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Romero J, Gamero M, Alviz I, Grushko M, Diaz JC, Lorente M, Gabr M, Toquica CC, Krishnan S, Velasco A, Lin A, Natale A, Zou F, Di Biase L. Catheter Ablation of Left Ventricular Summit Arrhythmias from Adjacent Anatomic Vantage Points. Card Electrophysiol Clin 2023; 15:31-37. [PMID: 36774134 DOI: 10.1016/j.ccep.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Idiopathic ventricular arrhythmias (VA), particularly left ventricular outflow tract (LVOT) VA accounts for up to 10% of all VAs referred for ablative therapy. In addition to being infrequent, its intricate anatomy and its pathophysiology make catheter ablation (CA) of these arrhythmias a challenge even for experts. In this scenario, detailed right ventricular outflow tract as well as LVOT electroanatomic mapping including epicardial mapping are essential. In this article, we will emphasize our approach toward the CA technique used for LVOT VA, particularly IVS and/or LVS VA originating from intramural foci, along with its acute and long-term efficacy and safety.
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Affiliation(s)
- Jorge Romero
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Maria Gamero
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Isabella Alviz
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Michael Grushko
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Juan Carlos Diaz
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Marta Lorente
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mohamed Gabr
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Suraj Krishnan
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Alejandro Velasco
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Aung Lin
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Fengwei Zou
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
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Conti S, Sabatino F, Cascino A, Ferrara G, Sgarito G. Dexmedetomidine for sedation during epicardial ablation for ventricular tachycardia: a single-center experience. J Interv Card Electrophysiol 2023; 66:79-85. [PMID: 36018425 DOI: 10.1007/s10840-022-01350-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 08/15/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Epicardial approach to ventricular tachycardia (VT) ablation is mainly performed under general anesthesia (GA). Although catheter manipulation and ablation in the epicardial space could be painful, GA lowers blood pressure and may interfere with arrhythmia induction and mapping, and the use of muscle relaxants precludes identification of the phrenic nerve (PN). Moreover, an anesthesiologist's presence is required during GA for the whole procedure, which may not always be possible. Therefore, we evaluated the feasibility and safety of epicardial VT ablations performed under conscious sedation using dexmedetomidine in our center. METHODS Between January 2018 and January 2022, all patients who underwent epicardial VT ablation under continuous dexmedetomidine infusion were prospectively included in the study. All patients received premedication 30 min before the epicardial puncture with paracetamol (acetaminophen 10 mg/ml) 1000 mg and ketorolac 30 mg. Sedation protocol included an intravenous bolus of midazolam hydrochloride (0.03-0.05 mg/kg) followed by continuous infusion of dexmedetomidine (0.2-0.7 mcg/kg/h). In addition, an intravenous fentanyl citrate bolus (0.7-1.4 mcg/kg) was given for short-term analgesia, followed by a second dose repeated after 30 to 45 min. Sedation-related complications were defined in case of respiratory failure, severe hypotension, and bradycardia requiring treatment. RESULTS Sixty-nine patients underwent epicardial or endo-epi VT ablation under conscious sedation and were included in the analysis. The mean age was 65.4 ± 12.1 years; forty-six patients were males (66.6%). All patients had drug-refractory recurrent VT. Forty-seven patients (68.1%) had non-ischemic cardiomyopathy (NICM), 13 patients (18.9%) had ischemic-cardiomyopathy (ICM), and 9 patients (13%) had myocarditis. Standard percutaneous sub-xiphoid access was attempted in all patients. Non-inducibility of any VT was achieved in 82.6% (9/9 myocarditis, 10/13 ICM, 38/47 NICM, n = 57/69 patients), inducibility of non-clinical VT in 13% (3/13 ICM, 6/38 NICM, n = 9/69 patients), and failure in 4.3% (3/38 NICM, n = 3/69 patients). Although we observed procedural-related complications in five patients (7.2%), one transient PN palsy, two pericarditis, and two vascular complications, those were not related to the conscious sedation protocol. No respiratory failure, severe hypotension, or bradycardia requiring treatment has been observed among the patients. CONCLUSIONS Prompt availability of anesthesiology support remains crucial for complex procedures such as epicardial VT ablation. Continuous infusion of dexmedetomidine and administration of midazolam and fentanyl seem to be a safe and effective sedation protocol in patients undergoing epicardial VT ablation.
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Affiliation(s)
- Sergio Conti
- Department of Cardiology, Electrophysiology Unit, ARNAS Civico - Di Cristina - Benfratelli, P.Zza Nicola Leotta, 4, 90127, Palermo, Italy.
| | - Francesco Sabatino
- Department of Cardiology, Electrophysiology Unit, ARNAS Civico - Di Cristina - Benfratelli, P.Zza Nicola Leotta, 4, 90127, Palermo, Italy
| | - Antonio Cascino
- Department of Cardiology, Electrophysiology Unit, ARNAS Civico - Di Cristina - Benfratelli, P.Zza Nicola Leotta, 4, 90127, Palermo, Italy
| | - Giuliano Ferrara
- Department of Cardiology, Electrophysiology Unit, ARNAS Civico - Di Cristina - Benfratelli, P.Zza Nicola Leotta, 4, 90127, Palermo, Italy
| | - Giuseppe Sgarito
- Department of Cardiology, Electrophysiology Unit, ARNAS Civico - Di Cristina - Benfratelli, P.Zza Nicola Leotta, 4, 90127, Palermo, Italy
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Impact of sex on clinical, procedural characteristics and outcomes of catheter ablation for ventricular arrhythmias according to underlying heart disease. JOURNAL OF INTERVENTIONAL CARDIAC ELECTROPHYSIOLOGY : AN INTERNATIONAL JOURNAL OF ARRHYTHMIAS AND PACING 2023; 66:203-213. [PMID: 35353320 DOI: 10.1007/s10840-022-01188-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 03/20/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Women are under-represented in many key studies and trials examining outcomes of catheter ablation (CA) for ventricular arrhythmias (VA). We compared characteristics between men and women undergoing their first catheter ablation for VA at a single centre over 10 years. METHODS The clinical, procedural characteristics and outcomes of 287 consecutive patients (male = 182, female = 105), undergoing their first CA at our centre over 10 years were compared according to sex and underlying heart disease. RESULTS In the ablation population, women were younger, had fewer co-morbidities, were less likely to have ischemic cardiomyopathy (ICM) and VA storm and were more likely to have idiopathic VA and premature ventricular complexes as the indication for ablation (P < 0.05 for all). Amongst idiopathic and non-ischemic cardiomyopathy (NICM) subgroups, baseline characteristics were similar; amongst ICM, women were younger and had higher numbers of drug failure pre-ablation (P = 0.05). Women were similar to men in all procedural characteristics, acute procedural success and complications, regardless of underlying heart disease. At median follow-up of 666 days, VA-free survival, overall mortality and survival free of death or transplant were comparable in both groups. Sex was not a predictor of these outcomes, after accounting for clinical and procedural characteristics. CONCLUSION Women represented 36% of the real-world population at our centre referred for CA of VA. There are key differences in clinical features of women versus men referred for VA ablation. Despite these differences, VA ablation in women can be accomplished with similar success and complication rates to men, regardless of underlying heart disease.
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Maher T, Clarke JR, Virk Z, d'Avila A. Patient Selection, Techniques, and Complication Mitigation for Epicardial Ventricular Tachycardia Ablation. Card Electrophysiol Clin 2022; 14:657-677. [PMID: 36396183 DOI: 10.1016/j.ccep.2022.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Percutaneous epicardial ventricular tachycardia ablation can decrease implanted cardioverter defibrillator shocks and hospitalizations; proper patient selection and procedural technique are imperative to maximize the benefit-risk ratio. The best candidates for epicardial ventricular tachycardia will depend on history of prior ablation, type of cardiomyopathy, and specific electrocardiogram and cardiac imaging findings. Complications include hemopericardium, hemoperitoneum, coronary vessel injury, and phrenic nerve injury. Modern epicardial mapping techniques provide new understandings of the 3-dimensional nature of reentrant ventricular tachycardia circuits across cardiomyopathy etiologies. Where epicardial access is not feasible, alternative techniques to reach epicardial ventricular tachycardia sources may be necessary.
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Affiliation(s)
- Timothy Maher
- Harvard Thorndike Electrophysiology Institute and Arrhythmia Service, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA
| | - John-Ross Clarke
- Harvard Thorndike Electrophysiology Institute and Arrhythmia Service, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA
| | - Zain Virk
- Harvard Medical School, Boston, MA, USA; Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, Nashville, TN, USA
| | - Andre d'Avila
- Harvard Thorndike Electrophysiology Institute and Arrhythmia Service, Beth Israel Deaconess Medical Center, 185 Pilgrim Road, Palmer 4, Boston, MA 02215, USA; Harvard Medical School, Boston, MA, USA.
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Valderrábano M. What to do when everything fails…Is alcohol the answer? HeartRhythm Case Rep 2022; 9:6-7. [PMID: 36685683 PMCID: PMC9845640 DOI: 10.1016/j.hrcr.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Miguel Valderrábano
- Address reprint requests and correspondence: Dr Miguel Valderrábano, 6550 Fannin St, Suite 1801, Smith Tower. Houston, TX 77030.
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Pavone C, Scacciavillani R, Narducci ML, Cellini F, Pelargonio G, Bencardino G, Perna F, Spera F, Pinnacchio G, Sanna T, Valentini V, Crea F. Successful ventricular tachycardia radioablation in a patient with previous chemical pleurodesis: A case report. Front Cardiovasc Med 2022; 9:937090. [PMID: 35924213 PMCID: PMC9339650 DOI: 10.3389/fcvm.2022.937090] [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: 05/08/2022] [Accepted: 06/27/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Stereotactic arrhythmia radioablation (STAR) is a novel technique for the ablation of ventricular tachycardia in patients with contraindications to standard procedures, i.e., radiofrequency ablation. Case presentation We report the case of a 73-year-old man with non-ischemic dilated cardiomyopathy and recurrent VT episodes. Electroanatomic mapping showed VT prevalently of epicardial origin, but direct epicardial access through subxyphoid puncture could not be performed due to pleuropericardial adhesions from a past history of chemical pleurodesis. STAR was performed, with no VT recurrence at 6 months follow-up. Conclusions Previous experiences with STAR have demonstrated its importance in the management of patients with refractory VT in whom other ablation strategies were not successful. Our case report highlights the use of STAR as a second choice in a patient with an unfavorable VT anatomical location and technical limitations to an optimal radiofrequency ablation. Moreover, it confirms STAR's effectiveness in the ablation of complex transmural lesions, which are more often associated with non-ischemic structural heart disease.
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Affiliation(s)
- Chiara Pavone
- Department of Cardiovascular Sciences, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
- *Correspondence: Chiara Pavone
| | - Roberto Scacciavillani
- Department of Cardiovascular Sciences, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Maria Lucia Narducci
- Department of Cardiovascular Sciences, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
- Maria Lucia Narducci
| | - Francesco Cellini
- Unit of Oncological Radiotherapy, Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Gemma Pelargonio
- Department of Cardiovascular Sciences, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Gianluigi Bencardino
- Department of Cardiovascular Sciences, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Francesco Perna
- Department of Cardiovascular Sciences, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Francesco Spera
- Department of Cardiovascular Sciences, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Gaetano Pinnacchio
- Department of Cardiovascular Sciences, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Tommaso Sanna
- Department of Cardiovascular Sciences, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Vincenzo Valentini
- Unit of Oncological Radiotherapy, Department of Diagnostic Imaging, Oncological Radiotherapy and Hematology, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular Sciences, Agostino Gemelli University Polyclinic (Istituto di Ricovero e Cura a Carattere Scientifico), Rome, Italy
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Kanagaratnam A, Virk SA, Pham T, Anderson RD, Turnbull S, Campbell T, Bennett R, Thomas SP, Lee G, Kumar S. Catheter Ablation for Ventricular Tachycardia in Ischaemic Versus Non-Ischaemic Cardiomyopathy: A Systematic Review and Meta-Analysis. Heart Lung Circ 2022; 31:1064-1074. [PMID: 35643798 DOI: 10.1016/j.hlc.2022.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 02/28/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND There are differences in substrate and ablation approaches for ventricular tachycardia (VT) in ischaemic (ICM) and non-ischaemic cardiomyopathy (NICM). OBJECTIVE To perform a systematic review and meta-analysis comparing clinical and procedural characteristics/outcomes of VT ablation in ICM versus NICM. METHODS Electronic databases were searched for comparative studies reporting outcomes of VT ablation in patients with ICM and NICM. Primary outcomes were acute procedural success, VT recurrence and long-term mortality. Meta-analyses were performed using random-effects modelling. RESULTS Thirty-one (31) studies (7,473 patients; 4,418 ICM and 3,055 NICM) were included. Patients with ICM were significantly older (67.0 vs 55.3 yrs), more commonly male (89% vs 79%), had lower left ventricular ejection fraction (29% vs 38%) were less likely to undergo epicardial access (11% vs 36%) and were more likely to require haemodynamic support during ablation (relative risk [RR] 1.30; 95% CI 1.01-1.69). Acute procedural success (i.e. non-inducibility of VT) was higher in the ICM cohort (RR 1.10, 95% CI 1.05-1.15). Recurrence of VT at follow-up was significantly lower in the ICM cohort (RR 0.77; 95% CI 0.70-0.84). Peri-procedural mortality, incidence of procedural complications and long-term mortality were not significantly different between the cohorts. CONCLUSIONS NICM and ICM patients undergoing VT ablation are fundamentally different in their clinical characteristics, ablation approaches, acute procedural outcomes and likelihood of VA recurrence. VT ablation in NICM has a lower likelihood of procedural success with increased risk of VA recurrence, consistent with known challenging arrhythmia substrate.
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Affiliation(s)
| | - Sohaib A Virk
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia
| | - Timmy Pham
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia
| | - Robert D Anderson
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia; Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Vic, Australia
| | - Samual Turnbull
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia
| | - Timothy Campbell
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia
| | - Richard Bennett
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia
| | - Stuart P Thomas
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia
| | - Geoffrey Lee
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Vic, Australia; Faculty of Medicine, Dentistry, and Health Science, University of Melbourne, Melbourne, Vic, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia; Westmead Applied Research Centre, University of Sydney, Sydney, NSW, Australia.
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Darma A, Bertagnolli L, Weber A, Dinov B, Torri F, Lurz JA, Shamloo AS, Dagres N, Bollmann A, Hindricks G, Arya A. Epicardial ablation of ventricular tachycardia in patients with structural heart disease: a single-centre experience over 12 years. Europace 2021; 23:1980-1988. [PMID: 34405874 DOI: 10.1093/europace/euab194] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/09/2021] [Indexed: 11/14/2022] Open
Abstract
AIMS Epicardial ablation has risen to an essential part of the treatment of ventricular tachycardias (VTs). In this study, we report the efficacy, risks, and current trends of epicardial ablation in structural heart disease as reported in a tertiary single centre over a 12-year period. METHODS AND RESULTS Two hundred and thirty-six patients referred for VT ablation underwent a successful epicardial access and were included in the analysis (89% non-ischaemic cardiomyopathy, 90% males, mean age 60 years, mean left ventricular ejection fraction 38.4%). After performing epicardial ablation the clinical VTs were eliminated in 87% of the patients and 71% of the cohort achieved freedom from VT during 22-month follow-up. Twelve patients (5%) suffered major procedure-related complications. Until the end of follow-up 47 (20%) patients died, 9 (4%) underwent a left ventricular assist device implantation and 10 (4%) patients received a heart transplantation. Antiarrhythmic drugs at baseline and during follow-up were independent predictors of VT recurrence. Atrial fibrillation, renal dysfunction, worse New York Heart Association class, and antiarrhythmic drugs at follow-up were associated with worse survival in our cohort. CONCLUSION In this large tertiary single-centre experience, percutaneous epicardial access was feasible in the large majority of the cohort with acceptably low complications rates. A combined endo-/epicardial approach resulted in 87% acute and 71% long-term success. Further studies are needed to clarify the role of routine combined endo-/epicardial ablation in these complex cardiomyopathies.
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Affiliation(s)
- Angeliki Darma
- Department of Cardiac Electrophysiology, Heart Center University Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany
| | - Livio Bertagnolli
- Department of Cardiac Electrophysiology, Heart Center University Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany
| | - Alexander Weber
- Department for Cardiology, KMG Güstrow Hospital, Güstrow, Germany
| | - Borislav Dinov
- Department of Cardiac Electrophysiology, Heart Center University Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany
| | - Federica Torri
- Department of Cardiac Electrophysiology, Heart Center University Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany
| | - Julia Anna Lurz
- Department of Cardiac Electrophysiology, Heart Center University Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany
| | - Alireza Sepehri Shamloo
- Department of Cardiac Electrophysiology, Heart Center University Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany
| | - Nikolaos Dagres
- Department of Cardiac Electrophysiology, Heart Center University Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany
| | - Andreas Bollmann
- Department of Cardiac Electrophysiology, Heart Center University Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany
| | - Gerhard Hindricks
- Department of Cardiac Electrophysiology, Heart Center University Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany
| | - Arash Arya
- Department of Cardiac Electrophysiology, Heart Center University Leipzig, Struempellstrasse 39, 04289 Leipzig, Germany
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Martinez-Sande JL, Gonzalez-Melchor L, Garcia-Seara J, Rodriguez-Mañero M, Fernandez-Lopez XA, Gonzalez Juanatey JR. Radiofrequency ablation of an atypical left accessory pathway from the left coronary cusp. HeartRhythm Case Rep 2020; 6:947-950. [PMID: 33365246 PMCID: PMC7749217 DOI: 10.1016/j.hrcr.2020.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | - Javier Garcia-Seara
- University Clinical Hospital of Santiago de Compostela, Santiago de Compostela, Spain
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Marazzato J, Marazzi R, Angeli F, Vilotta M, Bagliani G, Leonelli FM, De Ponti R. Ablation of Accessory Pathways with Challenging Anatomy. Card Electrophysiol Clin 2020; 12:555-566. [PMID: 33162003 DOI: 10.1016/j.ccep.2020.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Although catheter ablation of accessory pathways is deemed highly safe and effective, peculiar location of these pathways might lead to complex and potentially hazardous procedures requiring ablation in anatomic regions such as para-Hisian area, coronary sinus, and epicardial surface. The electrophysiologist should know these possible scenarios to plan the best strategy for safe and effective ablation of these uncommon accessory pathways.
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Affiliation(s)
- Jacopo Marazzato
- Department of Heart and Vessels, Ospedale di Circolo, Viale Borri, 57, Varese 21100, Italy; Department of Medicine and Surgery, University of Insubria, Viale Guicciardini, 9, Varese 21100, Italy
| | - Raffaella Marazzi
- Department of Heart and Vessels, Ospedale di Circolo, Viale Borri, 57, Varese 21100, Italy
| | - Fabio Angeli
- Department of Medicine and Surgery, University of Insubria, Viale Guicciardini, 9, Varese 21100, Italy; Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institutes, IRCCS, Via Crotto Roncaccio, 16, Tradate, Varese 21049, Italy
| | - Manola Vilotta
- Department of Heart and Vessels, Ospedale di Circolo, Viale Borri, 57, Varese 21100, Italy
| | - Giuseppe Bagliani
- Arrhythmology Unit, Cardiology Department, Foligno General Hospital, Via Massimo Arcamone, Foligno, Perugia 06034, Italy; Cardiovascular Disease Department, University of Perugia, Piazza Menghini 1, Perugia 06129, Italy
| | - Fabio M Leonelli
- Cardiology Department, James A. Haley Veterans' Hospital, University of South Florida, 13000 Bruce B Down Boulevard, Tampa, FL 33612, USA; University of South Florida, 4202 East Fowler Avenue, Tampa, FL 33620, USA
| | - Roberto De Ponti
- Department of Heart and Vessels, Ospedale di Circolo, Viale Borri, 57, Varese 21100, Italy; Department of Medicine and Surgery, University of Insubria, Viale Guicciardini, 9, Varese 21100, Italy.
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Abstract
Supraventricular arrhythmias are the most common cardiac arrhythmias encountered; however, it is uncommon that supraventricular tachycardias require percutaneous epicardial access for successful mapping and ablation. There are particular scenarios where epicardial access and ablation should be considered. Certain accessory pathways particularly in the posteroseptal region may require epicardial access for successful ablation. These pathways may also be approached from within the coronary sinus system. In addition, tachycardias near the phrenic nerve in the right atrium or left atrium may require epicardial access for successful ablation or to allow displacement of the phrenic nerve facilitating safe catheter ablation.
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Affiliation(s)
- Martin Aguilar
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Usha B Tedrow
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA; Harvard Medical School; Clinical Cardiac Electrophysiology Fellowship; Ventricular Arrhythmia Program.
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12
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Kuniewicz M, Krupiński M, Gosnell M, Budnicka K, Jakob N, Karkowski G, Urbańczyk-Zawadzka M, Lelakowski J, Walocha J. Applicability of computed tomography preoperative assessment of the LAA in LV summit ablations. J Interv Card Electrophysiol 2020; 61:357-363. [PMID: 32666410 PMCID: PMC8324620 DOI: 10.1007/s10840-020-00817-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/29/2020] [Indexed: 11/12/2022]
Abstract
Purpose Ventricular arrhythmias originating from the left ventricular summit (LVS) may present with challenges for catheter ablation. Recently, the left atrial appendage (LAA) became a new vantage point for mapping and ablating arrhythmias from that region, but data of possible usefulness is limited. Methods From September to December 2019, we retrospectively analyzed 48 consecutive patient hearts (20 male; mean age 57.9y ± 11.56) undergoing diagnostic coronary vessel imaging in 64 dual-source computer tomography angiography (CTA). Distances from the LAA to the LVS, LAA shape type, and coronary arteries in the LVS region were measured. Also, we compared the true LVS area from CTA with a calculated formula derived from LVS definition. Results The mean LVS area calculated from the formula was 291.58 mm2 (± 115.5) while the true area calculated from CT was 263.33 mm2 (± 99.49) (p = 0.44). The mean inaccessible area was 133.42 mm2 (± 72.89), accessible 95.67 mm2 (± 72.77). The mean LAA coverage over LVS was 196.08 mm2—which is approximately 75% of LVS size in general. The most common LAA shape was chicken wing (50%); windsock has the highest accessible area coverage on average (80.23%), followed by chicken wing (59.88%), broccoli (47.72%), and cactus (46.98%). The mean distance from LAA to the surface was 5.14 mm (1.5 to 10 mm) and was not correlated with BMI. LAA has a 98% coverage over the point of transition between the great cardiac vein and anterior interventricular vein. Conclusion Angio-CT assessment of the LAA over the LVS structures may be helpful in decision making before an ablation procedure. LAA appears to be a promising mapping approach in LVS arrhythmias.
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Affiliation(s)
- Marcin Kuniewicz
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland. .,Department of Electrocardiology, Institute of Cardiology, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland.
| | - M Krupiński
- Department of Radiology and Diagnostic Imaging, John Paul II Hospital, Krakow, Poland
| | - M Gosnell
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - K Budnicka
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - N Jakob
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - G Karkowski
- Department of Electrocardiology, Institute of Cardiology, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
| | - M Urbańczyk-Zawadzka
- Department of Radiology and Diagnostic Imaging, John Paul II Hospital, Krakow, Poland
| | - J Lelakowski
- Department of Electrocardiology, Institute of Cardiology, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
| | - J Walocha
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
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Edward JA, Nguyen DT. Patient Selection for Epicardial Ablation-Part I: The Role of Epicardial Ablation in Various Cardiac Disease States. J Innov Card Rhythm Manag 2020; 10:3897-3905. [PMID: 32477710 PMCID: PMC7252769 DOI: 10.19102/icrm.2019.101104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 03/29/2019] [Indexed: 11/30/2022] Open
Abstract
Epicardial catheter ablation is most commonly performed following unsuccessful endocardial ablation. Given the frequency of epicardial substrates in certain cardiomyopathic disease states, however, a combined endocardial–epicardial approach should be considered as a primary treatment strategy. Although epicardial ablation is primarily deployed in patients with ventricular arrhythmias, the role of epicardial approaches in supraventricular tachycardias (eg, atrial fibrillation, inappropriate sinus tachycardia, and—rarely—accessory pathways) is growing, with continued advances being made.
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Affiliation(s)
- Justin A Edward
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado Denver, Aurora, CO, USA
| | - Duy T Nguyen
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado Denver, Aurora, CO, USA
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14
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Percutaneous Epicardial Approach to Catheter Ablation of Cardiac Arrhythmias. JACC Clin Electrophysiol 2020; 6:1-20. [PMID: 31971898 DOI: 10.1016/j.jacep.2019.10.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/22/2019] [Accepted: 10/25/2019] [Indexed: 11/23/2022]
Abstract
Since their introduction >2 decades ago, percutaneous catheter-based epicardial mapping and ablation have become widely adopted by cardiac electrophysiologists around the world. Although epicardial mapping has been used for catheter ablation of a wide variety of cardiac arrhythmias, its most common use is for ablation of intramural and subepicardial substrates that give rise to ventricular tachycardia, particularly in patients with nonischemic cardiomyopathy. As such, the subxiphoid percutaneous epicardial approach has emerged as an important adjunct, and, in some cases, is the preferred strategy in this regard. This review discusses the rationale and indications for epicardial catheter mapping and/or ablation. This paper also reviews the prevalence of epicardial arrhythmias and their electrocardiographic criteria. In addition, it examines the anatomy of the pericardium and commonly used epicardial access techniques, as well as the optimal methodologies for epicardial mapping and ablation and the impact of epicardial fat. Finally, this review discusses the potential of the various complications associated with the percutaneous epicardial approach, in addition to patient-specific risk factors, and potential strategies to mitigate the risk of complications.
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15
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Aryana A, d'Avila A. Epicardial approach for cardiac electrophysiology procedures. J Cardiovasc Electrophysiol 2019; 31:345-359. [DOI: 10.1111/jce.14282] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/18/2019] [Accepted: 11/09/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Arash Aryana
- Department of Cardiology and Cardiac ElectrophysiologyMercy General Hospital and Dignity Health Heart and Vascular InstituteSacramento California
| | - André d'Avila
- Cardiac Arrhythmia ServiceHospital SOS CardioFlorianopolis Santa Catarina Brazil
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16
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Abstract
Ventricular tachycardia is commonly seen in medical practice. It may be completely benign or portend high risk for sudden cardiac death. Therefore, it is important that clinicians be familiar with and able to promptly recognize and manage ventricular tachycardia when confronted with it clinically. In many cases, curative therapy for a given ventricular arrhythmia may be provided after a thorough understanding of the underlying substrate and mechanism. In this article, the authors broadly review the current classification of the different ventricular arrhythmias encountered in medical practice, provide brief background regarding the different mechanisms, and discuss practical diagnosis and management scenarios.
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Affiliation(s)
- Soufian T AlMahameed
- Heart and Vascular Research Center, MetroHealth Campus of Case Western Reserve University, 2500 MetroHealth Medical Drive, Cleveland, OH 44109, USA.
| | - Ohad Ziv
- Heart and Vascular Research Center, MetroHealth Campus of Case Western Reserve University, 2500 MetroHealth Medical Drive, Cleveland, OH 44109, USA
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17
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Di Biase L, Romero J, Zado ES, Diaz JC, Gianni C, Hranitzki PM, Sanchez JE, Mohanty S, Al-Ahmad A, Mohanty P, Trivedi C, Della Rocca D, Santangeli P, Burkhardt JD, Garcia FC, Marchlinski FE, Natale A. Variant of ventricular outflow tract ventricular arrhythmias requiring ablation from multiple sites: Intramural origin. Heart Rhythm 2019; 16:724-732. [DOI: 10.1016/j.hrthm.2018.11.028] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Indexed: 10/27/2022]
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18
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Tzou WS, Rothstein PA, Cowherd M, Zipse MM, Tompkins C, Marzec L, Aleong RG, Schuller JL, Varosy PD, Borne RT, Mathew J, Tumolo A, Sandhu A, Nguyen DT, Sauer WH. Repeat ablation of refractory ventricular arrhythmias in patients with nonischemic cardiomyopathy: Impact of midmyocardial substrate and role of adjunctive ablation techniques. J Cardiovasc Electrophysiol 2018; 29:1403-1412. [PMID: 30033528 DOI: 10.1111/jce.13663] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 05/18/2018] [Accepted: 06/06/2018] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Multiple ablations are often necessary to manage ventricular arrhythmias (VAs) in nonischemic cardiomyopathy (NICM) patients. We assessed characteristics and outcomes and role of adjunctive, nonstandard ablation in repeat VA ablation (RAbl) in NICM. METHODS AND RESULTS Consecutive NICM patients undergoing RAbl were analyzed, with characteristics of the last VA ablations compared between those undergoing 1 versus multiple-repeat ablations (1-RAbl vs. >1RAbl), and between those with or without midmyocardial substrate (MMS). VA-free survival was compared. Eighty-eight patients underwent 124 RAbl, 26 with > 1RAbl, and 26 with MMS. 1-RAbl and > 1-RAbl groups were similar in age (57 ± 16 vs. 57 ± 17 years; P = 0.92), males (76% vs. 69%; P = 0.60), LVEF (40 ± 17% vs. 40 ± 18%; P = 0.96), and amiodarone use (31% vs. 46%, P = 0.22). One-year VA freedom between 1-RAbl vs. > 1RAbl was similar (82% vs. 80%; P = 0.81); adjunctive ablation was utilized more in >1RAbl (31% vs. 11%, P = 0.02), and complication rates were higher (27% vs. 7%, P = 0.01), most due to septal substrate and anticipated heart block. >1-RAbl patients had more MMS (62% vs. 16%, P < 0.01). Although MMS was associated with worse VA-free survival after 1-RAbl (43% vs. 69%, P = 0.01), when >1RAbl was performed, more often with nonstandard ablation, VA-free survival was comparable to non-MMS patients (85% vs. 81%; P = 0.69). More RAbls were required in MMS versus non-MMS patients (2.00 ± 0.98 vs. 1.16 ± 0.37; P < 0.001). CONCLUSION For NICM patients with recurrent, refractory VAs despite previous ablation, effective arrhythmia control can safely be achieved with subsequent ablation, although >1 repeat procedure with adjunctive ablation is often required, especially with MMS.
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Affiliation(s)
- Wendy S Tzou
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Peter A Rothstein
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Michael Cowherd
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Matthew M Zipse
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Christine Tompkins
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Lucas Marzec
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Ryan G Aleong
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Joseph L Schuller
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Paul D Varosy
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Ryan T Borne
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Jehu Mathew
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Alexis Tumolo
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Amneet Sandhu
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - Duy T Nguyen
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
| | - William H Sauer
- University of Colorado,, Cardiac Electrophysiology Section, Aurora, Colorado
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Yang J, Yang G, Chen H, Ju W, Yang B, Zhang F, Jin Y, Cao J, Qian L, Chen M. An alternative under-valve approach to ablate right-sided accessory pathways. Heart Rhythm 2018; 16:51-56. [PMID: 30031200 DOI: 10.1016/j.hrthm.2018.07.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Right-sided accessory pathway (RAP) ablation is sometimes challenging. OBJECTIVE Our study aimed to demonstrate an alternative ablation approach to RAPs under the tricuspid valve, especially when the conventional ablation attempts at the atrial side failed. METHODS Twelve patients with RAPs were enrolled, 8 of whom had previously failed ablation. With the help of a long sheath, the under-valve approach was attempted in 3 patients during tachycardia, in 2 patients during ventricular pacing, and in 7 patients during sinus rhythm. Three-dimensional electroanatomic mapping was performed in 3 patients during their repeat procedures. RESULTS The acute outcomes of the procedures in all patients were successful. Patients were free of tachycardia or recurrence of accessory pathway conduction during a median follow-up of 12.5 months (range 7-45 months). No complications were found during the procedure or follow-up period. CONCLUSION Radiofrequency ablation under the tricuspid valve to eliminate RAPs is feasible because of its stable contact and the accurate ablation of the ventricular insertion site. It provides an alternative approach to tough RAP ablation.
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Affiliation(s)
- Jun Yang
- Cardiovascular Medical Center of Jiangsu, Women and Children Branch Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China; Department of Cardiology, The Affiliated Wuxi No.2 People's Hospital of Nanjing Medical University, Wuxi, China
| | - Gang Yang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hongwu Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weizhu Ju
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Bing Yang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Fengxiang Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yan Jin
- Department of Cardiology, The Affiliated Wuxi No.2 People's Hospital of Nanjing Medical University, Wuxi, China
| | - Jianing Cao
- Department of Cardiology, The Affiliated Wuxi No.2 People's Hospital of Nanjing Medical University, Wuxi, China
| | - Lingmei Qian
- Cardiovascular Medical Center of Jiangsu, Women and Children Branch Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China.
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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Abstract
Ventricular tachycardia (VT) is the most common form of wide complex tachycardia and is associated with a high mortality rate. Electrocardiographic analysis remains paramount in diagnosis and helps to direct therapy. Antiarrhythmic agents, although effective in reducing arrhythmia burden, have never demonstrated a mortality benefit. The implantable cardioverter-defibrillator aids not only in the acute termination of ventricular arrhythmia, but provides a wealth of information for the long-term management of patients with VT. Contemporary treatment options such as catheter ablation are increasingly used and effective, but often remain imperfect, with recurrent VT being not uncommon.
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21
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Keramati AR, DeMazumder D, Misra S, Chrispin J, Assis FR, Raghuram C, Dey S, Calkins H, Tandri H. Anterior pericardial access to facilitate electrophysiology study and catheter ablation of ventricular arrhythmias: A single tertiary center experience. J Cardiovasc Electrophysiol 2017; 28:1189-1195. [PMID: 28727191 DOI: 10.1111/jce.13296] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 06/23/2017] [Accepted: 06/26/2017] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Epicardial ablation is becoming an important part of management in patients with ventricular tachycardia (VT). Posterior epicardial access via the Sosa or needle-in-needle (NIN) approach for epicardial VT ablation is considered to be the method of choice for most electrophysiologists. Anterior epicardial access as an alternative technique has recently been proposed, but there are limited data about its safety, efficacy, and the rate of immediate complications. In this study, we report our experience with anterior epicardial access between 2009 and 2016. METHODS Between 2009 and June 2016, 100 consecutive patients underwent epicardial VT ablation using an anterior approach. The success rate, epicardial bleeding, and other complications related to the epicardial access in these patients were compared to the previously reported rate of complications in patients whom epicardial access was performed using the NIN or Sosa techniques. RESULTS Anterior epicardial access was obtained successfully in 100% of patients in the first attempt. The success rate of the anterior approach was comparable with the reported success rate of the NIN technique (100% vs. 100%, P value not significant) but better than the Sosa technique (100% vs. 94%, P = 0.012). None of the patients in the anterior approach series suffered from significant pericardial bleeding (defined as greater than 80 mL of blood loss), RV puncture/damage, or need for an emergent cardiac surgery. CONCLUSION An anterior epicardial approach is feasible and appears to have an acceptable safety profile in comparison with other epicardial approaches.
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Affiliation(s)
- Ali R Keramati
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Deeptankar DeMazumder
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA.,Division of Cardiology, Department of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Satish Misra
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jonathan Chrispin
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Fabrizio R Assis
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Chava Raghuram
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Swati Dey
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Harikrishna Tandri
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
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22
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Outcomes after repeat ablation of ventricular tachycardia in structural heart disease: An analysis from the International VT Ablation Center Collaborative Group. Heart Rhythm 2017; 14:991-997. [DOI: 10.1016/j.hrthm.2017.03.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Indexed: 11/17/2022]
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23
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Pandian J, Kaur D, Yalagudri S, Devidutta S, Sundar G, Chennapragada S, Narasimhan C. Safety and efficacy of epicardial approach to catheter ablation of ventricular tachycardia - An institutional experience. Indian Heart J 2017; 69:170-175. [PMID: 28460764 PMCID: PMC5414949 DOI: 10.1016/j.ihj.2016.10.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 10/05/2016] [Accepted: 10/24/2016] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND AND AIM Epicardial approach to VT ablation increases the success rate of ablation but is not without complications. We studied the safety and efficacy of epicardial VT ablations performed at our institute. METHODS All patients who underwent epicardial VT ablation at our institute were studied retrospectively. The outcome of VT ablation was among three groups: ischaemic cardiomyopathy (ICM), non-ischaemic cardiomyopathy (NICM) and granulomatous myocarditis (GM). Safety outcomes assessed included all complications considered to be due to pericardial access or epicardial mapping/ablation. RESULTS A total of 54 patients (total 119 VTs, mean 2.2 (0.9)) were taken up for ablation procedure through epicardial access. Mean age: 47 (10) years, males: 83%. All patients had drug resistant recurrent VTs. The epicardial procedure was abandoned in three patients due to access issues; percutaneous sub-xiphoid access was employed in 48 and surgical approach in four patients. Complete success was achieved in 59% and partial success in 76%. The outcomes were poor in ICM patients as compared to those with GM and NICM. Overall success rates for all clinical VTs were 89% in GM, 90% in NICM and 67% in ICM. Success rates for epicardial VT ablation were 94%, 85% and 78% respectively for GM, NICM and ICM. Procedure related complications occurred in six patients. CONCLUSION Epicardial ablation for VT offers good immediate outcomes with acceptable safety profile.
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Affiliation(s)
| | - Daljeet Kaur
- CARE Hospital, Road No.1, Banjara Hills, Hyderabad 500 034, India
| | - Sachin Yalagudri
- CARE Hospital, Road No.1, Banjara Hills, Hyderabad 500 034, India
| | - Soumen Devidutta
- CARE Hospital, Road No.1, Banjara Hills, Hyderabad 500 034, India
| | - Gomathi Sundar
- CARE Hospital, Road No.1, Banjara Hills, Hyderabad 500 034, India
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24
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Ban JE, Park TY, Park SW. Percutaneous epicardial ablation of incessant atrial tachycardia originating from the left atrial appendage. J Thorac Dis 2017; 8:E1551-E1554. [PMID: 28066659 DOI: 10.21037/jtd.2016.11.86] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A 38-year-old woman presented with antiarrhythmic drug-refractory atrial tachycardia (AT). Holter recording demonstrated incessant episodes of AT followed by a long sinus pause. Electrophysiologic study revealed that the earliest endocardial activation was observed at the neck of the left atrial appendage (LAA). After unsuccessful endocardial ablation, epicardial access via a percutaneous subxiphoid approach demonstrated that the earliest epicardial atrial activation was observed on the opposite site to the endocardial LAA neck suggestive of ligament of Marshall (LOM) muscle sleeve as regarding the epicardial sharp potentials under guidance of a circular mapping catheter. Application of radiofrequency (RF) energy at this site terminated the tachycardia. After tachycardia ablation, the sinus pause also resolved.
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Affiliation(s)
- Ji-Eun Ban
- Division of Cardiology, Department of Pediatrics, Hallym University Medical Center, Seoul, Republic of Korea
| | - Tae Young Park
- Division of Cardiology, Department of Pediatrics, Hallym University Medical Center, Seoul, Republic of Korea
| | - Sang-Weon Park
- Division of Cardiology, Department of Internal Medicine, Korea University Medical Center, Seoul, Republic of Korea
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25
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Sternick EB, Faustino M, Correa FS, Pisani C, Scanavacca MI. Percutaneous Catheter Ablation of Epicardial Accessory Pathways. Arrhythm Electrophysiol Rev 2017; 6:80-84. [PMID: 28835839 DOI: 10.15420/aer.2017.6.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Radiofrequency (RF) catheter ablation is the treatment of choice in patients with accessory pathways (APs) and Wolff-Parkinson-White syndrome. Endocardial catheter ablation has limitations, including the inability to map and ablate intramural or subepicardial APs. Some of these difficulties can be overcome using an epicardial approach performed through the epicardial venous system or by percutaneous catheterisation of the pericardial space. When a suspected left inferior or infero-paraseptal AP is refractory to ablation or no early activation is found at the endocardium, a transvenous approach via the coronary sinus is warranted because such epicardial pathways can be in close proximity to the coronary venous system. Associated congenital abnormalities, such as right atrial appendage, right ventricle diverticulum, coronary sinus diverticulum and absence of coronary sinus ostium, may also hamper a successful outcome. Percutaneous epicardial subxiphoid approach should be considered when endocardial or transvenous mapping and ablation fails. Epicardial mapping may be successful. It can guide and enhance the effectiveness of endocardial ablation. The finding of no epicardial early activation leads to a more persistent new endocardial attempt. When both endocardial and epicardial ablation are unsuccessful, open-chest surgery is the only option to eliminate the AP.
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Affiliation(s)
- Eduardo Back Sternick
- Arrhythmia Unit, Biocor Instituto, Nova Lima, Brazil.,Medical Sciences Faculty of Minas Gerais, Belo Horizonte, Brazil
| | - Mariana Faustino
- Cardiology Department, Hospital Fernando Fonseca, Amadora, Portugal
| | | | - Cristiano Pisani
- Arrhythmia Clinical Unit, Heart Institute, University of Sao Paulo Medical School, Sao Paulo, Brazil
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27
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Roten L, Sacher F, Daly M, Pascale P, Komatsu Y, Ramoul K, Scherr D, Chaumeil A, Shah A, Denis A, Derval N, Hocini M, Haïssaguerre M, Jaïs P. Epicardial Ventricular Tachycardia Ablation for Which Patients? Arrhythm Electrophysiol Rev 2016; 1:39-45. [PMID: 26835028 DOI: 10.15420/aer.2012.1.39] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
With the widespread use of implantable cardioverter-defibrillators, an increasing number of patients present with ventricular tachycardia (VT). Large multicentre studies have shown that ablation of VT successfully reduces recurrent VT and this procedure is being performed by an increasing number of centres. However, for a number of reasons, many patients experience VT recurrence after ablation. One important reason for VT recurrence is the presence of an epicardial substrate involved in the VT circuit which is not affected by endocardial ablation. Epicardial access and ablation is now frequently performed either after failed endocardial VT ablation or as first-line treatment in selected patients. This review will focus on the available evidence for identifying VT of epicardial origin, and discuss in which patients an epicardial approach would be benefitial.
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Affiliation(s)
- Laurent Roten
- Hôpital Cardiologique du Haut-Lévêque and the Université Victor Segalen Bordeaux II, Bordeaux, France
| | - Frédéric Sacher
- Hôpital Cardiologique du Haut-Lévêque and the Université Victor Segalen Bordeaux II, Bordeaux, France
| | - Matthew Daly
- Hôpital Cardiologique du Haut-Lévêque and the Université Victor Segalen Bordeaux II, Bordeaux, France
| | - Patrizio Pascale
- Hôpital Cardiologique du Haut-Lévêque and the Université Victor Segalen Bordeaux II, Bordeaux, France
| | - Yuki Komatsu
- Hôpital Cardiologique du Haut-Lévêque and the Université Victor Segalen Bordeaux II, Bordeaux, France
| | - Khaled Ramoul
- Hôpital Cardiologique du Haut-Lévêque and the Université Victor Segalen Bordeaux II, Bordeaux, France
| | - Daniel Scherr
- Hôpital Cardiologique du Haut-Lévêque and the Université Victor Segalen Bordeaux II, Bordeaux, France
| | - Arnaud Chaumeil
- Hôpital Cardiologique du Haut-Lévêque and the Université Victor Segalen Bordeaux II, Bordeaux, France
| | - Ashok Shah
- Hôpital Cardiologique du Haut-Lévêque and the Université Victor Segalen Bordeaux II, Bordeaux, France
| | - Arnaud Denis
- Hôpital Cardiologique du Haut-Lévêque and the Université Victor Segalen Bordeaux II, Bordeaux, France
| | - Nicolas Derval
- Hôpital Cardiologique du Haut-Lévêque and the Université Victor Segalen Bordeaux II, Bordeaux, France
| | - Mélèze Hocini
- Hôpital Cardiologique du Haut-Lévêque and the Université Victor Segalen Bordeaux II, Bordeaux, France
| | - Michel Haïssaguerre
- Hôpital Cardiologique du Haut-Lévêque and the Université Victor Segalen Bordeaux II, Bordeaux, France
| | - Pierre Jaïs
- Hôpital Cardiologique du Haut-Lévêque and the Université Victor Segalen Bordeaux II, Bordeaux, France
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[Localization of the origin of idiopathic ventricular extrasystoles and tachycardia from the outflow tract]. Herzschrittmacherther Elektrophysiol 2015; 26:227-34. [PMID: 26272441 DOI: 10.1007/s00399-015-0384-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/15/2015] [Indexed: 10/23/2022]
Abstract
Premature ventricular contractions (PVC) are a common cause for complaints. As a rule PVCs are not life-threatening if no structural heart disease is present; however, due to the symptoms treatment is often required using either antiarrhythmic drugs or more commonly catheter ablation. The surface electrocardiogram (ECG) is very helpful in localizing the origin of the arrhythmia, in particular for differentiating right from left ventricular sources.
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Kumar S, Bazaz R, Barbhaiya CR, Enriquez AD, Helmbold AF, Chinitz JS, Baldinger SH, Mahida S, McConville JW, Tedrow UB, John RM, Michaud GF, Stevenson WG. “Needle-in-needle” epicardial access: Preliminary observations with a modified technique for facilitating epicardial interventional procedures. Heart Rhythm 2015; 12:1691-7. [DOI: 10.1016/j.hrthm.2015.03.045] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Indexed: 11/29/2022]
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Scanavacca M, Lara S, Hardy C, Pisani CF. How To Identify & Treat Epicardial Origin Of Outflow Tract Tachycardias. J Atr Fibrillation 2015; 7:1195. [PMID: 27957159 DOI: 10.4022/jafib.1195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 02/13/2015] [Accepted: 03/15/2015] [Indexed: 11/10/2022]
Abstract
The right ventricle outflow tract (RVOT) is the most common site of origin of idiopathic ventricular arrhythmias. The typical outflow tract arrhythmias pattern on ECG is an inferior axis deviation and left bundle branch block when originated on the RVOT and right bundle branch block morphology when originated on the left ventricular outflow tract (LVOT). There are several ECG tricks for different locations of origin. An increased Maximum Deflection Index (MDI) suggests epicardial origin of arrhythmia. In general the result of ablation is very good, but sometimes there are difficult and unsuccessful procedures. The origin in the aortic cusps and epicardium are the reason for failure in some cases. When they are epicardial, the arrhythmias can be accessed by the venous system or by subxiphoid epicardial mapping.
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Affiliation(s)
- Mauricio Scanavacca
- Arrhythmia Clinical Unit - Heart Institute - University of São Paulo Medical School
| | - Sissy Lara
- Arrhythmia Clinical Unit - Heart Institute - University of São Paulo Medical School
| | - Carina Hardy
- Arrhythmia Clinical Unit - Heart Institute - University of São Paulo Medical School
| | - Cristiano F Pisani
- Arrhythmia Clinical Unit - Heart Institute - University of São Paulo Medical School
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Guo XG, Sun QI, Ma J, Liu XU, Zhou GB, Yang JDU, Zhang S. Electrophysiological Characteristics and Radiofrequency Catheter Ablation of Accessory Pathway Connecting the Right Atrial Appendage and the Right Ventricle. J Cardiovasc Electrophysiol 2015; 26:845-852. [PMID: 25917416 DOI: 10.1111/jce.12693] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 03/29/2015] [Accepted: 04/13/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND The accessory pathway (AP) connecting the right atrial appendage (RAA) and the right ventricle (RV) is rare. OBJECTIVE We sought to investigate the feature of the AP connecting the RAA and the RV and the efficacy of radiofrequency catheter ablation via the endocardial access. METHODS We retrospectively analyzed 14 consecutive patients with 14 APs connecting the RAA and the RV managed by 15 procedures between January 2003 and December 2014. RESULTS Ten patients presented as preexcitation during sinus rhythm. All APs had retrograde conduction. None had either antegrade or retrograde decremental conduction property. Ablation targeting the sites at the tricuspid annulus failed in all patients. They were successfully managed by ablating the atrial insertion sites with a median of 10.5 (range 5-28) radiofrequency applications. Electrograms at the successful target showed high amplitude atrial electrogram and low amplitude or no ventricular electrogram. The atrial insertion sites were at the floor of the RAA in 10 patients and inside the lower lobe of the RAA in the remaining 4 patients. The shortest distance between the successful target and the tricuspid annulus in the right anterior oblique projection was 19.7 ± 4.0 mm. There were no complications or recurrences during a median follow-up period of 4.3 (range 0.2-11.8) years. CONCLUSION The APs connecting the RAA and the RV had typical conduction properties. The atrial insertion site favored the floor and the lower lobe of the RAA. Ablation targeting the atrial insertion sites was effective and safe, albeit multiple radiofrequency applications were needed.
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Affiliation(s)
- Xiao-Gang Guo
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Q I Sun
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian Ma
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - X U Liu
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Gong-Bu Zhou
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian-DU Yang
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu Zhang
- State Key Laboratory of Cardiovascular Disease, Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Scanavacca MI, Sternick EB, Pisani C, Lara S, Hardy C, d’Ávila A, Correa FS, Darrieux F, Hachul D, Marcial MB, Sosa EA. Accessory Atrioventricular Pathways Refractory to Catheter Ablation. Circ Arrhythm Electrophysiol 2015; 8:128-36. [DOI: 10.1161/circep.114.002373] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Epicardial mapping and ablation of accessory pathways through a subxiphoid approach can be an alternative when endocardial or epicardial transvenous mapping has failed.
Methods and Results—
We reviewed acute and long-term follow-up of 21 patients (14 males) referred for percutaneous epicardial accessory pathway ablation. There was a median of 2 previous failed procedures. All patients were highly symptomatic, 8 had atrial fibrillation (3 with cardiac arrest) and 13 had frequent symptomatic episodes of atrioventricular reentrant tachycardia. Six patients (28.5%) had a successful epicardial ablation. Five patients (23.8%) underwent a successful repeated endocardial mapping, and ablation after epicardial mapping yielded no early activation site. Epicardial mapping was helpful in guiding endocardial ablation in 2 patients (9.5%), showing that the earliest activation was simultaneous at the epicardium and endocardium. Four patients (19%) underwent successful open-chest surgery after failing epicardial/endocardial ablation. Two patients (9.5%) remained controlled under antiarrhythmic drugs after unsuccessful endocardial/epicardial ablation. Two patients had a coronary sinus diverticulum and one a right atrium to right ventricle diverticulum. Three patients acquired postablation coronary sinus stenosis. There was no major complication related to pericardial access.
Conclusions—
Percutaneous epicardial approach is an alternative when conventional endocardial or transvenous epicardial ablation fails in the elimination of the accessory pathway. A new attempt by endocardial approach was successful in a significant number of patients. Open-chest surgery may be required in symptomatic cases refractory to endocardial–epicardial approach.
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Affiliation(s)
- Maurício Ibrahim Scanavacca
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
| | - Eduardo Back Sternick
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
| | - Cristiano Pisani
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
| | - Sissy Lara
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
| | - Carina Hardy
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
| | - André d’Ávila
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
| | - Frederico Soares Correa
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
| | - Francisco Darrieux
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
| | - Denise Hachul
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
| | - Miguel Barbero Marcial
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
| | - Eduardo A. Sosa
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
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Kumar P, Ferns SJ, Gehi AK. Residual atrial signal or late ventricular signal after accessory pathway ablation: how to resolve the problem? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2014; 38:641-4. [PMID: 25534002 DOI: 10.1111/pace.12555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 10/30/2014] [Accepted: 11/10/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Prabhat Kumar
- Department of Medicine, Division of Cardiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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34
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Teranishi J, Okajima K, Kiuchi K, Shimane A, Fukuzawa K, Kanda G, Yokoi K, Yamada S, Taniguchi Y, Yasaka Y, Kawai H. Anatomical consideration for safe pericardiocentesis assessed by three-dimensional computed tomography: Should an anterior or posterior approach be used? J Arrhythm 2014. [DOI: 10.1016/j.joa.2014.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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CARRIGAN THOMASP, PATEL SMITA, YOKOKAWA MIKI, SCHMIDLIN ERIC, SWANSON SCOTT, MORADY FRED, BOGUN FRANK. Anatomic Relationships Between the Coronary Venous System, Surrounding Structures, and the Site of Origin of Epicardial Ventricular Arrhythmias. J Cardiovasc Electrophysiol 2014; 25:1336-42. [DOI: 10.1111/jce.12497] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 06/18/2014] [Accepted: 07/08/2014] [Indexed: 11/30/2022]
Affiliation(s)
- THOMAS P. CARRIGAN
- Division of Cardiovascular Medicine and Department of Radiology; University of Michigan; Ann Arbor Michigan USA
| | - SMITA PATEL
- Division of Cardiovascular Medicine and Department of Radiology; University of Michigan; Ann Arbor Michigan USA
| | - MIKI YOKOKAWA
- Division of Cardiovascular Medicine and Department of Radiology; University of Michigan; Ann Arbor Michigan USA
| | - ERIC SCHMIDLIN
- Division of Cardiovascular Medicine and Department of Radiology; University of Michigan; Ann Arbor Michigan USA
| | - SCOTT SWANSON
- Division of Cardiovascular Medicine and Department of Radiology; University of Michigan; Ann Arbor Michigan USA
| | - FRED MORADY
- Division of Cardiovascular Medicine and Department of Radiology; University of Michigan; Ann Arbor Michigan USA
| | - FRANK BOGUN
- Division of Cardiovascular Medicine and Department of Radiology; University of Michigan; Ann Arbor Michigan USA
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Hanumandla A, Kaur D, Shah M, Calambur N. Epicardial ablation of focal atrial tachycardia arising from left atrial appendage in children. Indian Pacing Electrophysiol J 2014; 14:199-202. [PMID: 25057221 PMCID: PMC4100085 DOI: 10.1016/s0972-6292(16)30776-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Focal left atrial tachycardia (FLAT) although a common cause of supraventricular tachycardia(SVT) among children, the one's arising from left atrial appendage (LAA) present a unique challenge for successful ablation because of anatomical location. We present two children with FLAT arising from the epicardial LAA, successfully mapped and ablated through percutaneuous epicardial approach.
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Affiliation(s)
| | - Daljeet Kaur
- Care Hospital, the Institute of Medical Sciences, Hyderabad, India
| | - Mandar Shah
- Care Hospital, the Institute of Medical Sciences, Hyderabad, India
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Fernandez-Armenta J, Berruezo A. How to recognize epicardial origin of ventricular tachycardias? Curr Cardiol Rev 2014; 10:246-56. [PMID: 24827797 PMCID: PMC4040876 DOI: 10.2174/1573403x10666140514103047] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 06/10/2013] [Accepted: 01/28/2014] [Indexed: 01/18/2023] Open
Abstract
Percutaneous pericardial access for epicardial mapping and ablation of ventricular arrhythmias has expanded considerably in recent years. After its description in patients with Chagas disease, the technique has provided relevant in-formation on the arrhythmia substrate in other cardiomyopathies and has improved the results of ablation procedures in various clinical settings. Electrocardiographic criteria proposed for the recognition of the epicardial origin of ventricular tachycardias are mainly based on analysis of the first QRS components. Ventricular activation at the epicardium has a slow initial component reflecting the transmural activation and influenced by the absence of Purkinje system in the epicardium. Various parameters (pseudodelta wave, intrinsicoid deflection and shortest RS interval) of these initial intervals predict an epicardial origin in patients with scar-related ventricular tachycardias with right bundle branch block morphology. Using the same concept, the maximum deflection index was defined for the location of idiopathic epicardial tachycardias remote from the aortic root. Electrocardiogram criteria based on the morphology of the first component of the QRS (q wave in lead I) have been proposed in patients with nonischemic cardiomyopathy. All these criteria seem to be substrate-specific and have several limitations. Other information, including type of underlying heart disease, previous failed endocardial ablation, and evidence of epicardial scar on magnetic resonance imaging, can help to plan the ablation procedure and decide on an epicardial approach.
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Affiliation(s)
| | - Antonio Berruezo
- Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clinic, C/ Villarroel 170, 08036 Barcelona, Spain.
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Abstract
Anterior pericardial puncture requires intimate knowledge of the mediastinal anatomy and careful review of the individual anatomic characteristics of each patient. Familiarity with the procedure's anatomic foundations and with the basic principles of each procedural step are critical, but once this is achieved, the procedure is safe and, in most cases, preferable to a standard inferior puncture. An uncomplicated and properly placed pericardial puncture is the basis of a successful of LARIAT suture delivery device procedure. Operators must master the intricacies of the anterior pericardial puncture before embarking on LARIAT left atrial appendage ligation.
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Affiliation(s)
- Miguel Valderrábano
- Division of Cardiac Electrophysiology, Department of Cardiology, Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Baylor College of Medicine, Weill College of Medicine, Cornell University, 6550 Fannin Street, Suite 1901, Houston, TX 77030, USA.
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Komatsu Y, Daly M, Sacher F, Cochet H, Denis A, Derval N, Jesel L, Zellerhoff S, Lim HS, Jadidi A, Nault I, Shah A, Roten L, Pascale P, Scherr D, Aurillac-Lavignolle V, Hocini M, Haïssaguerre M, Jaïs P. Endocardial Ablation to Eliminate Epicardial Arrhythmia Substrate in Scar-Related Ventricular Tachycardia. J Am Coll Cardiol 2014; 63:1416-26. [DOI: 10.1016/j.jacc.2013.10.087] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Revised: 09/03/2013] [Accepted: 10/07/2013] [Indexed: 11/17/2022]
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Abstract
Ventricular tachycardia (VT) may be secondary to many different underlying pathophysiologies. The nature of the underlying disorder determines amenability to catheter ablation, thus, dictating the circumstances under which it should be undertaken. The differing substrates also influence the choice of techniques that are used. The most intensively studied clinical subgroup of VT is re-entrant VT in the setting of ischemic heart disease. The approach to ablation in such patients is discussed in detail. Subsequent discussion focuses on other clinically encountered varieties of VT and the ablation methods used in each individual disease state.
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Affiliation(s)
- Eric J Kessler
- University of Chicago, Clinical Cardiac Electrophysiology Section, Department of Internal Medicine, Chicago, IL 60611, USA.
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Nonischemic cardiomyopathy substrate and ventricular tachycardia in the setting of coronary artery disease. Heart Rhythm 2013; 10:1622-7. [DOI: 10.1016/j.hrthm.2013.08.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Indexed: 11/20/2022]
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43
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TZOU WENDYS, NGUYEN DUYT, ALEONG RYANG, VAROSY PAULD, KATZ DAVIDF, HEATH RUSSELLR, SCHULLER JOSEPHL, LOWERY CHRISTOPHERM, LEWKOWIEZ LAURENT, SAUER WILLIAMH. Endocardial Electrogram Characteristics of Epicardial Ventricular Arrhythmias. J Cardiovasc Electrophysiol 2013; 24:649-54. [DOI: 10.1111/jce.12096] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Revised: 12/19/2012] [Accepted: 01/02/2013] [Indexed: 11/28/2022]
Affiliation(s)
- WENDY S. TZOU
- Section of Cardiac Electrophysiology; University of Colorado School of Medicine; Aurora Colorado USA
| | - DUY T. NGUYEN
- Section of Cardiac Electrophysiology; University of Colorado School of Medicine; Aurora Colorado USA
| | - RYAN G. ALEONG
- Section of Cardiac Electrophysiology; University of Colorado School of Medicine; Aurora Colorado USA
| | - PAUL D. VAROSY
- Section of Cardiac Electrophysiology; University of Colorado School of Medicine; Aurora Colorado USA
| | - DAVID F. KATZ
- Section of Cardiac Electrophysiology; University of Colorado School of Medicine; Aurora Colorado USA
| | - RUSSELL R. HEATH
- Section of Cardiac Electrophysiology; University of Colorado School of Medicine; Aurora Colorado USA
| | - JOSEPH L. SCHULLER
- Section of Cardiac Electrophysiology; University of Colorado School of Medicine; Aurora Colorado USA
| | - CHRISTOPHER M. LOWERY
- Section of Cardiac Electrophysiology; University of Colorado School of Medicine; Aurora Colorado USA
| | - LAURENT LEWKOWIEZ
- Section of Cardiac Electrophysiology; University of Colorado School of Medicine; Aurora Colorado USA
| | - WILLIAM H. SAUER
- Section of Cardiac Electrophysiology; University of Colorado School of Medicine; Aurora Colorado USA
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Abstract
Epicardial ablation has lately become a necessary tool to approach some ventricular tachycardias in different types of cardiomyopathy. Its diffusion is now limited to a few high volume centers not because of the difficulty of the pericardial puncture but since it requires high competence not only in the VT ablation field but also in knowing and recognizing the possible complications each of which require a careful treatment. This article will review the state of the art of epicardial ablation with special attention to the procedural aspects and to the possible selection criteria of the patients
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Affiliation(s)
- Giuseppe Maccabelli
- Arrhythmia Department and Clinical Electrophysiology Laboratories, Ospedale San Raffaele - IRCCS- Milan - Italy
| | - Hiroya Mizuno
- Department of Advanced Cardiovascular Therapeutics, Osaka University Graduate School of Medicine, Osaka Japan
| | - Paolo Della Bella
- Arrhythmia Department and Clinical Electrophysiology Laboratories, Ospedale San Raffaele - IRCCS- Milan - Italy
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Affiliation(s)
- Noel G Boyle
- UCLA Cardiac Arrhythmia Center, 100 UCLA Medical Plaza, Suite 660, Westwood Blvd, Los Angeles CA 90095-7392, USA.
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Di Biase L, Santangeli P, Bai R, Tung R, David Burkhardt J, Shivkumar K, Natale A. The Emerging Role of Epicardial Ablation. Card Electrophysiol Clin 2012; 4:425-437. [PMID: 26939962 DOI: 10.1016/j.ccep.2012.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Sosa and colleagues first described a percutaneous approach (via the subxiphoid area) to access the pericardial space in 1996. Epicardial mapping and ablation is increasingly used for the treatment of supraventricular and ventricular arrhythmias and represents an adjunctive approach for challenging arrhythmias to improve procedural success rates. Epicardial ablation should be considered not only after the failure of an endocardial ablation but often as a first-line approach. Complications may occur during percutaneous access and epicardial ablation, and these might be reduced or avoided by improved operator skills and experience. New tools to access the epicardial space are being evaluated.
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Affiliation(s)
- Luigi Di Biase
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX, USA; Department of Biomedical Engineering, University of Texas, 3000 North I-35, Suite 720, Austin, TX 78705, USA; Department of Cardiology, University of Foggia, Foggia, Italy
| | - Pasquale Santangeli
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX, USA; Department of Cardiology, University of Foggia, Foggia, Italy
| | - Rong Bai
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX, USA
| | - Roderick Tung
- UCLA Cardiac Arrhythmia Center, Los Angeles, CA, USA
| | - J David Burkhardt
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX, USA
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX, USA; Department of Biomedical Engineering, University of Texas, 3000 North I-35, Suite 720, Austin, TX 78705, USA; EP Services, California Pacific Medical Center, San Francisco, CA, USA; Division of Cardiology, Stanford University, Palo Alto, CA, USA; Case Western Reserve University, Cleveland, OH, USA; Interventional Electrophysiology, Scripps Clinic, San Diego, CA, USA
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PARK KYOUNGMIN, KIM YOUHO, MARCHLINSKI FRANCISE. Using the Surface Electrocardiogram to Localize the Origin of Idiopathic Ventricular Tachycardia. Pacing Clin Electrophysiol 2012; 35:1516-27. [DOI: 10.1111/j.1540-8159.2012.03488.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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d'Avila A, Koruth JS, Dukkipati S, Reddy VY. Epicardial access for the treatment of cardiac arrhythmias. Europace 2012; 14 Suppl 2:ii13-ii18. [DOI: 10.1093/europace/eus214] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Makhija A, Thachil A, Rao BH, Sharada K, Narasimhan C. Three dimensional epicardial mapping and ablation of recurrent non-ischaemic ventricular tachycardia. Indian Heart J 2012; 64:324-8. [PMID: 22664820 DOI: 10.1016/s0019-4832(12)60092-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Radiofrequency ablation is a therapeutic option for recurrent ventricular tachycardia (VT) in both ischaemic and non-ischaemic subsets. Usually this is attempted by mapping endocardially; however, in some situations epicardial approach may be needed to access the VT circuit. We report two cases in which epicardial approach was used to successfully ablate the VT, when endocardial ablation was ineffective.
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Affiliation(s)
- Aman Makhija
- Fellow Electrophysiology, CARE Hospitals, Institute of Medical Sciences, Hyderabad, India
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