” “medium,” or “long.” A total of 222 patients were enrolled, 74 per group. Results Duration per application was 105 (101‐108), 164 (160‐168), and 224 (219‐226) s and isolation was achieved in 79, 89, and 90% (P < 0.001) of the PVs after two applications in groups short, medium, and long, respectively. Only for the left PVs, the success rate of the short group was significantly less compared to the medium‐ and long‐duration groups (P < 0.001). PNI during the procedure occurred in 19 PVs (6.5%) in the medium and in 20 PVs (6.8%) in the long duration groups compared to only five PVs (1.7%) in the short duration group (P < 0.001). Conclusions Short cryoballoon ablation application times, less than 2 min, did affect the success for the left PVs but not for the right PVs and resulted in less PNI. A PV tailored approach with shorter application times for the right PVs might be advocated.
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Affiliation(s)
- Marleen M D Molenaar
- Medisch Spectrum Twente, Enschede, The Netherlands.,Universiteit Twente, Enschede, The Netherlands
| | | | | | | | | | | | | | | | | | | | - Kevin Vernooy
- Maastricht University Medical Centre, Maastricht, The Netherlands
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Anderson RH, Mohun TJ, Sánchez-Quintana D, Mori S, Spicer DE, Cheung JW, Lerman BB. The anatomic substrates for outflow tract arrhythmias. Heart Rhythm 2019; 16:290-297. [DOI: 10.1016/j.hrthm.2018.08.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Indexed: 12/13/2022]
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Cheung JW, Anderson RH, Markowitz SM, Lerman BB. Catheter Ablation of Arrhythmias Originating From the Left Ventricular Outflow Tract. JACC Clin Electrophysiol 2019; 5:1-12. [DOI: 10.1016/j.jacep.2018.11.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 11/13/2018] [Accepted: 11/21/2018] [Indexed: 12/12/2022]
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35
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Kawashima T, Sato F. Clarifying the anatomy of the atrioventricular node artery. Int J Cardiol 2018; 269:158-164. [DOI: 10.1016/j.ijcard.2018.07.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/29/2018] [Accepted: 07/03/2018] [Indexed: 12/12/2022]
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36
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Dong X, Tang M, Sun Q, Zhang S. Anatomical relevance of ablation to the pulmonary artery root: Clinical implications for characterizing the pulmonary sinus of Valsalva and coronary artery. J Cardiovasc Electrophysiol 2018; 29:1230-1237. [DOI: 10.1111/jce.13685] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 05/24/2018] [Accepted: 05/25/2018] [Indexed: 12/29/2022]
Affiliation(s)
- Xiaonan Dong
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences, and Peking Union Medical College Beijing China
| | - Min Tang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences, and Peking Union Medical College Beijing China
| | - Qi Sun
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences, and Peking Union Medical College Beijing China
| | - Shu Zhang
- Department of Cardiology, State Key Laboratory of Cardiovascular Disease, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences, and Peking Union Medical College Beijing China
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Gil DA, Swift LM, Asfour H, Muselimyan N, Mercader MA, Sarvazyan NA. Autofluorescence hyperspectral imaging of radiofrequency ablation lesions in porcine cardiac tissue. JOURNAL OF BIOPHOTONICS 2017; 10:1008-1017. [PMID: 27545317 PMCID: PMC5511096 DOI: 10.1002/jbio.201600071] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 06/21/2016] [Accepted: 07/29/2016] [Indexed: 05/22/2023]
Abstract
Radiofrequency ablation (RFA) is a widely used treatment for atrial fibrillation, the most common cardiac arrhythmia. Here, we explore autofluorescence hyperspectral imaging (aHSI) as a method to visualize RFA lesions and interlesional gaps in the highly collagenous left atrium. RFA lesions made on the endocardial surface of freshly excised porcine left atrial tissue were illuminated by UV light (365 nm), and hyperspectral datacubes were acquired over the visible range (420-720 nm). Linear unmixing was used to delineate RFA lesions from surrounding tissue, and lesion diameters derived from unmixed component images were quantitatively compared to gross pathology. RFA caused two consistent changes in the autofluorescence emission profile: a decrease at wavelengths below 490 nm (ascribed to a loss of endogenous NADH) and an increase at wavelengths above 490 nm (ascribed to increased scattering). These spectral changes enabled high resolution, in situ delineation of RFA lesion boundaries without the need for additional staining or exogenous markers. Our results confirm the feasibility of using aHSI to visualize RFA lesions at clinically relevant locations. If integrated into a percutaneous visualization catheter, aHSI would enable widefield optical surgical guidance during RFA procedures and could improve patient outcome by reducing atrial fibrillation recurrence.
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Affiliation(s)
- Daniel A. Gil
- Department of Pharmacology & Physiology, George Washington University School of Medicine and Health Sciences, 2300 Eye Street NW, Washington DC, USA
- Department of Biomedical Engineering, Vanderbilt University, 5824 Stevenson Center, PMB 351631, 2301 Vanderbilt Place, Nashville, TN, USA
| | - Luther M. Swift
- Department of Pharmacology & Physiology, George Washington University School of Medicine and Health Sciences, 2300 Eye Street NW, Washington DC, USA
| | - Huda Asfour
- Department of Pharmacology & Physiology, George Washington University School of Medicine and Health Sciences, 2300 Eye Street NW, Washington DC, USA
| | - Narine Muselimyan
- Department of Pharmacology & Physiology, George Washington University School of Medicine and Health Sciences, 2300 Eye Street NW, Washington DC, USA
| | - Marco A. Mercader
- Division of Cardiology, George Washington University Medical Faculty Associates, 2150 Pennsylvania Avenue NW, Suite 4-417, Washington DC, USA
| | - Narine A. Sarvazyan
- Department of Pharmacology & Physiology, George Washington University School of Medicine and Health Sciences, 2300 Eye Street NW, Washington DC, USA
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Randhawa A, Gupta T, Aggarwal A, Sahni D, Singh RS. Histological topography of the atrioventricular node and its extensions in relation to the cardiothoracic surgical landmarks in normal human hearts. Cardiovasc Pathol 2017; 30:38-44. [PMID: 28759818 DOI: 10.1016/j.carpath.2017.06.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 06/22/2017] [Accepted: 06/23/2017] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Atrioventricular (AV) nodal injury which results in cardiac conduction disorders is one of the potential complications of heart valve surgeries and radiofrequency catheter ablations. Understanding the topography of the AV conduction system in relation to the tricuspid and mitral valves will help in reducing these complications. METHODS A tissue block of 3cmx4cm, which contain the AV node, bundle of His and the AV nodal extensions, was excised at the AV septal junction in 20 apparently normal human hearts. The block was divided into three equal segments through vertical incisions perpendicular to the insertion of the septal leaflet of the tricuspid valve. Each segment was processed and stained with H&E and Gomori to study the different parts of the AV conduction system. RESULTS The lower pole of the AV node was located vertically above the tricuspid septal leaflet (TSL) in 100% (20/20) of cases and at the level of the muscular interventricular septum in 65% (13/20) of cases. The upper pole of the compact AV node was located at the level of the mitral valve leaflet (MVL) in 50% (10/20) of cases. The penetrating bundle of His was seen at the level of the TSL, while the branching bundle of His was situated 1.9±1.5 mm inferior to the TSL. The right and left posterior extensions of the AV node spanned from the MVL to 2.9±1.3 mm above the TSL. CONCLUSIONS A rectangular area (2.5 mm × 12 mm) in the Koch's triangle was devoid of AV nodal tissue and could be labeled as a safe area with no risk of conduction defects during valve surgeries. Information on the separation of AV nodal extensions from the TSL, MVL and muscular interventricular septum may play a crucial role in guiding and improving the safety of radiofrequency ablations.
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Affiliation(s)
- Arpandeep Randhawa
- Department of Anatomy, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012
| | - Tulika Gupta
- Department of Anatomy, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012.
| | - Anjali Aggarwal
- Department of Anatomy, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012
| | - Daisy Sahni
- Department of Anatomy, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012
| | - Rana Sandip Singh
- Department of Cardiothoracic Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012
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Al-Atassi T, Kimmaliardjuk DM, Dagenais C, Bourke M, Lam BK, Rubens FD. Should We Ablate Atrial Fibrillation During Coronary Artery Bypass Grafting and Aortic Valve Replacement? Ann Thorac Surg 2017; 104:515-522. [PMID: 28262298 DOI: 10.1016/j.athoracsur.2016.11.081] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 11/29/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study evaluates the safety and efficacy of concomitant atrial fibrillation (AF) ablation in patients with AF undergoing coronary artery bypass grafting (CABG) or aortic valve replacement (AVR) or both. METHODS This is a single-center retrospective study of patients with AF presenting for CABG or AVR or both between 2009 and 2013. They were divided into an ablation group that underwent concomitant AF ablation and a control group that did not. Follow-up data were obtained using telephone interviews. The data were 100% complete with a median follow-up of 30 months. RESULTS A total of 375 patients with AF presented for CABG (44%), AVR (27%), or CABG and AVR (29%). The ablation (129 patients) and control (246 patients) groups had similar baseline characteristics. The ablation group had significantly longer cardiopulmonary bypass and cross-clamp times, adding a mean of 31 ± 3 and 22 ± 3 minutes (p < 0.01 for both), respectively. There were similar unadjusted rates of hospital mortality (4.7% versus 5.3%, p = 0.79), stroke (3.1% versus 3.3%, p = 0.94), and reopening (4.7% versus 6.5%, p = 0.46) between the groups. The intensive care and hospital length of stays were similar. The ablation group had a lower incidence of postoperative AF (27% versus 78%, p < 0.01). Adjusted operative mortality was similar, but the intervention group had significantly lower odds of postoperative AF (odds ratio 0.11, p < 0.01). Although there was no difference in mid-term survival, the ablation group had higher mid-term AF-free survival (p < 0.01) and a trend toward higher anticoagulation-free (p = 0.09) and stroke-free survival (p = 0.08). CONCLUSIONS Concomitant AF ablation in patients with AF undergoing CABG or AVR or both does not increase perioperative rates of mortality or morbidity. Moreover, concomitant AF ablation is effective at reducing postoperative AF burden and increases mid-term AF-free survival.
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Affiliation(s)
- Talal Al-Atassi
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | - Camille Dagenais
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Michael Bourke
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Buu-Khanh Lam
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Fraser D Rubens
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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