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Santangeli P, Higuchi K, Sroubek J. Ventricular Tachycardia Ablation Endpoints: Moving Beyond Noninducibility. JACC Clin Electrophysiol 2024; 10:981-999. [PMID: 38385913 DOI: 10.1016/j.jacep.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 12/08/2023] [Accepted: 12/30/2023] [Indexed: 02/23/2024]
Abstract
In patients with structural heart disease and ventricular tachycardia (VT) undergoing catheter ablation, the response to programmed electrical stimulation (PES) at the end of the procedure has been traditionally used to evaluate the acute success and predict long-term outcomes. Although noninducibility at PES has been extensively investigated and validated in clinical trials and large multicenter registries, its performance in predicting long-term freedom from VT is suboptimal. In addition, PES has inherent limitations related to the influence of background antiarrhythmic drug therapy, periprocedural use of anesthesia, and the heterogeneity in PES protocols. The increased utilization of substrate-based ablation approaches that focus on ablation of abnormal electrograms identified with mapping in sinus or paced rhythm has been paralleled by a need for additional procedural endpoints beyond VT noninducibility at PES. This article critically appraises the relative merits and limitations of different procedural endpoints according to different ablation techniques for catheter ablation of scar-related VT.
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Affiliation(s)
- Pasquale Santangeli
- Section of Cardiac Pacing and Electrophysiology, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA.
| | - Koji Higuchi
- Section of Cardiac Pacing and Electrophysiology, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jakub Sroubek
- Section of Cardiac Pacing and Electrophysiology, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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2
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Kujiraoka H, Hojo R, Arai T, Takahashi M, Fukamizu S. Association between residual unipolar voltage and arrhythmia recurrence after left atrial posterior wall isolation for persistent atrial fibrillation. J Cardiovasc Electrophysiol 2023; 34:1622-1629. [PMID: 37393602 DOI: 10.1111/jce.15990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/01/2023] [Accepted: 06/21/2023] [Indexed: 07/04/2023]
Abstract
INTRODUCTION Posterior wall isolation (PWI) combined with pulmonary vein isolation (PVI) has proven effective for persistent atrial fibrillation (AF). However, when performing PWI, creating transmural lesions with subendocardial ablation is sometimes difficult. Endocardial unipolar voltage amplitude had a higher sensitivity than bipolar voltage mapping for identifying intramural viable myocardium in the atria. In this study, we aimed to retrospectively investigate the correlation between the residual potential in the posterior wall (PW) following PWI for persistent AF and atrial arrhythmia recurrence using endocardial unipolar voltage. METHODS This was a single-center observational study. Patients who underwent PVI and PWI for persistent AF in the first procedure between March 2018 and December 2021 at the Tokyo Metropolitan Hiroo Hospital were included in this study. The patients were divided into two groups based on the presence of residual unipolar PW potentials after PWI with a cutoff of 1.08 mV and the recurrence of atrial arrhythmias was compared. RESULTS In total, 109 patients were included in the analysis. Forty-three patients had residual unipolar potentials after PWI and 66 patients had no residual unipolar potentials. The atrial arrhythmia recurrence rate was significantly higher in the group with residual unipolar potential (41.8% vs. 17.9%, p = 0.003). The residual unipolar potential was an independent predictor of recurrence (odds ratio: 4.53; confidence interval: 1.67-12.3, p = 0.003). CONCLUSION Residual unipolar potential after PWI for persistent AF is associated with recurrent atrial arrhythmias.
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Affiliation(s)
- Hirofumi Kujiraoka
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Rintaro Hojo
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Tomoyuki Arai
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Masao Takahashi
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Seiji Fukamizu
- Department of Cardiology, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
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Yavin H, Younis A, Zilberman I, Krywanczyk A, Bubar ZP, Higuchi K, Barkagan M, Anter E. Atrial Endocardial Unipolar Voltage Mapping for Detection of Viable Intramural Myocardium: A Proof-of-Concept Study. Circ Arrhythm Electrophysiol 2023; 16:e011321. [PMID: 36595639 DOI: 10.1161/circep.122.011321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Endocardial bipolar voltage amplitude is largely derived from endocardial and subendocardial wall layers. This may result in situations of low bipolar voltage amplitude despite the presence of mid-myocardial including epicardial (ie, intramural-epicardial) viable myocardium. This study examined the utility of endocardial unipolar voltage mapping for detection of viable intramural-epicardial atrial myocardium. METHODS In 15 swine, an atrial intercaval ablation line with an intentional gap was created. Animals survived for 6 to 8 weeks before electroanatomical mapping followed by sacrifice. Gaps were determined by the presence of electrical conduction and classified based on the histopathologiclly layer(s) of viable myocardium into the following: (1) transmural, (2) endocardial, and (3) intramural-epicardial. Voltage data from healthy, scar, and gap points were exported into excel. The sensitivity and specificity of bipolar and unipolar voltage amplitude to detect intramural-epicardial gaps were compared using receiver operating characteristic analysis. RESULTS In 9 of 15 (60%) swine, a focal ablation gap was detected in the intercaval line, while in the remainder 6 of 15 (40%), the line was complete without gaps. Gaps were classified into transmural (n=3), endocardial (n=3), or intramural-epicardial (n=3). Intramural-epicardial gaps were characterized by very low bipolar voltage amplitude that was similar to areas with transmural scar (P=0.91). In comparison, unipolar voltage amplitude in intramural-epicardial gaps was significantly higher compared to transmural scar (P<0.001). Unipolar voltage amplitude had higher sensitivity (93% versus 14%, respectively) and similar specificity (95% versus 98%, respectively) to bipolar voltage for detection of intramural-epicardial gaps. CONCLUSIONS Atrial unipolar voltage mapping may be a useful technique for identifying viable intramural-epicardial myocardium in patients with endocardial scar.
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Affiliation(s)
- Hagai Yavin
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine (H.Y., A.Y., I.Z., K.H., E.A.), Cleveland Clinic, OH
| | - Arwa Younis
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine (H.Y., A.Y., I.Z., K.H., E.A.), Cleveland Clinic, OH
| | - Israel Zilberman
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine (H.Y., A.Y., I.Z., K.H., E.A.), Cleveland Clinic, OH
| | - Alison Krywanczyk
- Department of Pathology and Laboratory Medicine (A.K.), Cleveland Clinic, OH
| | | | - Koji Higuchi
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine (H.Y., A.Y., I.Z., K.H., E.A.), Cleveland Clinic, OH
| | - Michael Barkagan
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Shamir Medical Center, Be'er Ya'akov, Israel (M.B., E.A.)
| | - Elad Anter
- Cardiac Electrophysiology Section, Department of Cardiovascular Medicine (H.Y., A.Y., I.Z., K.H., E.A.), Cleveland Clinic, OH.,Cardiac Electrophysiology Section, Department of Cardiovascular Medicine, Shamir Medical Center, Be'er Ya'akov, Israel (M.B., E.A.)
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Anderson RD, Rodriguez Padilla J, Joens C, Masse S, Bhaskaran A, Magtibay K, Niri A, Asta J, Lai P, Azam MA, Vigmond E, Nanthakumar K. On the Electrophysiology and Mapping of Intramural Arrhythmic Focus. Circ Arrhythm Electrophysiol 2022; 15:e010384. [PMID: 35323037 DOI: 10.1161/circep.121.010384] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Conventional mapping of focal ventricular arrhythmias relies on unipolar electrogram characteristics and early local activation times. Deep intramural foci are common and associated with high recurrence rates following catheter-based radiofrequency ablation. We assessed the accuracy of unipolar morphological patterns and mapping surface indices to predict the site and depth of ventricular arrhythmogenic focal sources. METHODS An experimental beating-heart model used Langendorff-perfused, healthy swine hearts. A custom 56-pole electrode array catheter was positioned on the left ventricle. A plunge needle was placed perpendicular in the center of the grid to simulate arrhythmic foci at variable depths. Unipolar electrograms and local activation times were generated. Simulation models from 2 human hearts were also included with grids positioned simultaneously on the endocardium-epicardium from multiple left ventricular, septal, and outflow tract sites. RESULTS A unipolar Q or QS complex lacks specificity for superficial arrhythmic foci, as this morphology pattern occupies a large surface area and is the predominant pattern as intramural depth increases without developing a R component. There is progressive displacement from the arrhythmic focus to the surface exit as intramural focus depth increases. A shorter total activation time over the overlying electrode array, larger surface area within initial 20 ms activation, and a dual surface breakout pattern all indicate a deep focus. CONCLUSIONS Displacement from the focal intramural origin to the exit site on the mapping surface could lead to erroneous lesion delivery strategies. Traditional unipolar electrogram features lack specificity to predict the intramural arrhythmic source; however, novel endocardial-epicardial mapping surface indices can be used to determine the depth of arrhythmic foci.
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Affiliation(s)
- Robert D Anderson
- Hull Family Cardiac Fibrillation Management Laboratory, Division of Cardiology, University Health Network, Toronto General Hospital, Ontario, Canada (R.D.A., C.J., S.M., A.B., K.M., A.N., J.A., P.L., M.A.A., K.N.)
| | | | - Christian Joens
- Hull Family Cardiac Fibrillation Management Laboratory, Division of Cardiology, University Health Network, Toronto General Hospital, Ontario, Canada (R.D.A., C.J., S.M., A.B., K.M., A.N., J.A., P.L., M.A.A., K.N.)
| | - Stephane Masse
- Hull Family Cardiac Fibrillation Management Laboratory, Division of Cardiology, University Health Network, Toronto General Hospital, Ontario, Canada (R.D.A., C.J., S.M., A.B., K.M., A.N., J.A., P.L., M.A.A., K.N.)
| | - Abhishek Bhaskaran
- Hull Family Cardiac Fibrillation Management Laboratory, Division of Cardiology, University Health Network, Toronto General Hospital, Ontario, Canada (R.D.A., C.J., S.M., A.B., K.M., A.N., J.A., P.L., M.A.A., K.N.)
| | - Karl Magtibay
- Hull Family Cardiac Fibrillation Management Laboratory, Division of Cardiology, University Health Network, Toronto General Hospital, Ontario, Canada (R.D.A., C.J., S.M., A.B., K.M., A.N., J.A., P.L., M.A.A., K.N.)
| | - Ahmed Niri
- Hull Family Cardiac Fibrillation Management Laboratory, Division of Cardiology, University Health Network, Toronto General Hospital, Ontario, Canada (R.D.A., C.J., S.M., A.B., K.M., A.N., J.A., P.L., M.A.A., K.N.)
| | - John Asta
- Hull Family Cardiac Fibrillation Management Laboratory, Division of Cardiology, University Health Network, Toronto General Hospital, Ontario, Canada (R.D.A., C.J., S.M., A.B., K.M., A.N., J.A., P.L., M.A.A., K.N.)
| | - Patrick Lai
- Hull Family Cardiac Fibrillation Management Laboratory, Division of Cardiology, University Health Network, Toronto General Hospital, Ontario, Canada (R.D.A., C.J., S.M., A.B., K.M., A.N., J.A., P.L., M.A.A., K.N.)
| | - Mohammed Ali Azam
- Hull Family Cardiac Fibrillation Management Laboratory, Division of Cardiology, University Health Network, Toronto General Hospital, Ontario, Canada (R.D.A., C.J., S.M., A.B., K.M., A.N., J.A., P.L., M.A.A., K.N.)
| | - Edward Vigmond
- IHU Liryc, Hôpital Xavier Arnozan, Pessac Cedex, France (J.R.P., E.V.)
| | - Kumaraswamy Nanthakumar
- Hull Family Cardiac Fibrillation Management Laboratory, Division of Cardiology, University Health Network, Toronto General Hospital, Ontario, Canada (R.D.A., C.J., S.M., A.B., K.M., A.N., J.A., P.L., M.A.A., K.N.)
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Celik M, Emiroglu MY, Bayram Z, Izci S, Karagoz A, Akbal OY, Kahyaoglu M, Kup A, Yilmaz Y, Kirali MK, Ozdemir N. Electrophysiologic Changes and Their Effects on Ventricular Arrhythmias in Patients with Continuous-Flow Left Ventricular Assist Devices. ASAIO J 2022; 68:341-348. [PMID: 35213883 DOI: 10.1097/mat.0000000000001472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Ventricular arrhythmias (VAs) continue even after left ventricular assist device (LVAD) implantation. The effect of LVAD on VAs is controversial. We investigated electrophysiologic changes after LVAD and its effects on VAs development. A total of 107 implantable cardioverter-defibrillator (ICD) patients, with LVAD, were included in this study. Electrocardiographic parameters including QRS duration (between the beginning of the QRS complex and the end of the S wave), QT duration (between the first deflection of the QRS complex and the end of the T wave) corrected QT (QTc), QTc dispersion, fragmented QRS (F-QRS), and ICD recordings before, and post-LVAD first year were analyzed. All sustained VAs were classified as polymorphic ventricular tachycardia (PVT) or monomorphic VT (MVT). The QRS, QT, QTc durations, and QTc dispersion had decreased significantly after LVAD implantation (p < 0.001 for all). Also MVT increased significantly from 28.9% to 49.5% (p = 0.019) whereas PVT decreased from 27.1% to 4.67% (p = 0.04) compared to pre-LVAD period. A strong correlation was found between QT shortening and the decrease in PVT occurrence. Besides, the increase in the F-QRS after LVAD was associated with post-LVAD de nova MVT development. Finally, F-QRS before LVAD was found as an independent predictor of post-LVAD late VAs in multivariate analysis. Pre-existing or newly developed F-QRS was associated with post-LVAD late VAs, and it may be used to determine the risk of VAs after LVAD implantation.
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Affiliation(s)
- Mehmet Celik
- From the Department of Cardiology, KartalKosuyolu Heart and Research Hospital, Istanbul, Turkey
| | - Mehmet Yunus Emiroglu
- From the Department of Cardiology, KartalKosuyolu Heart and Research Hospital, Istanbul, Turkey
| | - Zubeyde Bayram
- From the Department of Cardiology, KartalKosuyolu Heart and Research Hospital, Istanbul, Turkey
| | - Servet Izci
- From the Department of Cardiology, KartalKosuyolu Heart and Research Hospital, Istanbul, Turkey
| | - Ali Karagoz
- From the Department of Cardiology, KartalKosuyolu Heart and Research Hospital, Istanbul, Turkey
| | - Ozgur Yasar Akbal
- From the Department of Cardiology, KartalKosuyolu Heart and Research Hospital, Istanbul, Turkey
| | - Muzaffer Kahyaoglu
- From the Department of Cardiology, KartalKosuyolu Heart and Research Hospital, Istanbul, Turkey
| | - Ayhan Kup
- From the Department of Cardiology, KartalKosuyolu Heart and Research Hospital, Istanbul, Turkey
| | - Yusuf Yilmaz
- Department of Cardiology, Istanbul Medeniyet University, Istanbul, Turkey
| | - Mehmet Kaan Kirali
- Department of Cardiovascular Surgery, KartalKosuyolu Heart and Research Hospital, Istanbul, Turkey
| | - Nihal Ozdemir
- From the Department of Cardiology, KartalKosuyolu Heart and Research Hospital, Istanbul, Turkey
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Haqqani HM. Ventricular Tachycardia Substrate Imaging by Cardiac Magnetic Resonance in ICD Patients: Believing Before Seeing. JACC Clin Electrophysiol 2022; 8:236-238. [PMID: 35210081 DOI: 10.1016/j.jacep.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Haris M Haqqani
- Department of Cardiology, The Prince Charles Hospital, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia.
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7
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Limitations and Pitfalls of Substrate Mapping for Ventricular Tachycardia. JACC Clin Electrophysiol 2021; 7:542-560. [PMID: 33888275 DOI: 10.1016/j.jacep.2021.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/08/2021] [Accepted: 02/08/2021] [Indexed: 12/11/2022]
Abstract
The fundamental hypothesis of substrate mapping for scar-mediated ventricular tachycardia is that surrogates of the isthmus can be identified and targeted with ablation during sinus rhythm. These surrogates include electrocardiographic indications for electric discontinuity such as fractionation, split, late, and long potentials, also evident as sites displaying activation slowing. However, ablation strategies targeting these surrogates during sinus rhythm have resulted in unacceptably high rates of clinical failures, promoting the idea that a more widespread ablation may be required. High-resolution mapping technologies provide an opportunity to examine the substrate at greater detail; however, their use has not yet translated into improved clinical outcomes. This may be related to ongoing efforts to examine the same surrogates at higher resolution instead of using high-resolution technologies for discovering new and potentially more specific surrogates. This article reviews common limitations and pitfalls of substrate mapping and discusses new opportunities for high-resolution mapping to increase the accuracy of substrate mapping: 1) multielectrode mapping catheters provide an opportunity to rapidly examine the substrate during electrophysiological conditions that more closely simulate ventricular tachycardia by means of activation from different directions and coupling intervals; 2) electrogram annotation methods based on the maximal negative derivative of the extracellular potential or maximal voltage are often inaccurate in nonuniform anisotropic tissue. The use of multielectrode catheters may improve the accuracy of electrogram annotation by using spatiotemporal dispersion of single-beat acquisitions and a localized indifferent reference; and 3) resetting and entrainment remain important methods for studying re-entry for and guiding ablation.
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Jan M, Žižek D, Prolič Kalinšek T, Kuhelj D, Trunk P, Kolar T, Kšela J, Rauber M, Yazici M. Minimising radiation exposure in catheter ablation of ventricular arrhythmias. BMC Cardiovasc Disord 2021; 21:306. [PMID: 34134637 PMCID: PMC8210369 DOI: 10.1186/s12872-021-02120-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 06/10/2021] [Indexed: 12/05/2022] Open
Abstract
Background Conventional fluoroscopy guided catheter ablation (CA) is an established treatment option for ventricular arrhythmias (VAs). However, with the complex nature of most procedures, patients and staff bare an increased radiation exposure. Near-zero or zero-fluoroscopy CA is an alternative method which could substantially reduce or even eliminate the radiation dose. Our aim was to analyse procedural outcomes with fluoroscopy minimising approach for treatment of VAs in patients with structurally normal hearts (SNH) and structural heart disease (SHD).
Methods Fifty-two (age 53.4 ± 17.8 years, 38 male, 14 female) consecutive patients who underwent CA of VAs in our institution between May 2018 and December 2019 were included. Procedures were performed primarily with the aid of the three-dimensional electro-anatomical mapping system and intra-cardiac echocardiography. Fluoroscopy was considered only in left ventricular (LV) summit mapping for coronary angiography and when epicardial approach was planned. Acute and long-term procedural outcomes were analysed. Results Sixty CA procedures were performed. Twenty-five patients had SHD-related VAs (Group 1) and 27 patients had SNH (Group 2). While Group 1 had significantly higher total procedural time (256.9 ± 71.7 vs 123.6 ± 42.2 min; p < 0.001) compared to Group 2, overall procedural success rate [77.4% (24/31) vs 89.7% (26/29); p = 0.20)] and recurrence rate after the first procedure [8/25, (32%) vs 8/27, (29.6%); p = 0.85] were similar in both groups. Fluoroscopy was used in 3 procedures in Group 1 where epicardial approach was needed and in 4 procedures in Group 2 where LV summit VAs were ablated. Overall procedure-related major complication rate was 5%. Conclusions Fluoroscopy minimising approach for CA of VAs is feasible and safe in patients with SHD and SNH. Fluoroscopy could not be completely abolished in VAs with epicardial and LV summit substrate location.
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Affiliation(s)
- Matevž Jan
- Cardiovascular Surgery Department, University Medical Centre Ljubljana, Zaloška 7, 1000, Ljubljana, Slovenia.
| | - David Žižek
- Cardiology Department, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Tine Prolič Kalinšek
- Cardiovascular Surgery Department, University Medical Centre Ljubljana, Zaloška 7, 1000, Ljubljana, Slovenia
| | - Dimitrij Kuhelj
- Clinical Institute for Radiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Primož Trunk
- Cardiovascular Surgery Department, University Medical Centre Ljubljana, Zaloška 7, 1000, Ljubljana, Slovenia
| | - Tadeja Kolar
- Cardiovascular Surgery Department, University Medical Centre Ljubljana, Zaloška 7, 1000, Ljubljana, Slovenia
| | - Juš Kšela
- Cardiovascular Surgery Department, University Medical Centre Ljubljana, Zaloška 7, 1000, Ljubljana, Slovenia
| | - Martin Rauber
- Cardiology Department, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Mehmet Yazici
- Cardiovascular Surgery Department, University Medical Centre Ljubljana, Zaloška 7, 1000, Ljubljana, Slovenia
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Targeting Abnormal Electrograms for Substrate-Based Ablation of Ventricular Tachycardia. JACC Clin Electrophysiol 2020; 6:812-814. [DOI: 10.1016/j.jacep.2020.04.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 04/06/2020] [Accepted: 04/08/2020] [Indexed: 11/19/2022]
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10
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Ladas TP, Sugrue A, Nan J, Vaidya VR, Padmanabhan D, Venkatachalam KL, Asirvatham SJ. Fundamentals of Cardiac Mapping. Card Electrophysiol Clin 2020; 11:433-448. [PMID: 31400868 DOI: 10.1016/j.ccep.2019.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
To characterize cardiac activity and arrhythmias, electrophysiologists can record the electrical activity of the heart in relation to its anatomy through a process called cardiac mapping (electroanatomic mapping, EAM). A solid understanding of the basic cardiac biopotentials, called electrograms, is imperative to construct and interpret the cardiac EAM correctly. There are several mapping approaches available to the electrophysiologist, each optimized for specific arrhythmia mechanisms. This article provides an overview of the fundamentals of EAM.
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Affiliation(s)
- Thomas P Ladas
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA
| | - Alan Sugrue
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA
| | - John Nan
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA
| | - Vaibhav R Vaidya
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA
| | - Deepak Padmanabhan
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA
| | - K L Venkatachalam
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Jacksonville, Florida, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Division of Heart Rhythm Services, Mayo Clinic, Rochester, MN, USA; Department of Pediatric and Adolescent Medicine, Division of Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA; Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN, USA.
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11
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Anderson RD, Lee G, Prabhu M, Patrick CJ, Trivic I, Campbell T, Chow CK, Kalman JM, Kumar S. Ten-year trends in catheter ablation for ventricular tachycardia vs other interventional procedures in Australia. J Cardiovasc Electrophysiol 2019; 30:2353-2361. [PMID: 31502315 DOI: 10.1111/jce.14143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/05/2019] [Accepted: 08/22/2019] [Indexed: 11/29/2022]
Abstract
AIMS Major technological and procedural advancements have reinvigorated catheter ablation as adjunctive therapy for drug-refractory ventricular tachycardia (VT). We examined temporal trends in VT ablations as compared to other interventional cardiovascular procedures namely, percutaneous coronary intervention (PCI) and atrial fibrillation (AF) ablation in Australia. METHODS AND RESULTS A retrospective review of procedural numbers for VT ablations, AF ablations, and PCI was performed from 2008/09-2016/17 the Australian Institute of Health, Welfare and Aging (AIHW), and Medicare Australia (MA) databases. Linear regression models were fitted to compare the trends in population-adjusted procedural numbers over the 10-year period. Data from the AIHW and MA sources respectively showed that (a) PCI had a 1.3% (AIHW data P = .15) and 1.8% (MA data P < .001) population-adjusted increment per year, (b) AF ablations had a 12.7% (P < .001) and 11.7% (P < .001) per year population-adjusted increment, and (c) VT ablations showed an 18% (P < .001) and 12.7% (P < .001) per year population-adjusted increment. Growth of PCI was increasing at a lower rate than AF ablations (P < .001 for both AIHW and MA sources). Growth of VT ablation was significantly higher than AF ablations and PCI (AIHW: 18% vs 12.7% [P = .004] and 1.3% per year [P < .001]). CONCLUSION Catheter-based VT ablation has increased significantly in Australia over the last decade, consistent with worldwide trends, and now surpassing all ablation procedures, including AF ablation and PCI for CAD. This data highlight the provision of additional resources to match the increasing demand for VT ablation procedures in Australia.
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Affiliation(s)
- Robert D Anderson
- Department of Cardiology, Faculty of Medicine, Dentistry, and Health Science, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia.,Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Geoffrey Lee
- Department of Cardiology, Faculty of Medicine, Dentistry, and Health Science, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Mukund Prabhu
- Department of Cardiology, Faculty of Medicine, Dentistry, and Health Science, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia.,Department of Cardiology, Royal Melbourne Hospital, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
| | - Cameron J Patrick
- Department of Mathematics and Statistics, University of Melbourne, Parkville, Victoria, Australia
| | - Ivana Trivic
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Timothy Campbell
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Clara K Chow
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Jonathan M Kalman
- Department of Cardiology, Faculty of Medicine, Dentistry, and Health Science, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Saurabh Kumar
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia.,Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
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Martinez-Mateu L, Romero L, Saiz J, Berenfeld O. Far-field contributions in multi-electrodes atrial recordings blur distinction between anatomical and functional reentries and may cause imaginary phase singularities - A computational study. Comput Biol Med 2019; 108:276-287. [PMID: 31015048 DOI: 10.1016/j.compbiomed.2019.02.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 02/14/2019] [Accepted: 02/21/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common cardiac arrhythmia and the most important cause of embolic stroke, requiring new technologies for its better understanding and therapies. Recent approaches to map the electrical activity during AF with multi-electrode systems aim at localizing patient-specific ablation targets of reentrant patterns. However, there is a critical need to determine the accuracy of those mapping systems. We performed computer simulations as a numerical approach of systematically evaluating the influence of far-field sources on the electrical recordings and detection of rotors. METHODS We constructed 2 computer models of atrial tissue: (i) a 2D sheet model with varying non-active cells area in its center, and (ii) a whole realistic 3D atrial model. Phase maps were built based on the Hilbert transform of the unipolar electrograms recorded by virtual 2D and 3D multi-electrode systems and rotors were tracked through phase singularities detections. RESULTS Analysis of electrograms recorded away from the 2D atrial model shows that the larger the distance between an electrode and the tissue model, the stronger the far-field sources contribution to the electrogram is. Importantly, even if an electrode is positioned in contact with the tissue, the electrogram contains significant contributions from distal sources that blur the distinction between anatomical and functional reentries. Moreover, when mapping the 3D atrial model, remote activity generated false phase singularities at locations without local reentrant excitation patterns. CONCLUSIONS Far-field contributions to electrograms during AF reduce the accuracy of detecting and interpreting reentrant activity.
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Affiliation(s)
- Laura Martinez-Mateu
- Centro de Investigación e Innovación en Bioingeniería, Universitat Politècnica de València, Valencia, Spain.
| | - Lucia Romero
- Centro de Investigación e Innovación en Bioingeniería, Universitat Politècnica de València, Valencia, Spain
| | - Javier Saiz
- Centro de Investigación e Innovación en Bioingeniería, Universitat Politècnica de València, Valencia, Spain
| | - Omer Berenfeld
- Center for Arrhythmia Research, University of Michigan, Ann Arbor, MI, USA
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Martin R, Hocini M, Haïsaguerre M, Jaïs P, Sacher F. Ventricular Tachycardia Isthmus Characteristics: Insights from High-density Mapping. Arrhythm Electrophysiol Rev 2019; 8:54-59. [PMID: 30918668 PMCID: PMC6434507 DOI: 10.15420/aer.2018.78.2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 01/30/2019] [Indexed: 12/20/2022] Open
Abstract
In the context of structural heart disease, ventricular tachycardia (VT) is related to surviving fibres in incomplete scar. New technologies which allow electroanatomic mapping at higher density and with smaller, more closely spaced electrodes have allowed new insights into the characteristics of VT circuits. VT isthmuses are complex structures, with multiple entrances, exits and dead ends of activation. The isthmus is frequently defined by regions of functional block and several VT circuits can be possible in a VT "critical zone". In this review, we discuss these new insights and how they may improve VT ablation strategies, as well as discussing emerging technologies which may further develop our understanding.
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Affiliation(s)
| | - Mélèze Hocini
- Bordeaux University Hospital, L’Institut de Rythmologie et Modélisation Cardiaque/INSERM 1045Bordeaux, France
| | - Michel Haïsaguerre
- Bordeaux University Hospital, L’Institut de Rythmologie et Modélisation Cardiaque/INSERM 1045Bordeaux, France
| | - Pierre Jaïs
- Bordeaux University Hospital, L’Institut de Rythmologie et Modélisation Cardiaque/INSERM 1045Bordeaux, France
| | - Frédéric Sacher
- Bordeaux University Hospital, L’Institut de Rythmologie et Modélisation Cardiaque/INSERM 1045Bordeaux, France
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Anter E, Kleber AG, Rottmann M, Leshem E, Barkagan M, Tschabrunn CM, Contreras-Valdes FM, Buxton AE. Infarct-Related Ventricular Tachycardia. JACC Clin Electrophysiol 2018; 4:1033-1048. [DOI: 10.1016/j.jacep.2018.04.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 04/19/2018] [Accepted: 04/26/2018] [Indexed: 10/28/2022]
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Hutchinson MD, Garza HHK. Contemporary Tools and Techniques for Substrate Ablation of Ventricular Tachycardia in Structural Heart Disease. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:16. [PMID: 29478118 DOI: 10.1007/s11936-018-0610-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
As we have witnessed in other arenas of catheter-based therapeutics, ventricular tachycardia (VT) ablation has become increasingly anatomical in its execution. Multi-modality imaging provides anatomical detail in substrate characterization, which is often complex in nonischemic cardiomyopathy patients. Patients with intramural, intraseptal, and epicardial substrates provide challenges in delivering effective ablation to the critical arrhythmia substrate due to the depth of origin or the presence of adjacent critical structures. Novel ablation techniques such as simultaneous unipolar or bipolar ablation can be useful to achieve greater lesion depth, though at the expense of increasing collateral damage. Disruptive technologies like stereotactic radioablation may provide a tailored approach to these complex patients while minimizing procedural risk. Substrate ablation is a cornerstone of the contemporary VT ablation procedure, and recent data suggest that it is as effective and more efficient that conventional activation guided ablation. A number of specific targets and techniques for substrate ablation have been described, and all have shown a fairly high success in achieving their acute procedural endpoint. Substrate ablation also provides a novel and reproducible procedural endpoint, which may add predictive value for VT recurrence beyond conventional programmed stimulation. Extrapolation of outcome data to nonischemic phenotypes requires caution given both the variability in substrate nonischemic distribution and the underrepresentation of these patients in previous trials.
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Affiliation(s)
- Mathew D Hutchinson
- Division of Cardiovascular Medicine, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ, USA. .,Sarver Heart Center, University of Arizona, 1501 N. Campbell Avenue, 4142B, Tucson, AZ, 85724, USA.
| | - Hyon-He K Garza
- Division of Cardiovascular Medicine, Department of Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
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Miller JM. Mark E Josephson: Clinical Investigator. Arrhythm Electrophysiol Rev 2017; 6:9-12. [PMID: 28507738 DOI: 10.15420/aer.2017.6.1:ed3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Mark E Josephson entered the world of clinical cardiac electrophysiology (EP) almost at its inception (1972); with so much to learn and so many directions one could take, he dived into the field with unbridled enthusiasm and an uncommon - perhaps almost unique - aptitude for asking questions and finding ways to answer them. Few aspects of EP escaped his indelible influence. In this short paper, I will attempt to touch on some of the high points of his astounding career as a clinical investigator.
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Affiliation(s)
- John M Miller
- Indiana University School of Medicine; Indiana University Health, Indianapolis, USA
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17
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Briceño DF, Romero J, Gianni C, Mohanty S, Villablanca PA, Natale A, Di Biase L. Substrate Ablation of Ventricular Tachycardia: Late Potentials, Scar Dechanneling, Local Abnormal Ventricular Activities, Core Isolation, and Homogenization. Card Electrophysiol Clin 2017; 9:81-91. [PMID: 28167088 DOI: 10.1016/j.ccep.2016.10.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Graham AJ, Orini M, Lambiase PD. Limitations and Challenges in Mapping Ventricular Tachycardia: New Technologies and Future Directions. Arrhythm Electrophysiol Rev 2017; 6:118-124. [PMID: 29018519 DOI: 10.15420/aer.2017.20.1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Recurrent episodes of ventricular tachycardia in patients with structural heart disease are associated with increased mortality and morbidity, despite the life-saving benefits of implantable cardiac defibrillators. Reducing implantable cardiac defibrillator therapies is important, as recurrent shocks can cause increased myocardial damage and stunning, despite the conversion of ventricular tachycardia/ventricular fibrillation. Catheter ablation has emerged as a potential therapeutic option either for primary or secondary prevention of these arrhythmias, particularly in post-myocardial infarction cases where the substrate is well defined. However, the outcomes of catheter ablation of ventricular tachycardia in structural heart disease remain unsatisfactory in comparison with other electrophysiological procedures. The disappointing efficacy of ventricular tachycardia ablation in structural heart disease is multifactorial. In this review, we discuss the issues surrounding this and examine the limitations of current mapping approaches, as well as newer technologies that might help address them.
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Affiliation(s)
| | - Michele Orini
- Barts Heart Centre, London.,Institute of Cardiovascular Science, UCL, London, United Kingdom
| | - Pier D Lambiase
- Barts Heart Centre, London.,Institute of Cardiovascular Science, UCL, London, United Kingdom
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Costea A. Ventricular Tachycardia Ablation: Are We as Successful as We Believe We Are? J Cardiovasc Electrophysiol 2016; 27:1325-1327. [PMID: 27624981 DOI: 10.1111/jce.13097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Alexandru Costea
- Arrhythmia Center, Heart Lung and Vascular Institute, University of Cincinnati, Cincinnati, Ohio, USA
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Abstract
The primary goal of catheter ablation of scar-related ventricular tachycardia (VT) is the interruption of critical areas of slow conduction responsible for the development and maintenance of the reentrant VT circuit. Most patients with scar-related VT present with unstable arrhythmias that are not amenable to interrogation from multiple sites to define the VT circuit based on the intracardiac activation sequence and the response to entrainment mapping. In order to effectively target unstable VTs, a number of ablation approaches have been described with the aim of targeting the abnormal substrate defined with mapping in sinus or paced rhythm. Some of these strategies (eg, late potential and local abnormal ventricular activity ablation or scar homogenization) target the entire abnormal substrate harboring abnormal electrograms, defined with a variety of different criteria. Scar dechanneling, linear ablation through sites matching VT with pacing, and the core isolation approach focus on more discrete regions within the abnormal substrate that have been proven relevant to the clinical and/or inducible arrhythmias by means of physiologic maneuvers, although this does not necessarily translate to fewer radiofrequency lesions to achieve the procedural end-point. Observational studies evaluating different substrate-based ablation techniques have reported fairly uniform arrhythmia-free survivals at short- and mid-term follow-up, although direct comparisons between different techniques are lacking. In this article, we summarize the different state-of-the-art substrate mapping and ablation approaches for targeting unstable VT, with a particular focus on the relative merits and limitations of the described techniques.
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Josephson ME, Anter E. Substrate Mapping for Ventricular Tachycardia: Assumptions and Misconceptions. JACC Clin Electrophysiol 2015; 1:341-352. [PMID: 29759461 DOI: 10.1016/j.jacep.2015.09.001] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 08/31/2015] [Accepted: 09/04/2015] [Indexed: 11/30/2022]
Abstract
Substrate mapping was developed to treat poorly tolerated infarct-related ventricular tachycardias (VTs). This concept was based on 30-year-old data derived from surgical and percutaneous mapping during sinus rhythm and VT that demonstrated specific electrograms (EGMs) that characterized the "arrhythmogenic substrate" of VT. Electrogram characteristics of the arrhythmogenic VT substrate during sinus rhythm included low-voltage, fractionation, long duration, split signals, and isolated late potentials as well as EGMs demonstrating adjacent early and late activation. Introduction of electroanatomical mapping (EAM) systems during the mid-1990s has allowed investigators to record electrograms in 3 dimensions and to identify sites assumed to represent the central common pathway ("isthmus") during re-entrant VTs. However, several important assumptions and misconceptions make currently used "substrate mapping" techniques inaccurate. These include: 1) re-entrant circuits are produced by fixed barriers of immutable "inexcitable" scar; 2) low voltage amplitude (≤0.5 mV) implies dense "inexcitable" scar; 3) isthmuses identified in patients with tolerated VTs using entrainment mapping are both valid and provide an accurate depiction of isthmuses in less hemodynamically tolerated VTs; and 4) current mapping tools and methods can delineate specific electrophysiologic features that will determine the barriers forming channels during re-entrant VTs. None of these assumptions has been validated and recent experimental and human data using higher resolution mapping with very small electrodes cast doubt on their validity. These data call for re-evaluation of substrate-mapping techniques to characterize the arrhythmogenic substrate of post-infarction VT. Standardization of recording techniques including electrode size, interelectrode spacing, tissue contact, catheter orientation, and wavefront activation must be taken into consideration.
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Affiliation(s)
- Mark E Josephson
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Elad Anter
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Vergara P, Roque C, Oloriz T, Mazzone P, Della Bella P. Substrate mapping strategies for successful ablation of ventricular tachycardia: a review. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2015; 83:104-11. [PMID: 23668956 DOI: 10.1016/j.acmx.2013.02.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 02/13/2013] [Accepted: 02/14/2013] [Indexed: 11/27/2022] Open
Abstract
Catheter ablation of ventricular tachycardia (VT) currently has an important role in the treatment of incessant ventricular tachycardia and reduction of the number of episodes of recurrent ventricular tachycardia. Conventional mapping techniques require ongoing tachycardia and haemodynamic stability during the procedure. However, in many patients with scar-related ventricular tachycardia, non-inducibility of clinical tachycardia, poor induction reproducibility, haemodynamic instability, and multiple ventricular tachycardias with frequent spontaneous changes of morphology, preclude tachycardia mapping. To overcome these limitations, new strategies for mapping and ablation in sinus rhythm (SR) - substrate mapping strategies - have been developed and are currently used by many centres. This review summarizes the progresses recently achieved in the ablative treatment of ventricular tachycardia using a substrate mapping approach in patients with structural heart disease.
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Affiliation(s)
- Pasquale Vergara
- Arrhythmia Unit and Electrophysiology Laboratories, San Raffaele Hospital, Milano, Italy.
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23
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Substrate-based approach for ventricular tachycardia in structural heart disease: Tips for mapping and ablation. J Arrhythm 2014. [DOI: 10.1016/j.joa.2014.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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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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Abstract
PURPOSE OF REVIEW Drug-refractory ventricular tachycardia in the setting of structural heart disease results in frequent implantable cardioverter defibrillator therapies and an increased risk of heart failure. Management requires catheter ablation procedures for effective suppression of the arrhythmia. RECENT FINDINGS Imaging and electroanatomic mapping technologies provide new insights into the myocardial structural abnormalities responsible for ventricular tachycardia. Integration of imaging data with three-dimensional mapping systems coupled with improved targeting of abnormal electrical signals may improve the ablation outcomes. New ablation tools show promise for the effective ablation of previously unreachable myocardial ventricular tachycardia circuits. SUMMARY Catheter ablation procedures have evolved over the last 2 decades. Improved technology may contribute to more widespread utilization of catheter ablation in the future.
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Carbucicchio C, Ahmad Raja N, Di Biase L, Volpe V, Dello Russo A, Trivedi C, Bartoletti S, Zucchetti M, Casella M, Russo E, Santangeli P, Moltrasio M, Tundo F, Fassini G, Natale A, Tondo C. High-density substrate-guided ventricular tachycardia ablation: role of activation mapping in an attempt to improve procedural effectiveness. Heart Rhythm 2013; 10:1850-8. [PMID: 24055940 DOI: 10.1016/j.hrthm.2013.09.059] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Indexed: 01/29/2023]
Abstract
BACKGROUND Advanced techniques of electroanatomical mapping efficiently guide ventricular tachycardia (VT) ablation strategies; in this context, the adjunctive value of combining activation mapping (AMap) to improve accuracy has not been elucidated. OBJECTIVE To investigate whether conventional AMap further contributes to the identification of critical sites of VT reentry and whether this translates into a more effective ablation outcome in a cohort of patients undergoing VT ablation. METHODS We prospectively enrolled 126 patients (mean age 65.3 ± 10.5 years; left ventricular ejection fraction 33.3% ± 7.2%) with ischemic (n = 89) or idiopathic (n = 37) dilated cardiomyopathy undergoing endocardial (n = 105) or endo-epicardial (n = 21) electroanatomical mapping and ablation. A substrate-guided strategy targeting surrogate markers of reentry was accomplished in all patients, but the feasibility and efficacy of AMap was preliminarily assessed for all induced VTs focusing on early VT suppression obtained during radiofrequency delivery. VT-free survival was assessed by ICD interrogation. RESULTS AMap successfully guided ablation in 62 of 104 (59.6%) patients with inducible VT(s). At 1 year, 6 of 126 (4.8%) patients died; VT recurred in 28 of 126 (22.2%) patients. No significant difference in VT recurrence rate was observed between patients in whom AMap proved effective versus those in whom substrate-guided ablation was not corroborated by AMap (16 of 62 [25.8%] vs 12 of 64 [18.8%]; log-rank test, P = .3). CONCLUSIONS Our findings support the efficacy of a substrate-guided strategy targeting specific markers of arrhythmogenicity identified during sinus rhythm. AMap proves highly efficient acutely but does not improve overall VT-free survival, suggesting that in patients with advanced cardiac disease, life-threatening arrhythmias can be successfully treated by ablation in sinus rhythm, thus limiting procedural risks.
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Affiliation(s)
- Corrado Carbucicchio
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino, IRCCS, Milan, Italy.
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Cokic I, Kali A, Wang X, Yang HJ, Tang RLQ, Thajudeen A, Shehata M, Amorn AM, Liu E, Stewart B, Bennett N, Harlev D, Tsaftaris SA, Jackman WM, Chugh SS, Dharmakumar R. Iron deposition following chronic myocardial infarction as a substrate for cardiac electrical anomalies: initial findings in a canine model. PLoS One 2013; 8:e73193. [PMID: 24066038 PMCID: PMC3774668 DOI: 10.1371/journal.pone.0073193] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 07/17/2013] [Indexed: 12/02/2022] Open
Abstract
Purpose Iron deposition has been shown to occur following myocardial infarction (MI). We investigated whether such focal iron deposition within chronic MI lead to electrical anomalies. Methods Two groups of dogs (ex-vivo (n = 12) and in-vivo (n = 10)) were studied at 16 weeks post MI. Hearts of animals from ex-vivo group were explanted and sectioned into infarcted and non-infarcted segments. Impedance spectroscopy was used to derive electrical permittivity () and conductivity (). Mass spectrometry was used to classify and characterize tissue sections with (IRON+) and without (IRON-) iron. Animals from in-vivo group underwent cardiac magnetic resonance imaging (CMR) for estimation of scar volume (late-gadolinium enhancement, LGE) and iron deposition (T2*) relative to left-ventricular volume. 24-hour electrocardiogram recordings were obtained and used to examine Heart Rate (HR), QT interval (QT), QT corrected for HR (QTc) and QTc dispersion (QTcd). In a fraction of these animals (n = 5), ultra-high resolution electroanatomical mapping (EAM) was performed, co-registered with LGE and T2* CMR and were used to characterize the spatial locations of isolated late potentials (ILPs). Results Compared to IRON- sections, IRON+ sections had higher, but no difference in. A linear relationship was found between iron content and (p<0.001), but not (p = 0.34). Among two groups of animals (Iron (<1.5%) and Iron (>1.5%)) with similar scar volumes (7.28%±1.02% (Iron (<1.5%)) vs 8.35%±2.98% (Iron (>1.5%)), p = 0.51) but markedly different iron volumes (1.12%±0.64% (Iron (<1.5%)) vs 2.47%±0.64% (Iron (>1.5%)), p = 0.02), QT and QTc were elevated and QTcd was decreased in the group with the higher iron volume during the day, night and 24-hour period (p<0.05). EAMs co-registered with CMR images showed a greater tendency for ILPs to emerge from scar regions with iron versus without iron. Conclusion The electrical behavior of infarcted hearts with iron appears to be different from those without iron. Iron within infarcted zones may evolve as an arrhythmogenic substrate in the post MI period.
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Affiliation(s)
- Ivan Cokic
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
| | - Avinash Kali
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, United States of America
- Department of Biomedical Engineering, University of California Los Angeles, Los Angeles, California, United States of America
| | - Xunzhang Wang
- Heart Institute, Cedars-Sinai Medical Center, Los Angeles California, United States of America
| | - Hsin-Jung Yang
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
- Department of Biomedical Engineering, University of California Los Angeles, Los Angeles, California, United States of America
| | - Richard L. Q. Tang
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
- Department of Radiology, Northwestern University, Chicago, Illinois, United States of America
| | - Anees Thajudeen
- Heart Institute, Cedars-Sinai Medical Center, Los Angeles California, United States of America
| | - Michael Shehata
- Heart Institute, Cedars-Sinai Medical Center, Los Angeles California, United States of America
| | - Allen M. Amorn
- Heart Institute, Cedars-Sinai Medical Center, Los Angeles California, United States of America
| | - Enzhao Liu
- Heart Institute, Cedars-Sinai Medical Center, Los Angeles California, United States of America
| | - Brian Stewart
- Rhythmia Medical, Burlington, Massachusetts, United States of America
| | - Nathan Bennett
- Rhythmia Medical, Burlington, Massachusetts, United States of America
| | - Doron Harlev
- Rhythmia Medical, Burlington, Massachusetts, United States of America
| | - Sotirios A. Tsaftaris
- Institutions Markets Technologies, Institute for Advanced Studies Lucca, Piazza S. Ponziano, Lucca, Italy
- Department of Electrical Engineering and Computer Science, Northwestern University, Evanston, Illinois, United States of America
- Department of Radiology, Northwestern University, Chicago, Illinois, United States of America
| | - Warren M. Jackman
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States of America
| | - Sumeet S. Chugh
- Heart Institute, Cedars-Sinai Medical Center, Los Angeles California, United States of America
- Department of Medicine, University of California Los Angeles, Los Angeles, California, United States of America
| | - Rohan Dharmakumar
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, United States of America
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, United States of America
- Department of Radiology, Northwestern University, Chicago, Illinois, United States of America
- Department of Medicine, University of California Los Angeles, Los Angeles, California, United States of America
- * E-mail:
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Sinno MC, Yokokawa M, Good E, Oral H, Pelosi F, Chugh A, Jongnarangsin K, Ghanbari H, Latchamsetty R, Morady F, Bogun F. Endocardial ablation of postinfarction ventricular tachycardia with nonendocardial exit sites. Heart Rhythm 2013; 10:794-9. [DOI: 10.1016/j.hrthm.2013.02.009] [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: 10/08/2012] [Indexed: 11/16/2022]
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Lin D. Ablation of ventricular tachycardia: inside-out or outside-in? Heart Rhythm 2013; 10:499-500. [PMID: 23286976 DOI: 10.1016/j.hrthm.2012.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2012] [Indexed: 10/27/2022]
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Della Bella P, Bisceglia C, Tung R. Multielectrode contact mapping to assess scar modification in post-myocardial infarction ventricular tachycardia patients. Europace 2013; 14 Suppl 2:ii7-ii12. [PMID: 22832917 DOI: 10.1093/europace/eus213] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Substrate-based approaches for ablation of unmappable ventricular tachycardia (VT) are strictly dependent on high-density mapping of the scar. Ultra-high-density mapping with multielectrode catheters facilitates an accurate and faster definition of sites critical for re-entry, due to the possibility of simultaneous recordings of local potential from different pairs of electrodes. Multipolar catheters can be advanced to map the endocardial or the epicardial surface. A strong correlation between the scar area determined by electroanatomical mapping and the histopathological scar size has been demonstrated. A double-transeptal technique allows for an accurate definition of target sites. The complex scar architecture has been investigated by ultra-high-density mapping, let the identification of islets of heterogeneity where electrograms adjacent to the preserved myocardium have an higher incidence of late potentials. Pacing manoeuvres can easily be performed from any pair of electrode, to demonstrate the involvement of late potentials into the VT circuit. This strategy allows for a clear-cut validation of late potential abolishment, and may offer advantages to shorten procedural and fluoroscopy times. Large series are necessary to definitively assess the potential role of multielectrode mapping as a guide for the substrate ablation approach in post-myocardial infarction VT patients.
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Affiliation(s)
- Paolo Della Bella
- Electrophysiology and Arrhythmologia Unit, Department of Cardiovascular Medicine, San Raffaele Hospital, Milan, Italy.
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HAQQANI HARISM, MARCHLINSKI FRANCISE. Improving the Resolution of Ventricular Tachycardia Substrate Mapping: Marrying (Ultra)Structure and Function. J Cardiovasc Electrophysiol 2012; 24:427-9. [DOI: 10.1111/jce.12061] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Della Bella P, Baratto F. Evolving patterns of ventricular tachycardia modifying our mapping techniques. Europace 2012; 14 Suppl 2:ii1-ii2. [DOI: 10.1093/europace/eus208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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VERGARA PASQUALE, TREVISI NICOLA, RICCO ANNALISA, PETRACCA FRANCESCO, BARATTO FRANCESCA, CIREDDU MANUELA, BISCEGLIA CATERINA, MACCABELLI GIUSEPPE, DELLA BELLA PAOLO. Late Potentials Abolition as an Additional Technique for Reduction of Arrhythmia Recurrence in Scar Related Ventricular Tachycardia Ablation. J Cardiovasc Electrophysiol 2012; 23:621-7. [DOI: 10.1111/j.1540-8167.2011.02246.x] [Citation(s) in RCA: 201] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Callans DJ. Can we eliminate noninducibility by programmed stimulation as an endpoint for ventricular tachycardia ablation in patients with structural heart disease? J Cardiovasc Electrophysiol 2012; 23:628-30. [PMID: 22452674 DOI: 10.1111/j.1540-8167.2011.02274.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Nakahara S, Tung R, Ramirez RJ, Gima J, Wiener I, Mahajan A, Boyle NG, Shivkumar K. Distribution of late potentials within infarct scars assessed by ultra high-density mapping. Heart Rhythm 2010; 7:1817-24. [PMID: 20682358 DOI: 10.1016/j.hrthm.2010.07.032] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2010] [Accepted: 07/25/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Late potential (LP) electrograms represent areas of slow conduction and are often sites critical to reentrant tachycardia circuits. The distribution of LPs within infarct scar is not known. OBJECTIVE The purpose of this study was to delineate infarct heterogeneity using ultra high-density mapping and to determine the location of LPs with respect to scar architecture. METHODS Detailed endocardial (n = 21) and epicardial (n = 8) ultra high-density mapping was performed to delineate the substrate for ventricular tachycardia (VT) in 21 patients with ischemic cardiomyopathy. LP was defined as a low-voltage electrogram (< 1.5 mV) with distinct onset after the QRS. Very late potentials (vLPs) were classified as LPs with onset > 100 ms after the QRS. RESULTS A mean of 787 ± 391 and 810 ± 375 points in the LV endocardium and epicardium were sampled. Multipolar mapping identified heterogeneous islets (HIs) with relatively preserved electrogram amplitudes (≥ 0.51 mv) within dense scar (8.5 ± 4.9/4.5 ± 2.6 HIs per endocardium/epicardium) in all patients. In maps on which putative VT isthmuses were identified (25/29), 57% of vLP were recorded in or adjacent to HI. An LP-targeted ablation strategy combined with pace mapping achieved acute success in all patients (complete success in 52% and partial success in 48%). After 15 ± 7 months, 65% of patients remained free of VT episodes. CONCLUSION Ultra high-density mapping with a multipolar catheter facilitates the delineation of heterogeneous scar architecture at higher resolution. Electrograms within and adjacent to HIs have a higher incidence of vLP, and these sites are frequently critical to reentry. These findings have important implications for substrate-based ablation strategies.
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Affiliation(s)
- Shiro Nakahara
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California 90095-1679, USA
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Relationship of late potentials to the ventricular tachycardia circuit defined by entrainment. J Interv Card Electrophysiol 2009; 26:21-9. [DOI: 10.1007/s10840-009-9421-8] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2009] [Accepted: 06/09/2009] [Indexed: 10/20/2022]
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Haqqani HM, Kalman JM, Roberts-Thomson KC, Balasubramaniam RN, Rosso R, Snowdon RL, Sparks PB, Vohra JK, Morton JB. Fundamental Differences in Electrophysiologic and Electroanatomic Substrate Between Ischemic Cardiomyopathy Patients With and Without Clinical Ventricular Tachycardia. J Am Coll Cardiol 2009; 54:166-73. [DOI: 10.1016/j.jacc.2009.04.024] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Revised: 03/30/2009] [Accepted: 04/20/2009] [Indexed: 10/20/2022]
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Aliot EM, Stevenson WG, Almendral-Garrote JM, Bogun F, Calkins CH, Delacretaz E, Bella PD, Hindricks G, Jais P, Josephson ME, Kautzner J, Kay GN, Kuck KH, Lerman BB, Marchlinski F, Reddy V, Schalij MJ, Schilling R, Soejima K, Wilber D. EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias: Developed in a partnership with the European Heart Rhythm Association (EHRA), a Registered Branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA). Europace 2009; 11:771-817. [DOI: 10.1093/europace/eup098] [Citation(s) in RCA: 283] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Haqqani HM, Marchlinski FE. Electrophysiologic substrate underlying postinfarction ventricular tachycardia: characterization and role in catheter ablation. Heart Rhythm 2009; 6:S70-6. [PMID: 19631910 DOI: 10.1016/j.hrthm.2009.04.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2009] [Indexed: 10/20/2022]
Abstract
The electrophysiologic substrate underlying the development of ventricular tachycardia (VT) in patients with prior infarction has been studied in depth. An increased understanding of its composition and role in the maintenance of reentrant VT has led to the development of substrate modification approaches to ablation of unmappable VT. The area of low bipolar voltage that corresponds to the subendocardial projection of the scar as well as specific potential targets within it have been defined. These targets are selected because they may be involved in forming, or are in close proximity to, critical diastolic isthmuses during VT. The targets include sites of good pacemaps in the border zone, corridors of relatively preserved voltage within dense scar, regions between electrically unexcitable scar, isolated potentials, very late potentials, and regions with good pacemaps which display long stimulus to QRS delays. Ablation strategies have been designed based on these targets, mostly incorporating linear lesions to transect putative isthmus sites. This review examines the role that the electrophysiologic substrate plays in the mechanism of scar-related VT and how this substrate is mapped, defined, and ablated.
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Affiliation(s)
- Haris M Haqqani
- Cardiovascular Division, University of Pennsylvania Health System, Philadelphia, Pennsylvania 19004, USA
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ZEPPENFELD KATJA, STEVENSON WILLIAMG. Ablation of Ventricular Tachycardia in Patients with Structural Heart Disease. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:358-74. [DOI: 10.1111/j.1540-8159.2008.00999.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Stepwise approach to substrate modification of ventricular tachycardia after myocardial infarction. Chin Med J (Engl) 2006. [DOI: 10.1097/00029330-200607020-00008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Abstract
Radiofrequency ablation is a valuable adjunctive therapy to implantable defibrillators in patients with recurrent monomorphic ventricular tachycardia (VT) after myocardial infarction. Episodes of VT are markedly reduced in most patients, and the major complications are less than 5%. Newer approaches allow successful ablation even when VT is unstable, and when multiple VTs are present. Epicardial mapping and ablation are needed in some patients. Continued advances in technology can be expected to further improve results.
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Affiliation(s)
- Kyoko Soejima
- Cardiovascular Division, Department of Internal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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Wolf T, Gepstein L, Dror U, Hayam G, Shofti R, Zaretzky A, Uretzky G, Oron U, Ben-Haim SA. Detailed endocardial mapping accurately predicts the transmural extent of myocardial infarction. J Am Coll Cardiol 2001; 37:1590-7. [PMID: 11345370 DOI: 10.1016/s0735-1097(01)01209-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study delineates between infarcts varying in transmurality by using endocardial electrophysiologic information obtained during catheter-based mapping. BACKGROUND The degree of infarct transmurality extent has previously been linked to patient prognosis and may have significant impact on therapeutic strategies. Catheter-based endocardial mapping may accurately delineate between infarcts differing in the transmural extent of necrotic tissue. METHODS Electromechanical mapping was performed in 13 dogs four weeks after left anterior descending coronary artery ligation, enabling three-dimensional reconstruction of the left ventricular chamber. A concomitant reduction in bipolar electrogram amplitude (BEA) and local shortening indicated the infarcted region. In addition, impedance, unipolar electrogram amplitude (UEA) and slew rate (SR) were quantified. Subsequently, the hearts were excised, stained with 2,3,5-triphenyltetrazolium chloride and sliced transversely. The mean transmurality of the necrotic tissue in each slice was determined, and infarcts were divided into <30%, 31% to 60% and 61% to 100% transmurality subtypes to be correlated with the corresponding electrical data. RESULTS From the three-dimensional reconstructions, a total of 263 endocardial points were entered for correlation with the degree of transmurality (4.6 +/- 2.4 points from each section). All four indices delineated infarcted tissue. However, BEA (1.9 +/- 0.7 mV, 1.4 +/- 0.7 mV, 0.8 +/- 0.4 mV in the three groups respectively, p < 0.05 between each group) proved superior to SR, which could not differentiate between the second (31% to 60%) and third (61% to 100%) transmurality subgroups, and to UEA and impedance, which could not differentiate between the first (<30%) and second transmurality subgroups. CONCLUSIONS The degree of infarct transmurality extent can be derived from the electrical properties of the endocardium obtained via detailed catheter-based mapping in this animal model.
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Affiliation(s)
- T Wolf
- Cardiovascular System Laboratory, The Bruce Rappaport Faculty of Medicine, Haifa, Israel
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Ellison KE, Stevenson WG, Sweeney MO, Lefroy DC, Delacretaz E, Friedman PL. Catheter ablation for hemodynamically unstable monomorphic ventricular tachycardia. J Cardiovasc Electrophysiol 2000; 11:41-4. [PMID: 10695460 DOI: 10.1111/j.1540-8167.2000.tb00734.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Hemodynamic collapse precludes extensive catheter mapping to identify focal target regions in many patients with ventricular tachycardia (VT) associated with heart disease. This study tested the feasibility of catheter ablation of poorly tolerated VTs by targeting a region identified during sinus rhythm. METHODS AND RESULTS Ablation was attempted in five patients, ages 44 to 59 years, with left ventricular ejection fractions of 0.15 to 0.20 and poorly tolerated VT causing multiple implantable defibrillator therapies (6 to 30 episodes/month). VT was due to prior infarction in three patients and nonischemic cardiomyopathy in two. Target regions were sought that met the following criteria: (1) evidence of slow conduction from fractionated sinus rhythm electrograms and stimulus-QRS delays during pace mapping, and (2) evidence that the region contains the reentrant circuit exit from pace mapping. In 4 of 5 patients, a target region was identified and radiofrequency lesions applied. Ablation abolished all recurrences of VT in 3 of 4 patients during follow-up of 14 to 22 months. There were no complications. CONCLUSION Ablation of poorly tolerated VT is feasible in some patients by mapping during sinus rhythm and performing ablation over a region of identifiable scar that contains abnormal conduction and a presumptive VT exit.
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Affiliation(s)
- K E Ellison
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA
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Lacroix D, Klug D, Grandmougin D, Jarwe M, Kouakam C, Kacet S. Ventricular tachycardia originating from the posteroseptal process of the left ventricle with inferior wall healed myocardial infarction. Am J Cardiol 1999; 84:181-6. [PMID: 10426337 DOI: 10.1016/s0002-9149(99)00231-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Ventricular tachycardia (VT) substrates may form in preferential locations and similar electrocardiographic patterns may be observed when ventricular activation starts from a particular site. We examined the role of the posterior inferior process of the left ventricle in the mechanism of VT occurring after inferior wall myocardial infarction. We reviewed isochronal maps of 40 VTs obtained at surgery in 13 patients, with a 128-electrode system using epicardial sock and endocardial balloon electrode arrays. Based on the epicardial to left endocardial relation we observed 7 tachycardias in 7 patients with onset of activation over the crux of the heart. This activation mimicked excitation through a posteroseptal accessory pathway. Endocardial activation maps showed breakthroughs occurring 6 to 40 ms later and did not give evidence in favor of macroreentry. In all but 1 VT, left-axis deviation was present (-30 to -75 degrees) with a positive concordance from leads V2 to V6 (QRS wave patterns were variable in V1). These tachycardias, which were clinical in 3 of 7 cases, were interpreted as arising from the posterior inferior process of the left ventricle and successfully ablated by left septal and epicardial cryolesions. In another patient, this concept was further validated by percutaneous radiofrequency ablation of a tachycardia with the previously described morphology. In conclusion, VT may originate from the posteroseptal process of the left ventricle with inferior wall healed myocardial infarction. Because these tachycardias can be successfully eliminated, their characteristic morphologies may provide clinical markers for the identification of patient candidates to surgical or nonsurgical ablative therapy.
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Affiliation(s)
- D Lacroix
- Department of Cardiology, University of Lille, France.
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Lacroix D, Warembourg H, Klug D, Decoene C, Kacet S. Intraoperative computerized mapping of ventricular tachycardia: differences between anterior and inferior myocardial infarctions. J Cardiovasc Electrophysiol 1999; 10:781-90. [PMID: 10376914 DOI: 10.1111/j.1540-8167.1999.tb00257.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Although direct ventricular tachycardia (VT) surgery has been shown to be effective for treatment of inferior myocardial infarction (MI), the differences in the arrhythmia substrates compared to anterior MI have not been systematically delineated. We sought to compare operative procedures and VT substrates between anterior and inferior MI locations. METHODS AND RESULTS Computerized mapping was performed in 30 patients with a 128-electrode system using epicardial sock and transatrial left ventricular endocardial balloon arrays, followed by combined endocardial resection and cryoablation. At surgery, there were 51 and 34 different VTs in 18 patients with anterior MI and 12 patients with inferior MI, respectively. The proportion of aneurysms was lower in inferior MI (25% vs 78%, P = 0.008). Total activation times accounted for 65% +/- 23% and 50% +/- 22% of the VT cycle length in anterior and inferior infarcts, respectively (P = 0.005). Complete superficial reentry was identified in 12 VTs related to anterior infarcts and in only two VTs associated with inferior infarction (P = 0.038). Involvement of papillary muscles occurred in two patients with inferior MI. Patients with inferior infarcts received more cryolesions and required epicardial cryolesions or mitral valve replacement more frequently, and their operative mortality was greater (2/12 vs 0/18). Noninducibility rate (89.3%) and 2-year survival (76% +/- 8%) did not differ according to infarct location. CONCLUSION VT associated with inferior MI can be ablated successfully; however, the substrate is more complex, with frequent participation of intramural layers rendering the ablative procedure more difficult.
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Affiliation(s)
- D Lacroix
- Department of Cardiology, University of Lille, France.
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Friedman PL. Is the postpacing interval of any value during ablation of postinfarction ventricular tachycardia? J Cardiovasc Electrophysiol 1999; 10:52-5. [PMID: 9930909 DOI: 10.1111/j.1540-8167.1999.tb00641.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- P L Friedman
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA
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Stevenson WG, Delacretaz E, Friedman PL, Ellison KE. Identification and ablation of macroreentrant ventricular tachycardia with the CARTO electroanatomical mapping system. Pacing Clin Electrophysiol 1998; 21:1448-56. [PMID: 9670190 DOI: 10.1111/j.1540-8159.1998.tb00217.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Monomorphic ventricular tachycardias associated with regions of scar are most commonly due to reentry. Catheter based techniques have recently been described for mapping of reentry circuits. Fluoroscopic methods have obvious limitations when attempting to map large ventricular reentry circuit and localize target-sites of radiofrequency ablation. Three-dimensional right ventricular endocardial mapping was performed in a 38-year-old patient with ventricular tachycardia 28 years after surgical correction of tetralogy of Fallot by using the CARTO electroanatomical system. The map of electrogram voltage showed low amplitude electrograms over the anterior wall of the right ventricle extending into the right ventricular outflow tract, consistent with the location of the ventriculotomy scar. Recording of local activation time was combined with entrainment mapping to define the macroreentrant circuit during ventricular tachycardia. Since the activation propagated through a broad path around the right ventriculotomy scar, ablation was performed by creating a line of block, which was facilitated by tagging of the lesion sites on the endocardial activation map. Large ventricular reentry circuits can be identified and interrupted by creation of a line of block to interrupt a broad path. A practical approach to mapping combining analysis of electrogram voltage, activation sequence, and entrainment is presented.
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Affiliation(s)
- W G Stevenson
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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stevenson WG, Friedman PL, Ganz LI. Radiofrequency catheter ablation of ventricular tachycardia late after myocardial infarction. J Cardiovasc Electrophysiol 1997; 8:1309-19. [PMID: 9395175 DOI: 10.1111/j.1540-8167.1997.tb01023.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Radiofrequency catheter ablation is a promising method for controlling ventricular tachycardia (VT) due to prior myocardial infarction. Limitations of mapping and ablation techniques have largely restricted its use to selected patients who have hemodynamically tolerated sustained monomorphic VT that allows catheter mapping. Multiple monomorphologies of VT, which are usually present, often complicate the ablation procedure and interpretation of ablation effects. Ablation is generally restricted to experienced centers and is usually reserved for patients who have failed other therapies. Despite these difficulties, successful ablation can be life-saving in patients with incessant VT and can markedly improve quality of life with frequent shocks from implantable defibrillators.
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Affiliation(s)
- W G stevenson
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA
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