1
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Dhakal BP, Patel NA, Garg L, Frankel DS, Hyman MC, Guandalini GS, Supple GE, Nazarian S, Kumareswaran R, Riley MP, Santangeli P, Lin D, Callans DJ, Arkles J, Schaller RD, Tschabrunn CM, Zado ES, Marchlinski FE, Dixit S. Utility of Very High-Output Pacing to Identify VT Circuits in Patients Manifesting Traditionally Inexcitable Scar. JACC Clin Electrophysiol 2023; 9:2523-2533. [PMID: 37715743 DOI: 10.1016/j.jacep.2023.08.015] [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: 06/13/2023] [Revised: 08/11/2023] [Accepted: 08/13/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Entrainment and pace mapping are used to identify critical components (CCs) of ventricular tachycardia (VT) circuits. In patients with dense myocardial scarring, VT circuits may elude capture at standard high pacing outputs (up to 10 mA at a 2-millisecond pulse width). OBJECTIVES The purpose of this study was to assess the utility of very high-output pacing (V-HOP, 50 mA at 2 milliseconds) for identifying CCs of VT circuits after standard high pacing output failed to elicit capture in densely scarred myocardial tissue. METHODS Our standard VT ablation approach included electroanatomic mapping for substrate characterization and entrainment and/or pace mapping to identify CCs of VT circuits. Patients that required V-HOP to capture sites of interest comprised the study cohort. Ablation endpoints were VT termination and noninducibility. RESULTS Twenty-five patients (71 ± 10 years of age, all males) undergoing 26 VT ablations met the inclusion criteria. The mean left ventricular ejection fraction was 30% ± 14%, and 85% had ischemic cardiomyopathy. V-HOP was used to successfully entrain VT in 17 patients, yielding central isthmus sites in 10 and entrance/exit sites in 4. VT terminated with radiofrequency ablation at these sites in 15 patients. In 9 patients, V-HOP identified scar locations with a delayed exit. Acute procedural success was achieved in 24 patients without any adverse events. Over a follow-up period of 16 ± 21 months, 2 patients experienced VT recurrence requiring repeat ablation during which the same location was targeted successfully in 1 patient. CONCLUSIONS In VT patients with a dense scar that is traditionally inexcitable, V-HOP can identify CCs of the re-entrant circuit and guide successful ablation.
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Affiliation(s)
- Bishnu P Dhakal
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Neel A Patel
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lohit Garg
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Frankel
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew C Hyman
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gustavo S Guandalini
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gregory E Supple
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Saman Nazarian
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ramanan Kumareswaran
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael P Riley
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pasquale Santangeli
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Lin
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J Callans
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey Arkles
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert D Schaller
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cory M Tschabrunn
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erica S Zado
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sanjay Dixit
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Atreya AR, Yalagudri SD, Subramanian M, Rangaswamy VV, Saggu DK, Narasimhan C. Best Practices for the Catheter Ablation of Ventricular Arrhythmias. Card Electrophysiol Clin 2022; 14:571-607. [PMID: 36396179 DOI: 10.1016/j.ccep.2022.08.007] [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: 06/16/2023]
Abstract
Techniques for catheter ablation have evolved to effectively treat a range of ventricular arrhythmias. Pre-operative electrocardiographic and cardiac imaging data are very useful in understanding the arrhythmogenic substrate and can guide mapping and ablation. In this review, we focus on best practices for catheter ablation, with emphasis on tailoring ablation strategies, based on the presence or absence of structural heart disease, underlying clinical status, and hemodynamic stability of the ventricular arrhythmia. We discuss steps to make ablation safe and prevent complications, and techniques to improve the efficacy of ablation, including optimal use of electroanatomical mapping algorithms, energy delivery, intracardiac echocardiography, and selective use of mechanical circulatory support.
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Affiliation(s)
- Auras R Atreya
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India; Division of Cardiovascular Medicine, Electrophysiology Section, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sachin D Yalagudri
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India
| | - Muthiah Subramanian
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India
| | | | - Daljeet Kaur Saggu
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India
| | - Calambur Narasimhan
- Electrophysiology Section, AIG Hospitals Institute of Cardiac Sciences and Research, Hyderabad, India.
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3
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Nayyar S. Intracardiac Electrogram Targets for Ventricular Tachycardia Ablation. Card Electrophysiol Clin 2022; 14:559-570. [PMID: 36396178 DOI: 10.1016/j.ccep.2022.06.001] [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: 06/16/2023]
Abstract
The pathogenesis of ventricular tachycardia (VT) in most patients with a prior myocardial scarring is reentry involving compartmentalized muscle fibers protected within the scar. Often the 12-lead ECG morphology of the VT itself is not available when treated with a defibrillator. Consequently, VT ablation takes on an interesting challenge of finding critical targets in sinus rhythm. High-density recordings are essential to evaluate a substrate based on whole electrogram voltage and activation delay, supplemented with substrate perturbation through alternate site pacing or introducing an extra stimulation. In this article, we discuss contemporary intracardiac electrogram targets for VT ablation, with explanation on each of their specific fundamental physiology.
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Affiliation(s)
- Sachin Nayyar
- Townsville University Hospital, James Cook University, Townsville, Queensland, Australia.
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4
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Comparison between Standard and High-Definition Multi-Electrode Mapping Catheter in Ventricular Tachycardia Ablation. J Cardiovasc Dev Dis 2022; 9:jcdd9080232. [PMID: 35893222 PMCID: PMC9330382 DOI: 10.3390/jcdd9080232] [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: 06/26/2022] [Revised: 07/16/2022] [Accepted: 07/19/2022] [Indexed: 12/10/2022] Open
Abstract
A high-definition mapping catheter has been introduced, allowing for bipolar recording along and across the spline with a rapid assessment of voltage, activation, and directionality of conduction. We aimed to evaluate differences in mapping density, accuracy, time, and consequently RF time between different mapping catheters used for ventricular tachycardia (VT) ablation. We enrolled consecutive patients undergoing VT ablation at our center. Patients were divided into the LiveWire 2-2-2 mm catheter (group A) and the HD Grid SE (group B). Primary endpoints were total RF delivery time, the number of points acquired in sinus rhythm and VT, and the scar area. Fifty-one patients were enrolled, 22 in group A and 29 in group B. More points were acquired in the Grid group in sinus rhythm (SR) and during VT (2060.78 ± 1600.38 vs. 3278.63 ± 3214.45, p = 0.05; 4201.13 ± 5141.61 vs. 10,569.43 ± 13,644.94, p = 0.02, respectively). The scar area was smaller in group B (Bipolar area, cm2 4.52 ± 2.72 vs. 2.89 ± 2.81, p = 0.05. Unipolar area, cm2 7.47 ± 4.55 vs. 5.56 ± 2.79, p = 0.03). Radiofrequency (RF) time was shorter in the Grid group (30.52 ± 13.94 vs. 22.16 ± 11.03, p = 0.014). LPs and LAVAs were eliminated in overall >93% of patients. No differences were found in terms of arrhythmia-free survival at follow-up. In conclusion, the use of a high-definition mapping catheter was associated with significantly shorter mapping time during VT and RF time. Significantly more points were acquired in SR and during VT. During remap, we also observed more LAVAs and LPs requiring further ablation.
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5
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Richardson TD, Stevenson WG. High Density Pace-Mapping for Scar-related Ventricular Tachycardia Ablation. J Cardiovasc Electrophysiol 2022; 33:1810-1812. [PMID: 35665563 DOI: 10.1111/jce.15585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 05/26/2022] [Indexed: 11/28/2022]
Abstract
Despite advances in medical and interventional therapies, ventricular tachycardia (VT) due to reentrant activity within complex regions of myocardial scar remains a common late complication of myocardial infarction This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Travis D Richardson
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - William G Stevenson
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Callans DJ, Donahue JK. Repolarization Heterogeneity in Human Post-Infarct Ventricular Tachycardia. JACC Clin Electrophysiol 2022; 8:713-718. [PMID: 35738846 DOI: 10.1016/j.jacep.2022.03.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 03/01/2022] [Accepted: 03/02/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Slow conduction, caused by fibrosis between surviving myocytes and connexin remodeling, is an important prerequisite for post-infarction ventricular tachycardia (VT); however, slow conduction is present throughout the infarct whereas VT circuits are finite in number and discrete. In a porcine model of VT, re-entrant circuits occur at region of significant repolarization heterogeneity caused by up-regulation of potassium channel β-subunits KCNE3 (increasing repolarization current) and KCNE4 (decreasing repolarization current), causing heterogeneous action potential durations. OBJECTIVES This study was designed to determine whether re-entrant circuits in human post-infarction VT are associated with repolarization heterogeneity. METHODS In 6 patients, left ventricular mapping was performed during induced VT to identify sites within the VT circuit. Subsequently, unipolar mapping (3.5-mm tip ablation catheter) was performed to characterize activation-recovery intervals (ARIs), which are surrogates for local action potential durations, at sites documented within the VT circuit isthmus (IN) compared to sites within the infarct scar but outside of the VT circuit (OUT). RESULTS ARIs were significantly shorter in the IN compared with the OUT sites (420.2 ± 79.3 ms vs 462 ± 52.8 ms; P = 0.01). In all patients. sites that were associated with the circuit always had shorter ARI values than did those sampled from OUT regions. CONCLUSIONS VT circuit sites in human post-infarct VT are associated with repolarization heterogeneity, similar to what was previously reported in a porcine model. This suggests the possibility of a common mechanism between humans and the porcine model of post-infarct VT, and that development of ablation strategies or small molecule or genetic therapies to restore normal repolarization kinetics may be antiarrhythmic.
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Affiliation(s)
- David J Callans
- Cardiac Electrophysiology Section, Cardiovascular Medicine Division, Department of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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7
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Schleberger R, Schwarzl JM, Moser J, Nies M, Höller A, Münkler P, Dinshaw L, Jungen C, Lemoine MD, Maury P, Sacher F, Martin CA, Wong T, Estner HL, Jaïs P, Willems S, Eickholt C, Meyer C. The impact of ultra-high-density mapping on long-term outcome after catheter ablation of ventricular tachycardia. Sci Rep 2022; 12:9139. [PMID: 35650230 PMCID: PMC9160260 DOI: 10.1038/s41598-022-12918-7] [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: 12/12/2021] [Accepted: 05/18/2022] [Indexed: 11/09/2022] Open
Abstract
Ultra-high-density (UHD) mapping can improve scar area detection and fast activation mapping in patients undergoing catheter ablation of ventricular tachycardia (VT). The aim of the present study was to compare the outcome after VT ablation guided by UHD and conventional point-by-point 3D-mapping. The acute and long-term ablation outcome of 61 consecutive patients with UHD mapping (64-electrode mini-basket catheter) was compared to 61 consecutive patients with conventional point-by-point 3D-mapping using a 3.5 mm tip catheter. Patients, whose ablation was guided by UHD mapping had an improved 24-months outcome in comparison to patients with conventional mapping (cumulative incidence estimate of the combination of recurrence or disease-related death of 52.4% (95% confidence interval (CI) [36.9-65.7]; recurrence: n = 25; disease-related death: n = 4) versus 69.6% (95% CI [55.9-79.8]); recurrence: n = 31; disease-related death n = 11). In a cause-specific Cox proportional hazards model, UHD mapping (hazard ratio (HR) 0.623; 95% CI [0.390-0.995]; P = 0.048) and left ventricular ejection fraction > 30% (HR 0.485; 95% CI [0.290-0.813]; P = 0.006) were independently associated with lower rates of recurrence or disease-related death. Other procedural parameters were similar in both groups. In conclusion, UHD mapping during VT ablation was associated with fewer VT recurrences or disease-related deaths during long-term follow-up in comparison to conventional point-by-point mapping. Complication rates and other procedural parameters were similar in both groups.
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Affiliation(s)
- Ruben Schleberger
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
| | - Jana M Schwarzl
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Moser
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Moritz Nies
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexandra Höller
- Center of Experimental Medicine, Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Paula Münkler
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany
| | - Leon Dinshaw
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christiane Jungen
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany.,Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden University Medical Center, Leiden, The Netherlands
| | - Marc D Lemoine
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philippe Maury
- Department of Cardiology, University Hospital Rangueil, Toulouse, France
| | - Frederic Sacher
- LIRYC Institute, CHU Bordeaux, University of Bordeaux, Bordeaux, France
| | - Claire A Martin
- Royal Papworth Hospital, National Health Service Foundation Trust, Cambridge, UK
| | - Tom Wong
- Heart Rhythm Center, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, London, UK
| | - Heidi L Estner
- Department of Internal Medicine I - Cardiology, University Hospital Munich, Ludwig-Maximilian University Munich, Munich, Germany
| | - Pierre Jaïs
- LIRYC Institute, CHU Bordeaux, University of Bordeaux, Bordeaux, France
| | - Stephan Willems
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany.,Department of Cardiology, Asklepios Hospital St. Georg, Hamburg, Germany
| | - Christian Eickholt
- Department of Cardiology, Asklepios Hospital St. Georg, Hamburg, Germany
| | - Christian Meyer
- DZHK (German Center for Cardiovascular Research), Partner Site Hamburg/Kiel/Lübeck, Berlin, Germany. .,Department of Cardiology, Cardiac Neuro- and Electrophysiology Research Consortium (cNEP), EVK Düsseldorf, Düsseldorf, Germany. .,Cardiac Neuro- and Electrophysiology Research Consortium (cNEP), Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.
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8
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de Oliveira Dietrich C, de Oliveira Hollanda L, Cirenza C, de Paola AAV. Epicardial and Endocardial Ablation Based on Channel Mapping in Patients With Ventricular Tachycardia and Chronic Chagasic Cardiomyopathy: Importance of Late Potential Mapping During Sinus Rhythm to Recognize the Critical Substrate. J Am Heart Assoc 2021; 11:e021889. [PMID: 34927451 PMCID: PMC9075208 DOI: 10.1161/jaha.121.021889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background Ventricular tachycardia (VT) in patients with chronic chagasic cardiomyopathy (CCC) is associated with considerable morbidity and mortality. Catheter ablation of VT in patients with CCC is very complex and challenging. The main goal of this work was to assess the efficacy of VT catheter ablation guided by late potentials (LPs) in patients with CCC. Methods and Results Seventeen consecutive patients with refractory VT and CCC were prospectively included in the study. Combined endo‐epicardial voltage and late activation mapping were obtained during baseline rhythm to define scarred and LP areas, respectively. The end point of the ablation procedure was the elimination of all identified LPs. Epicardial and endocardial dense scars (<0.5 mV) were detected in 17/17 and 15/17 patients, respectively. LPs were detected in the epicardial scars of 16/17 patients and in the endocardial scars of 14/15 patients. A total of 63 VTs were induced in 17 patients; 22/63 (33%) were stable and entrained, presenting LPs recorded in the isthmus sites. The end point of ablation was achieved in 15 of 17 patients. Ablation was not completed in 2 patients because of cardiac tamponade or vicinity of the phrenic nerve and circumflex artery. Three patients (2 with unsuccessful ablation) had VT recurrence during follow‐up (39 months). Conclusions Endo‐epicardial LP mapping allows us to identify the putative isthmuses of different VTs and effectively perform catheter ablation in patients with CCC and drug‐refractory VTs.
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Affiliation(s)
- Cristiano de Oliveira Dietrich
- Clinical Cardiac Electrophysiology Cardiology Division Department of Medicine Hospital São Paulo Escola Paulista de Medicina - Universidade Federal of São Paulo São Paulo Brazil
| | - Lucas de Oliveira Hollanda
- Clinical Cardiac Electrophysiology Cardiology Division Department of Medicine Hospital São Paulo Escola Paulista de Medicina - Universidade Federal of São Paulo São Paulo Brazil
| | - Claudio Cirenza
- Clinical Cardiac Electrophysiology Cardiology Division Department of Medicine Hospital São Paulo Escola Paulista de Medicina - Universidade Federal of São Paulo São Paulo Brazil
| | - Angelo Amato Vincenzo de Paola
- Clinical Cardiac Electrophysiology Cardiology Division Department of Medicine Hospital São Paulo Escola Paulista de Medicina - Universidade Federal of São Paulo São Paulo Brazil
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Gaeta S, Bahnson TD, Henriquez C. High-Resolution Measurement of Local Activation Time Differences From Bipolar Electrogram Amplitude. Front Physiol 2021; 12:653645. [PMID: 33967825 PMCID: PMC8100452 DOI: 10.3389/fphys.2021.653645] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 03/30/2021] [Indexed: 11/13/2022] Open
Abstract
Localized changes in myocardial conduction velocity (CV) are pro-arrhythmic, but high-resolution mapping of local CV is not yet possible during clinical electrophysiology procedures. This is in part because measurement of local CV at small spatial scales (1 mm) requires accurate annotation of local activation time (LAT) differences with very high temporal resolution (≤1 ms), beyond that of standard clinical methods. We sought to develop a method for high-resolution measurement of LAT differences and validate against existing techniques. First, we use a simplified theoretical model to identify a quantitative relationship between the LAT difference of a pair of electrodes and the peak amplitude of the bipolar EGM measured between them. This allows LAT differences to be calculated from bipolar EGM peak amplitude, by a novel "Determination of EGM Latencies by Transformation of Amplitude" (DELTA) method. Next, we use simulated EGMs from a computational model to validate this method. With 1 kHz sampling, LAT differences less than 4 ms were more accurately measured with DELTA than by standard LAT annotation (mean error 3.8% vs. 22.9%). In a 1-dimensional and a 2-dimension model, CV calculations were more accurate using LAT differences found by the DELTA method than by standard LAT annotation (by unipolar dV/dt timing). DELTA-derived LAT differences were more accurate than standard LAT annotation in simulated complex fractionated EGMs from a model incorporating fibrosis. Finally, we validated the DELTA method in vivo using 18,740 bipolar EGMs recorded from the left atrium of 10 atrial fibrillation patients undergoing catheter ablation. Using clinical EGMs, there was agreement in LAT differences found by DELTA, standard LAT annotation, and unipolar waveform cross-correlation. These results demonstrate an underlying relationship between a bipolar EGM's peak amplitude and the activation time difference between its two electrodes. Our computational modeling and clinical results suggest this relationship can be leveraged clinically to improve measurement accuracy for small LAT differences, which may improve CV measurement at small spatial scales.
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Affiliation(s)
- Stephen Gaeta
- Inova Heart and Vascular Institute, Falls Church, VA, United States.,Division of Cardiology, Duke University Medical Center, Durham, NC, United States
| | - Tristram D Bahnson
- Division of Cardiology, Duke University Medical Center, Durham, NC, United States
| | - Craig Henriquez
- Department of Biomedical Engineering, Duke University, Durham, NC, United States
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10
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Schwarzl JM, Schleberger R, Kahle AK, Höller A, Schwarzl M, Schaeffer BN, Münkler P, Moser J, Akbulak RÖ, Eickholt C, Dinshaw L, Dickow J, Maury P, Sacher F, Martin CA, Wong T, Estner HL, Jaïs P, Willems S, Meyer C. Specific electrogram characteristics impact substrate ablation target area in patients with scar-related ventricular tachycardia-insights from automated ultrahigh-density mapping. J Cardiovasc Electrophysiol 2021; 32:376-388. [PMID: 33368769 DOI: 10.1111/jce.14859] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/26/2020] [Accepted: 11/09/2020] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Substrate-based catheter ablation approaches to ventricular tachycardia (VT) focus on low-voltage areas and abnormal electrograms. However, specific electrogram characteristics in sinus rhythm are not clearly defined and can be subject to variable interpretation. We analyzed the potential ablation target size using automatic abnormal electrogram detection and studied findings during substrate mapping in the VT isthmus area. METHODS AND RESULTS Electrogram characteristics in 61 patients undergoing scar-related VT ablation using ultrahigh-density 3D-mapping with a 64-electrode mini-basket catheter were analyzed retrospectively. Forty-four complete substrate maps with a mean number of 10319 ± 889 points were acquired. Fractionated potentials detected by automated annotation and manual review were present in 43 ± 21% of the entire low-voltage area (<1.0 mV), highly fractionated potentials in 7 ± 8%, late potentials in 13 ± 15%, fractionated late potentials in 7 ± 9% and isolated late potentials in 2 ± 4%, respectively. Highly fractionated potentials (>10 ± 1 fractionations) were found in all isthmus areas of identified VT during substrate mapping, while isolated late potentials were distant from the critical isthmus area in 29%. CONCLUSION The ablation target area varies enormously in size, depending on the definition of abnormal electrograms. Clear linking of abnormal electrograms with critical VT isthmus areas during substrate mapping remains difficult due to a lack of specificity rather than sensitivity. However, highly fractionated, low-voltage electrograms were found to be present in all critical VT isthmus sites.
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Affiliation(s)
- Jana M Schwarzl
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ruben Schleberger
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ann-Kathrin Kahle
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexandra Höller
- Institute of Medical Biometry and Epidemiology, Center of Experimental Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Schwarzl
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), Berlin, Germany
| | - Benjamin N Schaeffer
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Paula Münkler
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), Berlin, Germany
| | - Julia Moser
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ruken Ö Akbulak
- Department of Cardiology, Asklepios Hospital St. Georg, Hamburg, Germany
| | - Christian Eickholt
- Department of Cardiology, Asklepios Hospital St. Georg, Hamburg, Germany
| | - Leon Dinshaw
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jannis Dickow
- Department of Cardiology, University Heart and Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philippe Maury
- Department of Cardiology, University Hospital Rangueil, Toulouse, France
| | - Frederic Sacher
- Department of Cardiac Electrophysiology, LIRYC Institute, Bordeaux University Hospital, Bordeaux, France
| | - Claire A Martin
- Department of Cardiology, Royal Papworth Hospital, National Health Service Foundation Trust, Cambridge, UK
| | - Tom Wong
- Heart Rhythm Center, Imperial College London, The Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Heidi L Estner
- Department of Internal Medicine I - Cardiology, University Hospital Munich, Ludwig-Maximilian University Munich, Munich, Germany
| | - Pierre Jaïs
- Department of Cardiac Electrophysiology, LIRYC Institute, Bordeaux University Hospital, Bordeaux, France
| | - Stephan Willems
- DZHK (German Center for Cardiovascular Research), Berlin, Germany.,Department of Cardiology, Asklepios Hospital St. Georg, Hamburg, Germany
| | - Christian Meyer
- DZHK (German Center for Cardiovascular Research), Berlin, Germany.,Division of Cardiology, cardiac Neuro- and Electrophysiology Research Consortium (cNEP), EVK Düsseldorf, Düsseldorf, Germany.,Institute for Neural and Sensory Physiology, Cardiac Neuro- and Electrophysiology Research Consortium (cNEP), Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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11
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Cai C, Wang J, Niu H, Hua W, Chu J, Zhang S. Multipolar mapping for catheter ablation of premature ventricular complexes originating from papillary muscles in the structurally normal heart: a case series. BMC Cardiovasc Disord 2020; 20:464. [PMID: 33115432 PMCID: PMC7594480 DOI: 10.1186/s12872-020-01747-z] [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: 08/16/2020] [Accepted: 10/18/2020] [Indexed: 11/10/2022] Open
Abstract
Background Previous studies on radiofrequency catheter ablation of premature ventricular complexes (PVCs) arising from the left ventricle (LV) papillary muscles (PM) show a modest procedural success rate with higher recurrence rate. Our study sought to explore the utility of using a multipolar mapping with a steerable linear duodecapolar catheter for ablating the PM PVCs. Methods Detailed endocardial multipolar mapping was performed using a steerable linear duodecapolar catheter in 6 consecutive PM PVCs patients with structurally normal heart. The clinical features and procedural data as well as success rate were analysed. Results LV endocardial electroanatomic mapping was performed in all patients via a retrograde aortic approach using a duodecapolar mapping catheter. All patients displayed a PVC burden with 16.2 ± 5.4%. Duodecapolar catheter mapping demonstrated highly efficiency with an average procedure time (95.8 ± 7.4 min) and fluoroscopy time (14.2 ± 1.5 min). The mean number of ablation applications points was 6.8 ± 1.9 with an average overall ablation duration of 6.1 ± 3.0 min. The values of earliest activation time during mapping using duodecapolar catheter were 37.8 ± 7.2 ms. All patients demonstrated acute successful ablation, and the PVC burden in all patients after an average follow-up of 8.5 ± 2.0 months was only 0.7%. There were no complications during the procedures and after follow-up. Conclusions Mapping and ablation of PM PVCs using a duodecapolar catheter facilitated the identification of earliest activation potentials and pace mapping, and demonstrated a high success rate during follow-up.
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Affiliation(s)
- Chi Cai
- The Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beilishi Road No. 167, Xicheng District, Beijing, 100037, China
| | - Jing Wang
- The Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beilishi Road No. 167, Xicheng District, Beijing, 100037, China.
| | - Hongxia Niu
- The Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beilishi Road No. 167, Xicheng District, Beijing, 100037, China
| | - Wei Hua
- The Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beilishi Road No. 167, Xicheng District, Beijing, 100037, China
| | - Jianmin Chu
- The Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beilishi Road No. 167, Xicheng District, Beijing, 100037, China
| | - Shu Zhang
- The Cardiac Arrhythmia Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beilishi Road No. 167, Xicheng District, Beijing, 100037, China
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12
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Nazarian S, Misra S. Order in Disorder. JACC Clin Electrophysiol 2020; 6:1086-1088. [DOI: 10.1016/j.jacep.2020.05.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 05/20/2020] [Indexed: 11/28/2022]
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13
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Saluja D, Bar-On T, Hayam G, Kassotis J, Kostis WJ, Coromilas J. The Rapid Prediction of Focal Wavefront Origins: Integration With a 3-Dimensional Mapping System. JACC Clin Electrophysiol 2020; 6:1478-1487. [PMID: 33213807 DOI: 10.1016/j.jacep.2020.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 05/20/2020] [Accepted: 05/20/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES This study assessed the accuracy of an algorithm that predicts the origin of focal arrhythmias using a limited number of data points. BACKGROUND Despite advances in technology, ablations can be time-consuming, and activation mapping continues to have inherent limitations. The authors developed an algorithm that can predict the origin of a focal wavefront using the location and activation timing information in 2 pairs of sampled points. This algorithm was incorporated into an electroanatomic mapping (EAM) system to assess its accuracy in a 3-dimensional clinical environment. METHODS EAM data from patients who underwent successful ablation of a focal wavefront using the CARTO3 system were loaded onto an offline version of the software modified to contain the algorithm. Prediction curves were retrospectively generated. Predictive accuracy, defined as the distance between true and predicted origin wavefront origins, was measured. RESULTS Seventeen wavefronts in as many patients (2 with atrial tachycardia, 3 with orthodromic re-entrant tachycardia, 8 with premature ventricular complex and/or ventricular tachycardia, 4 with focal pulmonary vein isolation breakthroughs) were studied. Thirty-three origin predictions were attempted (1.9 ± 0.4 per patient) using 132 points. Predictions were successfully calculated in 31 of 33 (93.9%) attempts and were accurate to within 5.7 ± 6.9 mm. Individual prediction curves were accurate to within 3.0 ± 4.7 mm. CONCLUSIONS Focal wavefront origins may be accurately predicted in 3 dimensions using a novel algorithm incorporated into an EAM system.
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Affiliation(s)
- Deepak Saluja
- Department of Medicine, Columbia University, New York, New York, USA.
| | | | | | - John Kassotis
- Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - William J Kostis
- Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - James Coromilas
- Department of Medicine, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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14
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Sadek MM, Muser D, Santangeli P, Marchlinski FE. Epicardial Ablation in Nonischemic Ventricular Tachyardia. Card Electrophysiol Clin 2020; 12:321-328. [PMID: 32771186 DOI: 10.1016/j.ccep.2020.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In patients with nonischemic cardiomyopathy, epicardial ablation is critical in targeting epicardial paravalvular substrate. Epicardial access and ablation can be performed safely with attention to epicardial structures, such as the coronary arteries, phrenic nerve, and epicardial fat. This review explores the indications, techniques, complications, and outcomes of epicardial ablation in patients with nonischemic cardiomyopathy. Although epicardial ablation adds to the complexity and risk of the ablation procedure, it is a vital tool that, combined with endocardial mapping and ablation, improves outcomes in patients with nonischemic cardiomyopathy suffering from ventricular arrhythmias.
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Affiliation(s)
- Mouhannad M Sadek
- Arrhythmia Service, Division of Cardiology, The Ottawa Hospital-General Campus, Box 703, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada
| | - Daniele Muser
- Cardiac Electrophysiology, Cardiovascular Division, Hospital of the University of Pennsylvania, 9 Founders Pavilion - Cardiology, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Pasquale Santangeli
- Cardiac Electrophysiology, Cardiovascular Division, Hospital of the University of Pennsylvania, 9 Founders Pavilion - Cardiology, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Francis E Marchlinski
- Cardiac Electrophysiology, Cardiovascular Division, Hospital of the University of Pennsylvania, 9 Founders Pavilion - Cardiology, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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15
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Nayyar S, Downar E, Bhaskaran AP, Massé S, Nanthakumar K. Signature signal strategy: Electrogram-based ventricular tachycardia mapping. Heart Rhythm 2020; 17:2000-2009. [PMID: 32590152 DOI: 10.1016/j.hrthm.2020.06.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/16/2020] [Accepted: 06/19/2020] [Indexed: 11/16/2022]
Abstract
Multiple decades of work have recognized complexities of substrates responsible for ventricular tachycardia (VT). There is sufficient evidence that 3 critical components of a re-entrant VT circuit, namely, region of slow conduction, zone of unidirectional block, and exit site, are located in spatial vicinity to each other in the ventricular scar. Each of these components expresses characteristic electrograms in sinus rhythm, at initiation of VT, and during VT, respectively. Despite this, abnormal electrograms are widely targeted without appreciation of these signature electrograms during contemporary VT ablation. Our aim is to stimulate physiology-based VT mapping and a targeted ablation of VT. In this article, we focus on these 3 underappreciated aspects of the physiology of ischemic scar-related VT circuits that have practical applications during a VT ablation procedure. We explore the anatomic and functional elements underlying these distinctive bipolar electrograms, specifically the contribution of tissue branching, conduction restitution, and wave curvature to the substrate, as they pertain to initiation and maintenance of VT. We propose a VT ablation approach based on these 3 electrogram features that can be a potential practical means to recognize critical elements of a VT circuit and target ablation.
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Affiliation(s)
- Sachin Nayyar
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada; Division of Cardiology, Townsville University Hospital, Townsville, Queensland, Australia; Department of Medicine, James Cook University, Townsville, Queensland, Australia.
| | - Eugene Downar
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada
| | - Abhishek P Bhaskaran
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada
| | - Stéphane Massé
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada
| | - Kumaraswamy Nanthakumar
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada
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16
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Malaczynska-Rajpold K, Blaszyk K, Kociemba A, Pyda M, Posadzy-Malaczynska A, Grajek S. Islets of heterogeneous myocardium within the scar in cardiac magnetic resonance predict ventricular tachycardia after myocardial infarction. J Cardiovasc Electrophysiol 2020; 31:1452-1461. [PMID: 32227520 DOI: 10.1111/jce.14461] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 03/06/2020] [Accepted: 03/24/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION We assessed findings in cardiac magnetic resonance (CMR) as predictors of ventricular tachycardia (VT) after myocardial infarction (MI), which could allow for more precise identification of patients at risk of sudden cardiac death. METHODS Forty-eight patients after prior MI were enrolled and divided into two groups: with (n = 24) and without (n = 24) VT. VT was confirmed by electrophysiological study and exit site was estimated based on 12-lead electrocardiogram. All patients underwent CMR with late gadolinium enhancement. RESULTS The examined groups did not differ significantly in clinical and demographical parameters (including LV ejection fraction). There was a significant difference in the infarct age between the VT and non-VT group (15.8 ± 8.4 vs 7.1 ± 6.7 years, respectively; P = .002), with the cut-off point at the level of 12 years. In the scar core, islets of heterogeneous myocardium were revealed. They were defined as areas of potentially viable myocardium within or adjacent to the core scar. The number of islets was the strongest independent predictor of VT (odds ratio [OR], 1.42; confidence interval [CI], 1.17-1.73), but total islet size and the largest islet area were also significantly higher in the VT group (OR, 1.04; CI, 1.02-1.07 and OR, 1.16; CI, 1.01-1.27, respectively). Myocardial segments with fibrosis forming 25%-75% of the ventricular wall were associated with a higher incidence of VT (7.5 ± 2.1 vs 5.7 ± 2.6; P = .014). Three-dimension CMR reconstruction confirmed good correlation of the location of the islets/channels with VT exit site during electroanatomical mapping in five cases. CONCLUSIONS The identification and quantification of islets of heterogeneous myocardium within the scar might be useful for predicting VT in patients after MI.
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Affiliation(s)
- Katarzyna Malaczynska-Rajpold
- Heart Division, Royal Brompton & Harefield NHS Foundation Trust, London, UK.,1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Krzysztof Blaszyk
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Anna Kociemba
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland.,Heart Division, Affidea International Oncology Centre, Poznan, Poland
| | - Malgorzata Pyda
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Stefan Grajek
- 1st Department of Cardiology, Poznan University of Medical Sciences, Poznan, Poland
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17
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Nayyar S, Downar E, Beheshti M, Liang T, Massé S, Magtibay K, Bhaskaran A, Saeed Y, Vigmond E, Nanthakumar K. Information theory to tachycardia therapy: electrogram entropy predicts diastolic microstructure of reentrant ventricular tachycardia. Am J Physiol Heart Circ Physiol 2019; 316:H134-H144. [DOI: 10.1152/ajpheart.00581.2018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
There is no known strategy to differentiate which multicomponent electrograms in sinus rhythm maintain reentrant ventricular tachycardia (VT). Low entropy in the voltage breakdown of a multicomponent electrogram can localize conditions suitable for reentry but has not been validated against the classic VT activation mapping. We examined whether low entropy in a late and diversely activated ventricular scar region characterizes and differentiates the diastolic path of VT and represents protected tissue channels devoid of side branches. Intraoperative bipolar electrogram (BiEGM) activation and entropy maps were obtained during sinus rhythm in 17 patients with ischemic cardiomyopathy and compared with diastolic activation paths of VT (total of 39 VTs). Mathematical modeling of a zigzag main channel with side branches was also used to further validate structural representation of low entropy in the ventricular scar. A median of one region per patient (range: 1–2 regions) was identified in sinus rhythm, in which BiEGMwith the latest mean activation time and adjacent minimum entropy were assembled together in a high-activation dispersion region. These regions accurately recognized diastolic paths of 34 VTs, often to multiple inducible VTs within a single individual arrhythmogenic region. In mathematical modeling, side branching from the main channel had a strong influence on the BiEGMcomposition along the main channel. The BiEGMobtained from a long unbranched channel had the lowest entropy compared with those with multiple side branches. In conclusion, among a population of multicomponent sinus electrograms, those that demonstrate low entropy and are delayed colocalize to critical long-protected channels of VT. This information is pertinent for planning VT ablation in sinus rhythm.NEW & NOTEWORTHY Entropy is a measure to quantify breakdown in information. Electrograms from a protected tissue channel can only possess a few states in their voltage and thus less information. In contrast, current-load interactions from side branches in unprotected channels introduce a number of dissimilar voltage deflections and thus high information. We compare here a mapping approach based on entropy against a rigorous reference standard of activation mapping during VT and entropy was assessed in sinus rhythm.
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Affiliation(s)
- Sachin Nayyar
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada
| | - Eugene Downar
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada
| | - Mohammadali Beheshti
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada
| | - Timothy Liang
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada
| | - Stéphane Massé
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada
| | - Karl Magtibay
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada
| | - Abhishek Bhaskaran
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada
| | - Yawer Saeed
- The Hull Family Cardiac Fibrillation Management Laboratory, Toronto General Hospital, Toronto, Ontario, Canada
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18
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Nayyar S, Kuklik P, Tomlinson G, Suszko A, Chauhan VS. Differential pacing from two sites to diagnose risk of ventricular arrhythmia and death. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 42:189-200. [PMID: 30515873 DOI: 10.1111/pace.13566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 11/25/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND QRS abnormalities may not be apparent in sinus rhythm in electrically stable cardiomyopathy patients who can have quiescent but highly arrhythmogenic substrate. Here, we test the hypothesis that differential changes in QRS construction during right-ventricular apex pacing (RVP) as opposed to atrial pacing (AP) will identify latent substrate for ventricular arrhythmias (VA) and death. METHODS Forty patients with cardiomyopathy free of VA underwent baseline 114-electrode body-surface electrocardiogram during AP (100 beats per minute [bpm]) and RVP (100 and 120 bpm). The filtered-averaged QRS at each electrode was deconstructed into individual intra-QRS and post-QRS ventricular myopotentials (VMP ). The primary outcome was VA or death. Prognostic accuracy of VMP was validated using V1 to V6 leads in another prospective cohort of 44-cardiomyopathy patients. RESULTS Twenty-six patients were eligible for initial analysis. After 5 ± 2 years of follow-up, eight (31%) patients had VA (VAPos ) while rest were uneventful (VANeg ). During AP100 , VAPos patients expressed more VMP than VANeg patients (16 ± 1 vs 12 ± 1, P = 0.02). RVP100 and RVP120 in VAPos patients introduced an additional 5.5 ± 0.5 and 6.0 ± 0.5 VMP (P < 0.0001 vs AP100 ). The relative change with RVP120 versus AP100 in VANeg patients exceeded VAPos patients by 1.2 ± 0.5 VMP (P = 0.03). Increment in VMP count of <8 in lead-V5 with RVP120 compared to AP100 best predicted VA (area under curve 0.81, P = 0.01). In the validation cohort, primary outcome occurred in 13 (33%) patients. Native QRS features and AP100 alone failed to predict primary outcome. Patients with increment in VMP count of <8 in lead-V5 with RVP120 versus AP100 had 7.9-fold increased risk of primary outcome (95% confidence interval 1.01, 61.61; P = 0.049). CONCLUSION Cardiomyopathy patients at risk of VA or death perturb the QRS less than low-risk patients with differential pacing. This functional response may be useful to identify arrhythmogenic substrate.
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Affiliation(s)
- Sachin Nayyar
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Pawel Kuklik
- Department of Cardiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - George Tomlinson
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Adrian Suszko
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Vijay S Chauhan
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
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Catheter Ablation of Post-Infarct VT: Mechanisms, Strategies and Outcomes. Heart Lung Circ 2018; 28:76-83. [PMID: 30482686 DOI: 10.1016/j.hlc.2018.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/02/2018] [Accepted: 10/03/2018] [Indexed: 12/29/2022]
Abstract
Ventricular arrhythmias are one of the leading causes of death in patients with a prior myocardial infarction. Implantable cardioverter-defibrillators (ICDs) are very effective in the prevention of sudden cardiac death but the risk of recurrence remains an issue since defibrillation does not alter the underlying substrate. Recurrent ICD shocks are distressing and are associated with an increase in mortality. Catheter ablation is an effective treatment for recurrent ventricular tachycardia in these patients, particularly when antiarrhythmic therapy produces side effects or is ineffective. This paper reviews the underlying mechanisms of VT in patients with a prior myocardial infarction, and the indications, strategies and outcomes of catheter ablation.
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20
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John RM, Kanagasundram AN, Stevenson WG. Substrate Mapping for Functionally Defined Ventricular Re-Entry. JACC Clin Electrophysiol 2018; 4:1049-1051. [DOI: 10.1016/j.jacep.2018.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 05/04/2018] [Accepted: 05/15/2018] [Indexed: 11/29/2022]
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21
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Koutbi L, Maille B, Peyrol M, Hourdain J, Salaun E, Deharo JC, Franceschi F. High-density mapping for catheter ablation of premature ventricular complexes originating from left ventricular papillary muscles: A case series. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:1071-1077. [PMID: 29947109 DOI: 10.1111/pace.13417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 04/27/2018] [Accepted: 04/27/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE Ablation of premature ventricular complexes (PVCs) originating from left-sided papillary muscles is challenging. We tested a new approach by performing high-density mapping of PVC. METHODS AND RESULTS We used a 20-pole deflectable spiral catheter during ablation procedures in four consecutive patients. Three presented with mitral valve prolapse, one with dilated cardiomyopathy. PVC burden was 24 ± 13%. The procedures lasted 182 ± 55.4 minutes, including 10 ± 3.2 minutes of radiofrequency. In all patients, mapping evidenced internal primary activation relative to the left ventricle shell (mean distance 21.3 ± 5.1 mm). Endocavitary prematurity was -38.3 ± 4.8 ms. Primary ablation success was achieved for all patients. CONCLUSIONS High-density mapping of the papillary muscles in the left ventricle using a spiral catheter may be feasible. We identified the PVC foci away from the left ventricular shell. This consolidates the assumption for the origin of these ectopic beats at the junction between the chordae tendineae and the papillary muscles.
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Affiliation(s)
- Linda Koutbi
- Department of Cardiology, Assistance Publique - Hôpitaux de Marseille (APHM), Aix-Marseille University, Timone Hospital, France
| | - Baptiste Maille
- Department of Cardiology, Assistance Publique - Hôpitaux de Marseille (APHM), Aix-Marseille University, Timone Hospital, France.,UMR MD2, Aix Marseille University (AMU), Marseille, France
| | - Michael Peyrol
- Department of Cardiology, Assistance Publique - Hôpitaux de Marseille (APHM), Aix-Marseille University, North Hospital, France
| | - Jérôme Hourdain
- Department of Cardiology, Assistance Publique - Hôpitaux de Marseille (APHM), Aix-Marseille University, Timone Hospital, France
| | - Erwan Salaun
- Department of Cardiology, Assistance Publique - Hôpitaux de Marseille (APHM), Aix-Marseille University, Timone Hospital, France
| | - Jean-Claude Deharo
- Department of Cardiology, Assistance Publique - Hôpitaux de Marseille (APHM), Aix-Marseille University, Timone Hospital, France.,UMR MD2, Aix Marseille University (AMU), Marseille, France
| | - Frédéric Franceschi
- Department of Cardiology, Assistance Publique - Hôpitaux de Marseille (APHM), Aix-Marseille University, Timone Hospital, France.,UMR MD2, Aix Marseille University (AMU), Marseille, France
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22
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Aziz Z, Tung R. Novel Mapping Strategies for Ventricular Tachycardia Ablation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:34. [PMID: 29572643 DOI: 10.1007/s11936-018-0615-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Despite advances in antiarrhythmic and device therapy, ventricular tachycardia (VT) continues to be a major cause of increased morbidity and mortality. During scar-mediated monomorphic ventricular tachycardia ablation, the search for critical isthmus sites continues to be the primary goal during successful ablative procedures. However, given the overwhelming hemodynamic instability of most ventricular arrhythmias (> 70%), VT ablation is increasingly performed during sinus rhythm. This technique requires either a greater reliance on isthmus surrogates, or more extensive ablation techniques and is a more probabilistic approach to substrate modification. We believe that a better understanding of scar physiology and activation during sinus rhythm has important implications for clinical workflow and mechanistic improvements with current ablation strategies. With advancements in high-density mapping and multi-electrode catheter technology, mapping of VT substrates is performed with higher resolution, with improved visualization of local abnormal ventricular activities (LAVA), and with a more nuanced functional understanding of late potentials. As a prerequisite, our practice for VT ablation starts with a high-density structural map to identify voltage abnormalities as well as an isochronal functional map of sinus rhythm activation to identify region of discontinuous wavefront propagation. As the era of increased automation has emerged, there continues to be vast array of customizable features, and we have adopted the use of multiple wavefront mapping to further elucidate possible arrhythmogenic substrate. Our emerging understanding of how scar propagation patterns relate to areas of abnormal signals and critical isthmuses may greatly improve the ability to identify surrogates during sinus rhythm and help localize the most arrhythmogenic regions within a given scar. In the hemodynamically unstable patients, we routinely integrate isochronal late activation mapping (ILAM) to identify areas of slow conduction to initiate our targeted ablation and substrate modification. Multi-electrode delineation of the entire reentrant VT circuit has value in understanding the size of the circuit, rotational nature, and transmural extent of human reentry. Correlative studies between the activation of the complete VT circuit and sinus rhythm are likely to provide important mechanistic insights on where fixed and/or functional block occurs within a complex scar substrate.
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Affiliation(s)
- Zaid Aziz
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, 5841 S. Maryland Ave. MC 6080, Chicago, IL, 60637, USA
| | - Roderick Tung
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, 5841 S. Maryland Ave. MC 6080, Chicago, IL, 60637, USA.
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Guttman MA, Tao S, Fink S, Kolandaivelu A, Halperin HR, Herzka DA. Non-contrast-enhanced T 1 -weighted MRI of myocardial radiofrequency ablation lesions. Magn Reson Med 2018; 79:879-889. [PMID: 28497622 PMCID: PMC5681891 DOI: 10.1002/mrm.26750] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/27/2017] [Accepted: 04/15/2017] [Indexed: 11/10/2022]
Abstract
PURPOSE To demonstrate imaging of radiofrequency ablation lesions with non-contrast-enhanced T1 -weighted (T1w) MRI. METHODS Fifteen swine underwent left ventricular ablation followed by MRI using different preparations: endocardial or epicardial ablation of naïve animal, or endocardial ablation of animal with myocardial infarction. Lesion imaging was performed using free-breathing, non-contrast-enhanced, T1w sequence with long inversion time (TI). Also acquired were T1 maps and delayed contrast-enhanced (DCE) imaging. Hearts were excised for ex vivo imaging, and sliced for gross pathology and histology. RESULTS All ablations were visibly enhanced in non-contrast-enhanced T1w imaging using TI = 700 ms. T1w enhancement agreed with regions of necrosis in gross pathology and histology. Enhanced lesion cores were surrounded by dark bands containing contraction band necrosis, hematoma, and edema. In animals with myocardial infarction, chronic scar was hypointense in T1w, whereas acute ablations were enhanced, allowing discrimination between chronic scar and acute lesions, unlike DCE. Contrast was sufficient to create 3D volume renderings of lesions after minor postprocessing. CONCLUSIONS Non-contrast-enhanced T1w imaging with long TI promises to be an effective method for visualizing necrosis within radiofrequency ablation lesions. Enhancement is more specific and stationary than that from DCE. The imaging can be repeated as needed, unlike DCE, and may be especially useful for assessing ablations during or after a procedure. Magn Reson Med 79:879-889, 2018. © 2017 International Society for Magnetic Resonance in Medicine.
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Affiliation(s)
- Michael A. Guttman
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Susumu Tao
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sarah Fink
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Aravindan Kolandaivelu
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Henry R. Halperin
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Radiology and Radiological Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Daniel A. Herzka
- Department of Biomedical Engineering, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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24
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Chung FP, Lin CY, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Chao TF, Liao JN, Chang TY, Chen SA. Catheter Ablation of Ventricular Tachycardia in Arrhythmogenic Right Ventricular Dysplasia/Cardiomyopathy. Korean Circ J 2018; 48:890-905. [PMID: 30238706 PMCID: PMC6158456 DOI: 10.4070/kcj.2018.0268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 09/11/2018] [Accepted: 09/12/2018] [Indexed: 12/14/2022] Open
Abstract
Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is predominantly an inherited cardiomyopathy with typical histopathological characteristics of fibro-fatty infiltration mainly involving the right ventricular (RV) inflow tract, RV outflow tract, and RV apex in the majority of patients. The above pathologic evolution frequently brings patients with ARVD/C to medical attention owing to the manifestation of syncope, sudden cardiac death (SCD), ventricular arrhythmogenesis, or heart failure. To prevent future or recurrent SCD, an implantable cardiac defibrillator (ICD) is highly desirable in patients with ARVD/C who had experienced unexplained syncope, hemodynamically intolerable ventricular tachycardia (VT), ventricular fibrillation, and/or aborted SCD. Notably, the management of frequent ventricular tachyarrhythmias in ARVD/C is challenging, and the use of antiarrhythmic drugs could be unsatisfactory or limited by the unfavorable side effects. Therefore, radiofrequency catheter ablation (RFCA) has been implemented to treat the drug-refractory VT in ARVD/C for decades. However, the initial understanding of the link between fibro-fatty pathogenesis and ventricular arrhythmogenesis in ARVD/C is scarce, the efficacy and prognosis of endocardial RFCA alone were limited and disappointing. The electrophysiologists had broken through this frontier after better illustration of epicardial substrates and broadly application of epicardial approaches in ARVD/C. In recent works of literature, the application of epicardial ablation also successfully results in higher procedural success and decreases VT recurrences in patients with ARVD/C who are refractory to the endocardial approach during long-term follow-up. In this article, we review the important evolution on the delineation of arrhythmogenic substrates, ablation strategies, and ablation outcome of VT in patients with ARVD/C.
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Affiliation(s)
- Fa Po Chung
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Chin Yu Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.,Department of Internal Medicine, Taipei Veterans General Hospital, Yuan-Shan Branch, I-LAN, Taiwan
| | - Yenn Jiang Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Shih Lin Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Li Wei Lo
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Yu Feng Hu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Ta Chuan Tuan
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Tze Fan Chao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Jo Nan Liao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Ting Yung Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Shih Ann Chen
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Clinical Medicine, Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.
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25
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Maagh P, Christoph A, Dopp H, Mueller MS, Plehn G, Meissner A. High-Density Mapping in Ventricular Tachycardia Ablation: A PentaRay ® Study. Cardiol Res 2017; 8:293-303. [PMID: 29317972 PMCID: PMC5755661 DOI: 10.14740/cr636w] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 11/28/2017] [Indexed: 11/11/2022] Open
Abstract
Background High-density mapping of ventricular tachycardia (VT) with PentaRay® (Biosense-Webster) provides high resolution with discrimination of local abnormal electrograms and slow conducting channels. We evaluate the feasibility of PentaRay® to characterize the anatomical substrate and assume an influence of the outcome despite limitations. Methods Over a 24-month period, 26 endocardial and four epicardial maps were obtained of 26 VT patients (18 ischemic cardiomyopathy (ICM, 69.2%) and 8 non-ischemic cardiomyopathy (NICM, 30.8%), age 65 ± 9 years). Catheter ablation (CA) was performed with the aim of transecting the isthmus. The endpoint was non-inducibility of any VT. Manual review of the maps was performed and focused on evaluating scarring, bipolar electrograms, and procedure times. Results In 55.6 ± 34.4 min, 1,085.9 ± 726.2 points were created. The mean ablation time was 50.8 ± 30.1 min. The endpoint was achieved in 12 patients (46.2%). The mean dense scar area and the mean patchy scar area were 49.4 ± 51.8 cm2 (range 0 - 190 cm2) and 14.7 ± 14.9 cm2 (range 0 - 110 cm2), respectively. Analyzing the learning curve, we found a tendency in decreasing procedure times. During the course of follow-up treatment averaging a 14-month period, device interrogation showed that 17 patients (65.4%) had remained free of any arrhythmia recurrence. Conclusion The high-density maps with PentaRay® were safely created in a short period of time. Our manual review of the maps reveals limitations of current annotation criteria; nevertheless, medium-term outcomes were encouraging. Further prospective studies are required to validate our findings in a larger cohort of patients.
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Affiliation(s)
- Petra Maagh
- Department of Cardiology, Electrophysiology and Intensive Care, Klinikum Merheim, University Witten/Herdecke/Germany, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Arnd Christoph
- Department of Cardiology, Electrophysiology and Intensive Care, Klinikum Merheim, University Witten/Herdecke/Germany, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Henning Dopp
- Department of Cardiology, Electrophysiology and Intensive Care, Klinikum Merheim, University Witten/Herdecke/Germany, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Markus Sebastian Mueller
- Department of Cardiology, Electrophysiology and Intensive Care, Klinikum Merheim, University Witten/Herdecke/Germany, Ostmerheimer Str. 200, 51109 Cologne, Germany
| | - Gunnar Plehn
- Department of Cardiology and Angiology, Malteser-Krankenhaus St. Anna, Albertus-Magnus-Str. 33, 47259 Duisburg, Germany.,Ruhr-University of Bochum, Universitatsstrasse 150, 44801 Bochum, Germany
| | - Axel Meissner
- Department of Cardiology, Electrophysiology and Intensive Care, Klinikum Merheim, University Witten/Herdecke/Germany, Ostmerheimer Str. 200, 51109 Cologne, Germany.,Ruhr-University of Bochum, Universitatsstrasse 150, 44801 Bochum, Germany
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26
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Nayyar S, Wilson L, Ganesan A, Sullivan T, Kuklik P, Young G, Sanders P, Roberts-Thomson KC. Electrophysiologic features of protected channels in late postinfarction patients with and without spontaneous ventricular tachycardia. J Interv Card Electrophysiol 2017; 51:13-24. [PMID: 29236200 DOI: 10.1007/s10840-017-0299-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Accepted: 11/16/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Protected channels of surviving myocytes in late postinfarction ventricular scar predispose to ventricular tachycardia (VT). However, only a few patients develop VT spontaneously. We studied differences in electric remodeling and protected channels in late postinfarction patients with and without spontaneous VT. METHODS Patients with ischemic cardiomyopathy (ICM) with recurrent sustained monomorphic VT (n = 22) were compared with stable ICM patients without spontaneous VT (control group; n = 5). Left ventricular mapping was performed with a 20-pole catheter. Detailed pace mapping was used to identify channels of protected conduction, and confirmed, when feasible, by entrainment. Anatomical and electrophysiological properties of VT channels and non-VT channels in VT patients and channels in controls were evaluated. RESULTS Seventy-three (median 3) VTs were inducible in VT patients compared to two (median 0) in controls. The VT channels in VT patients (n = 57, 3 ± 1 per patient) were lengthier (mean ± SEM 53 ± 5 vs. 33 ± 4 vs. 24 ± 8 mm), had longer S-QRS (73 ± 4 vs. 63 ± 3 vs. 44 ± 8 ms), longer conduction time (103 ± 13 vs. 33 ± 4 vs. 24 ± 8 ms), and slower conduction velocity (CV) (0.85 ± 0.21 vs. 1.39 ± 0.20 vs. 1.31 ± 0.41 m/s) than non-VT channels in VT patients (n = 183, 8 ± 6 per patient) (p ≤ 0.01) and channels in controls (n = 46, 9 ± 8 per patient) (p ≤ 0.01). Additionally, non-VT channels in VT patients had longer S-QRS (p = 0.02); however, they were similar in length, conduction time, and CV compared to channels in controls. CONCLUSIONS Channels supporting VT are lengthier, with longer conduction times and slower CV compared to channels in patients without spontaneous VT. These observations may explain why some ICM patients have spontaneous VT and others do not.
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Affiliation(s)
- Sachin Nayyar
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Level 5, McEwin Building, North Terrace, Adelaide, SA, 5000, Australia
| | - Lauren Wilson
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Level 5, McEwin Building, North Terrace, Adelaide, SA, 5000, Australia
| | - Anand Ganesan
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Level 5, McEwin Building, North Terrace, Adelaide, SA, 5000, Australia
| | - Thomas Sullivan
- School of Public Health, University of Adelaide, Adelaide, Australia
| | - Pawel Kuklik
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Level 5, McEwin Building, North Terrace, Adelaide, SA, 5000, Australia
| | - Glenn Young
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Level 5, McEwin Building, North Terrace, Adelaide, SA, 5000, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Level 5, McEwin Building, North Terrace, Adelaide, SA, 5000, Australia
| | - Kurt C Roberts-Thomson
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Level 5, McEwin Building, North Terrace, Adelaide, SA, 5000, Australia.
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27
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Yamashita S, Cochet H, Sacher F, Mahida S, Berte B, Hooks D, Sellal JM, Al Jefairi N, Frontera A, Komatsu Y, Lim HS, Amraoui S, Denis A, Derval N, Sermesant M, Laurent F, Hocini M, Haïssaguerre M, Montaudon M, Jaïs P. Impact of New Technologies and Approaches for Post-Myocardial Infarction Ventricular Tachycardia Ablation During Long-Term Follow-Up. Circ Arrhythm Electrophysiol 2017; 9:CIRCEP.116.003901. [PMID: 27406604 DOI: 10.1161/circep.116.003901] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 06/14/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND During the past years, many innovations have been introduced to facilitate catheter ablation of post-myocardial infarction ventricular tachycardia. However, the predictors of outcome after ablation were not thoroughly studied. METHODS AND RESULTS From 2009 to 2013, consecutive patients referred for post-myocardial infarction ventricular tachycardia ablation were included. The end point of the procedure was complete elimination of local abnormal ventricular activities (LAVA) and ventricular tachycardia (VT) noninducibility. The predictors of outcome with primary end point of VT recurrence were assessed. A total of 125 patients were included (age: 64±11 years; 7 women) for 142 procedures. The left ventricle was accessed via transseptal, retrograde aortic, and epicardial approaches in 87%, 33%, and 37% of patients, respectively. Three-dimensional electroanatomical mapping system was used in 70%, multipolar catheter in 51%, and real-time image integration in 38% (from magnetic resonance imaging in 39% and multidetector computed tomography in 93%) of patients. Before ablation, VT was inducible in 75%, and endocardial/epicardial LAVA were present in 88%/75%. After ablation, complete LAVA elimination was achieved in 60%, and VT noninducibility in 83%. During a median follow-up of 850 days (interquartile range, 439-1707), VT recurrence was observed in 36%. Multivariable analysis identified 3 independent outcome predictors: the ability to achieve complete LAVA elimination (R(2)=0.29; P<0.0001; risk ratio=0.52 [0.38-0.70]), the use of real-time image integration (R(2)=0.21; P=0.0006; risk ratio=0.49 [0.33-0.74]), and the use of multipolar catheters (R(2)=0.08; P=0.05; risk ratio=0.75 [0.56-1.00]). CONCLUSIONS Achievement of complete LAVA elimination and use of scar integration from imaging and multipolar catheters to focus high-density mapping are independent predictors of VT-free survival after catheter ablation for post-myocardial infarction ventricular tachycardia.
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Affiliation(s)
- Seigo Yamashita
- From the Department of Cardiac Electrophysiology (S.Y., F.S., S.M., B.B., D.H., J.-M.S., N.A.J., A.F., Y.K., H.S.L., S.A., A.D., N.D., M.H., M.H., P.J.) and Department of Cardiovascular Imaging, (H.C., F.L., M.M.), Hôpital Cardiologique du Haut-Lévêque-CHU de Bordeaux, Pessac, France; IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030, Université de Bordeaux-Inserm U1045, Pessac, France (H.C., F.S., A.D., N.D., F.L., M. Hocini, M. Haïssaguerre, M.M., P.J.); and Inria, Asclepios Team, Sophia Antipolis, France (M.S.).
| | - Hubert Cochet
- From the Department of Cardiac Electrophysiology (S.Y., F.S., S.M., B.B., D.H., J.-M.S., N.A.J., A.F., Y.K., H.S.L., S.A., A.D., N.D., M.H., M.H., P.J.) and Department of Cardiovascular Imaging, (H.C., F.L., M.M.), Hôpital Cardiologique du Haut-Lévêque-CHU de Bordeaux, Pessac, France; IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030, Université de Bordeaux-Inserm U1045, Pessac, France (H.C., F.S., A.D., N.D., F.L., M. Hocini, M. Haïssaguerre, M.M., P.J.); and Inria, Asclepios Team, Sophia Antipolis, France (M.S.)
| | - Frédéric Sacher
- From the Department of Cardiac Electrophysiology (S.Y., F.S., S.M., B.B., D.H., J.-M.S., N.A.J., A.F., Y.K., H.S.L., S.A., A.D., N.D., M.H., M.H., P.J.) and Department of Cardiovascular Imaging, (H.C., F.L., M.M.), Hôpital Cardiologique du Haut-Lévêque-CHU de Bordeaux, Pessac, France; IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030, Université de Bordeaux-Inserm U1045, Pessac, France (H.C., F.S., A.D., N.D., F.L., M. Hocini, M. Haïssaguerre, M.M., P.J.); and Inria, Asclepios Team, Sophia Antipolis, France (M.S.)
| | - Saagar Mahida
- From the Department of Cardiac Electrophysiology (S.Y., F.S., S.M., B.B., D.H., J.-M.S., N.A.J., A.F., Y.K., H.S.L., S.A., A.D., N.D., M.H., M.H., P.J.) and Department of Cardiovascular Imaging, (H.C., F.L., M.M.), Hôpital Cardiologique du Haut-Lévêque-CHU de Bordeaux, Pessac, France; IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030, Université de Bordeaux-Inserm U1045, Pessac, France (H.C., F.S., A.D., N.D., F.L., M. Hocini, M. Haïssaguerre, M.M., P.J.); and Inria, Asclepios Team, Sophia Antipolis, France (M.S.)
| | - Benjamin Berte
- From the Department of Cardiac Electrophysiology (S.Y., F.S., S.M., B.B., D.H., J.-M.S., N.A.J., A.F., Y.K., H.S.L., S.A., A.D., N.D., M.H., M.H., P.J.) and Department of Cardiovascular Imaging, (H.C., F.L., M.M.), Hôpital Cardiologique du Haut-Lévêque-CHU de Bordeaux, Pessac, France; IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030, Université de Bordeaux-Inserm U1045, Pessac, France (H.C., F.S., A.D., N.D., F.L., M. Hocini, M. Haïssaguerre, M.M., P.J.); and Inria, Asclepios Team, Sophia Antipolis, France (M.S.)
| | - Darren Hooks
- From the Department of Cardiac Electrophysiology (S.Y., F.S., S.M., B.B., D.H., J.-M.S., N.A.J., A.F., Y.K., H.S.L., S.A., A.D., N.D., M.H., M.H., P.J.) and Department of Cardiovascular Imaging, (H.C., F.L., M.M.), Hôpital Cardiologique du Haut-Lévêque-CHU de Bordeaux, Pessac, France; IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030, Université de Bordeaux-Inserm U1045, Pessac, France (H.C., F.S., A.D., N.D., F.L., M. Hocini, M. Haïssaguerre, M.M., P.J.); and Inria, Asclepios Team, Sophia Antipolis, France (M.S.)
| | - Jean-Marc Sellal
- From the Department of Cardiac Electrophysiology (S.Y., F.S., S.M., B.B., D.H., J.-M.S., N.A.J., A.F., Y.K., H.S.L., S.A., A.D., N.D., M.H., M.H., P.J.) and Department of Cardiovascular Imaging, (H.C., F.L., M.M.), Hôpital Cardiologique du Haut-Lévêque-CHU de Bordeaux, Pessac, France; IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030, Université de Bordeaux-Inserm U1045, Pessac, France (H.C., F.S., A.D., N.D., F.L., M. Hocini, M. Haïssaguerre, M.M., P.J.); and Inria, Asclepios Team, Sophia Antipolis, France (M.S.)
| | - Nora Al Jefairi
- From the Department of Cardiac Electrophysiology (S.Y., F.S., S.M., B.B., D.H., J.-M.S., N.A.J., A.F., Y.K., H.S.L., S.A., A.D., N.D., M.H., M.H., P.J.) and Department of Cardiovascular Imaging, (H.C., F.L., M.M.), Hôpital Cardiologique du Haut-Lévêque-CHU de Bordeaux, Pessac, France; IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030, Université de Bordeaux-Inserm U1045, Pessac, France (H.C., F.S., A.D., N.D., F.L., M. Hocini, M. Haïssaguerre, M.M., P.J.); and Inria, Asclepios Team, Sophia Antipolis, France (M.S.)
| | - Antonio Frontera
- From the Department of Cardiac Electrophysiology (S.Y., F.S., S.M., B.B., D.H., J.-M.S., N.A.J., A.F., Y.K., H.S.L., S.A., A.D., N.D., M.H., M.H., P.J.) and Department of Cardiovascular Imaging, (H.C., F.L., M.M.), Hôpital Cardiologique du Haut-Lévêque-CHU de Bordeaux, Pessac, France; IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030, Université de Bordeaux-Inserm U1045, Pessac, France (H.C., F.S., A.D., N.D., F.L., M. Hocini, M. Haïssaguerre, M.M., P.J.); and Inria, Asclepios Team, Sophia Antipolis, France (M.S.)
| | - Yuki Komatsu
- From the Department of Cardiac Electrophysiology (S.Y., F.S., S.M., B.B., D.H., J.-M.S., N.A.J., A.F., Y.K., H.S.L., S.A., A.D., N.D., M.H., M.H., P.J.) and Department of Cardiovascular Imaging, (H.C., F.L., M.M.), Hôpital Cardiologique du Haut-Lévêque-CHU de Bordeaux, Pessac, France; IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030, Université de Bordeaux-Inserm U1045, Pessac, France (H.C., F.S., A.D., N.D., F.L., M. Hocini, M. Haïssaguerre, M.M., P.J.); and Inria, Asclepios Team, Sophia Antipolis, France (M.S.)
| | - Han S Lim
- From the Department of Cardiac Electrophysiology (S.Y., F.S., S.M., B.B., D.H., J.-M.S., N.A.J., A.F., Y.K., H.S.L., S.A., A.D., N.D., M.H., M.H., P.J.) and Department of Cardiovascular Imaging, (H.C., F.L., M.M.), Hôpital Cardiologique du Haut-Lévêque-CHU de Bordeaux, Pessac, France; IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030, Université de Bordeaux-Inserm U1045, Pessac, France (H.C., F.S., A.D., N.D., F.L., M. Hocini, M. Haïssaguerre, M.M., P.J.); and Inria, Asclepios Team, Sophia Antipolis, France (M.S.)
| | - Sana Amraoui
- From the Department of Cardiac Electrophysiology (S.Y., F.S., S.M., B.B., D.H., J.-M.S., N.A.J., A.F., Y.K., H.S.L., S.A., A.D., N.D., M.H., M.H., P.J.) and Department of Cardiovascular Imaging, (H.C., F.L., M.M.), Hôpital Cardiologique du Haut-Lévêque-CHU de Bordeaux, Pessac, France; IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030, Université de Bordeaux-Inserm U1045, Pessac, France (H.C., F.S., A.D., N.D., F.L., M. Hocini, M. Haïssaguerre, M.M., P.J.); and Inria, Asclepios Team, Sophia Antipolis, France (M.S.)
| | - Arnaud Denis
- From the Department of Cardiac Electrophysiology (S.Y., F.S., S.M., B.B., D.H., J.-M.S., N.A.J., A.F., Y.K., H.S.L., S.A., A.D., N.D., M.H., M.H., P.J.) and Department of Cardiovascular Imaging, (H.C., F.L., M.M.), Hôpital Cardiologique du Haut-Lévêque-CHU de Bordeaux, Pessac, France; IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030, Université de Bordeaux-Inserm U1045, Pessac, France (H.C., F.S., A.D., N.D., F.L., M. Hocini, M. Haïssaguerre, M.M., P.J.); and Inria, Asclepios Team, Sophia Antipolis, France (M.S.)
| | - Nicolas Derval
- From the Department of Cardiac Electrophysiology (S.Y., F.S., S.M., B.B., D.H., J.-M.S., N.A.J., A.F., Y.K., H.S.L., S.A., A.D., N.D., M.H., M.H., P.J.) and Department of Cardiovascular Imaging, (H.C., F.L., M.M.), Hôpital Cardiologique du Haut-Lévêque-CHU de Bordeaux, Pessac, France; IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030, Université de Bordeaux-Inserm U1045, Pessac, France (H.C., F.S., A.D., N.D., F.L., M. Hocini, M. Haïssaguerre, M.M., P.J.); and Inria, Asclepios Team, Sophia Antipolis, France (M.S.)
| | - Maxime Sermesant
- From the Department of Cardiac Electrophysiology (S.Y., F.S., S.M., B.B., D.H., J.-M.S., N.A.J., A.F., Y.K., H.S.L., S.A., A.D., N.D., M.H., M.H., P.J.) and Department of Cardiovascular Imaging, (H.C., F.L., M.M.), Hôpital Cardiologique du Haut-Lévêque-CHU de Bordeaux, Pessac, France; IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030, Université de Bordeaux-Inserm U1045, Pessac, France (H.C., F.S., A.D., N.D., F.L., M. Hocini, M. Haïssaguerre, M.M., P.J.); and Inria, Asclepios Team, Sophia Antipolis, France (M.S.)
| | - François Laurent
- From the Department of Cardiac Electrophysiology (S.Y., F.S., S.M., B.B., D.H., J.-M.S., N.A.J., A.F., Y.K., H.S.L., S.A., A.D., N.D., M.H., M.H., P.J.) and Department of Cardiovascular Imaging, (H.C., F.L., M.M.), Hôpital Cardiologique du Haut-Lévêque-CHU de Bordeaux, Pessac, France; IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030, Université de Bordeaux-Inserm U1045, Pessac, France (H.C., F.S., A.D., N.D., F.L., M. Hocini, M. Haïssaguerre, M.M., P.J.); and Inria, Asclepios Team, Sophia Antipolis, France (M.S.)
| | - Mélèze Hocini
- From the Department of Cardiac Electrophysiology (S.Y., F.S., S.M., B.B., D.H., J.-M.S., N.A.J., A.F., Y.K., H.S.L., S.A., A.D., N.D., M.H., M.H., P.J.) and Department of Cardiovascular Imaging, (H.C., F.L., M.M.), Hôpital Cardiologique du Haut-Lévêque-CHU de Bordeaux, Pessac, France; IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030, Université de Bordeaux-Inserm U1045, Pessac, France (H.C., F.S., A.D., N.D., F.L., M. Hocini, M. Haïssaguerre, M.M., P.J.); and Inria, Asclepios Team, Sophia Antipolis, France (M.S.)
| | - Michel Haïssaguerre
- From the Department of Cardiac Electrophysiology (S.Y., F.S., S.M., B.B., D.H., J.-M.S., N.A.J., A.F., Y.K., H.S.L., S.A., A.D., N.D., M.H., M.H., P.J.) and Department of Cardiovascular Imaging, (H.C., F.L., M.M.), Hôpital Cardiologique du Haut-Lévêque-CHU de Bordeaux, Pessac, France; IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030, Université de Bordeaux-Inserm U1045, Pessac, France (H.C., F.S., A.D., N.D., F.L., M. Hocini, M. Haïssaguerre, M.M., P.J.); and Inria, Asclepios Team, Sophia Antipolis, France (M.S.)
| | - Michel Montaudon
- From the Department of Cardiac Electrophysiology (S.Y., F.S., S.M., B.B., D.H., J.-M.S., N.A.J., A.F., Y.K., H.S.L., S.A., A.D., N.D., M.H., M.H., P.J.) and Department of Cardiovascular Imaging, (H.C., F.L., M.M.), Hôpital Cardiologique du Haut-Lévêque-CHU de Bordeaux, Pessac, France; IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030, Université de Bordeaux-Inserm U1045, Pessac, France (H.C., F.S., A.D., N.D., F.L., M. Hocini, M. Haïssaguerre, M.M., P.J.); and Inria, Asclepios Team, Sophia Antipolis, France (M.S.)
| | - Pierre Jaïs
- From the Department of Cardiac Electrophysiology (S.Y., F.S., S.M., B.B., D.H., J.-M.S., N.A.J., A.F., Y.K., H.S.L., S.A., A.D., N.D., M.H., M.H., P.J.) and Department of Cardiovascular Imaging, (H.C., F.L., M.M.), Hôpital Cardiologique du Haut-Lévêque-CHU de Bordeaux, Pessac, France; IHU LIRYC ANR-10-IAHU-04, Equipex MUSIC ANR-11-EQPX-0030, Université de Bordeaux-Inserm U1045, Pessac, France (H.C., F.S., A.D., N.D., F.L., M. Hocini, M. Haïssaguerre, M.M., P.J.); and Inria, Asclepios Team, Sophia Antipolis, France (M.S.)
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Nayyar S, Kuklik P, Ganesan AN, Sullivan TR, Wilson L, Young GD, Sanders P, Roberts-Thomson KC. Development of Time- and Voltage-Domain Mapping (V-T-Mapping) to Localize Ventricular Tachycardia Channels During Sinus Rhythm. Circ Arrhythm Electrophysiol 2017; 9:CIRCEP.116.004050. [PMID: 27913399 DOI: 10.1161/circep.116.004050] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 09/28/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND In ventricular scar, impulse spread is slow because it traverses split and zigzag channels of surviving muscle. We aimed to evaluate scar electrograms to determine their local delay (activation time) and inequality in voltage splitting (entropy), and their relationship to channels. We reasoned that unlike innocuous channels, which are often short with multiple side branches, ventricular tachycardia (VT) supporting channels have very slow impulse spread and possess low entropy because of their longer protected length and relative lack of side-branching. METHODS AND RESULTS Patients with ischemic cardiomyopathy and multiple VT were studied. In initial mapping stage (16 patients and 58 VTs), left ventricular endocardial mapping was performed in sinus rhythm. Detailed pace mapping was used to identify VT channels and confirmed, when feasible, by entrainment. Scar electrograms were analyzed in time and voltage domains to determine mean activation time, dispersion in activation time, and entropy. Predictive performances of these properties to detect VT channels were tested. In the application stage (7 patients and 20 VTs), these properties were prospectively tested to guide catheter ablation. A mean number of 763±203 sampling points were taken. From 1770 pace maps, 47 channels corresponded to VTs. A combination of scar electrograms with the latest mean activation time and minimum entropy, in a high activation dispersion region, accurately recognized regions containing VT channels (κ=0.89, sensitivity=86%, specificity=100%, positive predictive value=93%, and negative predictive value=100%). Finally, focused ablation within 5-mm rim of the prospective channel regions eliminated 18 of 20 inducible VTs. CONCLUSIONS Activation time and entropy mapping in the scar accurately identify VT channels during sinus rhythm. The method integrates principles of reentry formation to recognize VT channels without pace mapping or mapping during VT.
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Affiliation(s)
- Sachin Nayyar
- From the Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia (S.N., P.K., A.N.G., L.W., G.D.Y., P.S., K.C.R.-T.); and School of Public Health, University of Adelaide, Australia (T.R.S.)
| | - Pawel Kuklik
- From the Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia (S.N., P.K., A.N.G., L.W., G.D.Y., P.S., K.C.R.-T.); and School of Public Health, University of Adelaide, Australia (T.R.S.)
| | - Anand N Ganesan
- From the Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia (S.N., P.K., A.N.G., L.W., G.D.Y., P.S., K.C.R.-T.); and School of Public Health, University of Adelaide, Australia (T.R.S.)
| | - Thomas R Sullivan
- From the Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia (S.N., P.K., A.N.G., L.W., G.D.Y., P.S., K.C.R.-T.); and School of Public Health, University of Adelaide, Australia (T.R.S.)
| | - Lauren Wilson
- From the Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia (S.N., P.K., A.N.G., L.W., G.D.Y., P.S., K.C.R.-T.); and School of Public Health, University of Adelaide, Australia (T.R.S.)
| | - Glenn D Young
- From the Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia (S.N., P.K., A.N.G., L.W., G.D.Y., P.S., K.C.R.-T.); and School of Public Health, University of Adelaide, Australia (T.R.S.)
| | - Prashanthan Sanders
- From the Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia (S.N., P.K., A.N.G., L.W., G.D.Y., P.S., K.C.R.-T.); and School of Public Health, University of Adelaide, Australia (T.R.S.)
| | - Kurt C Roberts-Thomson
- From the Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Australia (S.N., P.K., A.N.G., L.W., G.D.Y., P.S., K.C.R.-T.); and School of Public Health, University of Adelaide, Australia (T.R.S.).
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Scar Homogenization Versus Limited-Substrate Ablation in Patients With Nonischemic Cardiomyopathy and Ventricular Tachycardia. J Am Coll Cardiol 2016; 68:1990-1998. [DOI: 10.1016/j.jacc.2016.08.033] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 07/29/2016] [Accepted: 08/02/2016] [Indexed: 12/22/2022]
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Recent advances in ablation of ventricular tachycardia associated with structural heart disease: overcoming the challenges of functional and fixed barriers. Curr Opin Cardiol 2016; 31:64-71. [PMID: 26627313 DOI: 10.1097/hco.0000000000000242] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW Ablation of ventricular tachycardia in structural heart disease has evolved to include techniques to ablate the myocardial substrate in sinus rhythm for ventricular tachycardias that are noninducible or hemodynamically unstable. The intricacies of the complex functional and fixed components of the myocardial scar involved in the arrhythmic mechanisms require careful consideration in identifying targets for substrate ablation identified in sinus rhythm. RECENT FINDINGS The substrate ablation approach referred to as 'scar homogenization' aims to thoroughly abolish any abnormal electrical activity inside the scar. However, this extensive approach may target bystander abnormal activity that is not necessarily related to arrhythmias. Recently, different substrate ablation strategies have been developed to more selectively target areas of the scar responsible for ventricular tachycardia. New technologies have also been introduced to provide offline analysis of the electroanatomical substrate, and to improve high-density mapping of the myocardial scar. SUMMARY Recent advances have improved the ability to ablate ventricular tachycardia using techniques that allow targeting the responsible myocardial substrate while in sinus rhythm. Further research using higher-density mapping with more sophisticated online and offline analysis will aid in the assessment of the complex arrhythmogenicity of the scar and improve efficacy of ventricular tachycardia ablation.
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Capítulo 11. Utilidad del mapeo tridimensional en la ablación de la taquicardia ventricular isquémica. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2016.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Proietti R, Roux JF, Verma A, Alturki A, Bernier ML, Essebag V. A Historical Perspective on the Role of Functional Lines of Block in the Re-entrant Circuit of Ventricular Tachycardia. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2016; 39:490-6. [PMID: 26852719 DOI: 10.1111/pace.12827] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 01/13/2016] [Accepted: 01/25/2016] [Indexed: 12/29/2022]
Abstract
The ablation strategy for ventricular tachycardia (VT) rapidly evolved from an entrainment mapping approach for identification of the critical isthmus of the re-entrant circuit during monomorphic VT, toward a substrate-based approach aiming to ablate surrogate markers of the circuit during sinus rhythm in hemodynamically nontolerated and polymorphic VT. The latter approach implies an assumption that the circuits responsible for the arrhythmia are anatomical or fixed, and present during sinus rhythm. Accordingly, the lines of block delimiting the channels of the circuits are often considered fixed, although there is evidence that they are functional or more frequently a combination of fixed and functional. The electroanatomical substrate-based approach to VT ablation performed during sinus rhythm is increasingly adopted in clinical practice and often described as scar homogenization, scar dechanneling, or core isolation. However, whether the surrogate markers of the VT circuit during sinus rhythm match the circuit during arrhythmias remains to be fully demonstrated. The myocardial scar is a heterogeneous electrophysiological milieu with complex arrhythmogenic mechanisms that potentially coexist simultaneously. Moreover, the scar consists of different areas of diverse refractoriness and conduction. It can be misleading to limit the arrhythmogenic perspective of the myocardial scar to fixed or anatomical barriers held responsible for the re-entry circuit. Greater understanding of the role of functional lines of block in VT and the validity of the surrogate targets being ablated is necessary to further improve the technique and outcome of VT ablation.
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Affiliation(s)
- Riccardo Proietti
- McGill University Health Center, Montreal, Quebec, Canada.,Cardiology Department, Luigi Sacco Hospital, Milan, Italy
| | - Jean-Francois Roux
- McGill University Health Center, Montreal, Quebec, Canada.,Centre Hospitalier Universite de Sherbrooke, Quebec, Canada
| | - Atul Verma
- McGill University Health Center, Montreal, Quebec, Canada.,Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Ahmed Alturki
- McGill University Health Center, Montreal, Quebec, Canada
| | | | - Vidal Essebag
- McGill University Health Center, Montreal, Quebec, Canada.,Hôpital Sacré-Coeur de Montréal, Montreal, Quebec, Canada
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John RM, Stevenson W. Current Management of Ventricular Tachycardia: Approaches and Timing. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2016. [DOI: 10.15212/cvia.2015.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Jackson N, Gizurarson S, Viswanathan K, King B, Massé S, Kusha M, Porta-Sanchez A, Jacob JR, Khan F, Das M, Ha ACT, Pashaei A, Vigmond E, Downar E, Nanthakumar K. Decrement Evoked Potential Mapping: Basis of a Mechanistic Strategy for Ventricular Tachycardia Ablation. Circ Arrhythm Electrophysiol 2015; 8:1433-42. [PMID: 26480929 DOI: 10.1161/circep.115.003083] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 10/13/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Substrate-based mapping for ventricular tachycardia (VT) ablation is hampered by its inability to determine critical sites of the VT circuit. We hypothesized that those potentials, which delay with a decremental extrastimulus (decrement evoked potentials or DEEPs), are more likely to colocalize with the diastolic pathways of VT circuits. METHODS AND RESULTS DEEPs were identified in intraoperative left ventricular maps from 6 patients with ischemic cardiomyopathy (total 9 VTs) and were compared with late potential (LP) and activation maps of the diastolic pathway for each VT. Mathematical modeling was also used to further validate and elucidate the mechanisms of DEEP mapping. All patients demonstrated regions of DEEPs and LPs. The mean endocardial surface area of these potentials was 18±4% and 21±6%, respectively (P=0.13). The mean sensitivity for identifying the diastolic pathway in VT was 50±23% for DEEPs and 36±32% for LPs (P=0.31). The mean specificity was 43±23% versus 20±8% for DEEP and LP mapping, respectively (P=0.031). The electrograms that displayed the greatest decrement in each case had a sensitivity and specificity for the VT isthmus of 29±10% and 95±1%, respectively. Mathematical modeling studies recapitulated DEEPs at the VT isthmus and demonstrated their role in VT initiation with a critical degree of decrement. CONCLUSIONS In this preliminary study, DEEP mapping was more specific than LP mapping for identifying the critical targets of VT ablation. The mechanism of DEEPs relates to conduction velocity restitution magnified by zigzag conduction within scar channels.
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Affiliation(s)
- Nicholas Jackson
- From the Toronto General Hospital, Toronto, Ontario, Canada (N.J., S.G., K.V., B.K., S.M., M.K., A.P.-S., J.R.J., F.K., M.D., A.C.T.H., E.D., K.N.); Laboratory IMB, University of Bordeaux, Talence, France (A.P., E.V.); and LIRYC Cardiac Electrophysiology and Heart Modelling Institute, University of Bordeaux Foundation, Pessac, France (A.P., E.V.)
| | - Sigfus Gizurarson
- From the Toronto General Hospital, Toronto, Ontario, Canada (N.J., S.G., K.V., B.K., S.M., M.K., A.P.-S., J.R.J., F.K., M.D., A.C.T.H., E.D., K.N.); Laboratory IMB, University of Bordeaux, Talence, France (A.P., E.V.); and LIRYC Cardiac Electrophysiology and Heart Modelling Institute, University of Bordeaux Foundation, Pessac, France (A.P., E.V.)
| | - Karthik Viswanathan
- From the Toronto General Hospital, Toronto, Ontario, Canada (N.J., S.G., K.V., B.K., S.M., M.K., A.P.-S., J.R.J., F.K., M.D., A.C.T.H., E.D., K.N.); Laboratory IMB, University of Bordeaux, Talence, France (A.P., E.V.); and LIRYC Cardiac Electrophysiology and Heart Modelling Institute, University of Bordeaux Foundation, Pessac, France (A.P., E.V.)
| | - Benjamin King
- From the Toronto General Hospital, Toronto, Ontario, Canada (N.J., S.G., K.V., B.K., S.M., M.K., A.P.-S., J.R.J., F.K., M.D., A.C.T.H., E.D., K.N.); Laboratory IMB, University of Bordeaux, Talence, France (A.P., E.V.); and LIRYC Cardiac Electrophysiology and Heart Modelling Institute, University of Bordeaux Foundation, Pessac, France (A.P., E.V.)
| | - Stephane Massé
- From the Toronto General Hospital, Toronto, Ontario, Canada (N.J., S.G., K.V., B.K., S.M., M.K., A.P.-S., J.R.J., F.K., M.D., A.C.T.H., E.D., K.N.); Laboratory IMB, University of Bordeaux, Talence, France (A.P., E.V.); and LIRYC Cardiac Electrophysiology and Heart Modelling Institute, University of Bordeaux Foundation, Pessac, France (A.P., E.V.)
| | - Marjan Kusha
- From the Toronto General Hospital, Toronto, Ontario, Canada (N.J., S.G., K.V., B.K., S.M., M.K., A.P.-S., J.R.J., F.K., M.D., A.C.T.H., E.D., K.N.); Laboratory IMB, University of Bordeaux, Talence, France (A.P., E.V.); and LIRYC Cardiac Electrophysiology and Heart Modelling Institute, University of Bordeaux Foundation, Pessac, France (A.P., E.V.)
| | - Andreu Porta-Sanchez
- From the Toronto General Hospital, Toronto, Ontario, Canada (N.J., S.G., K.V., B.K., S.M., M.K., A.P.-S., J.R.J., F.K., M.D., A.C.T.H., E.D., K.N.); Laboratory IMB, University of Bordeaux, Talence, France (A.P., E.V.); and LIRYC Cardiac Electrophysiology and Heart Modelling Institute, University of Bordeaux Foundation, Pessac, France (A.P., E.V.)
| | - John Roshan Jacob
- From the Toronto General Hospital, Toronto, Ontario, Canada (N.J., S.G., K.V., B.K., S.M., M.K., A.P.-S., J.R.J., F.K., M.D., A.C.T.H., E.D., K.N.); Laboratory IMB, University of Bordeaux, Talence, France (A.P., E.V.); and LIRYC Cardiac Electrophysiology and Heart Modelling Institute, University of Bordeaux Foundation, Pessac, France (A.P., E.V.)
| | - Fakhar Khan
- From the Toronto General Hospital, Toronto, Ontario, Canada (N.J., S.G., K.V., B.K., S.M., M.K., A.P.-S., J.R.J., F.K., M.D., A.C.T.H., E.D., K.N.); Laboratory IMB, University of Bordeaux, Talence, France (A.P., E.V.); and LIRYC Cardiac Electrophysiology and Heart Modelling Institute, University of Bordeaux Foundation, Pessac, France (A.P., E.V.)
| | - Moloy Das
- From the Toronto General Hospital, Toronto, Ontario, Canada (N.J., S.G., K.V., B.K., S.M., M.K., A.P.-S., J.R.J., F.K., M.D., A.C.T.H., E.D., K.N.); Laboratory IMB, University of Bordeaux, Talence, France (A.P., E.V.); and LIRYC Cardiac Electrophysiology and Heart Modelling Institute, University of Bordeaux Foundation, Pessac, France (A.P., E.V.)
| | - Andrew C T Ha
- From the Toronto General Hospital, Toronto, Ontario, Canada (N.J., S.G., K.V., B.K., S.M., M.K., A.P.-S., J.R.J., F.K., M.D., A.C.T.H., E.D., K.N.); Laboratory IMB, University of Bordeaux, Talence, France (A.P., E.V.); and LIRYC Cardiac Electrophysiology and Heart Modelling Institute, University of Bordeaux Foundation, Pessac, France (A.P., E.V.)
| | - Ali Pashaei
- From the Toronto General Hospital, Toronto, Ontario, Canada (N.J., S.G., K.V., B.K., S.M., M.K., A.P.-S., J.R.J., F.K., M.D., A.C.T.H., E.D., K.N.); Laboratory IMB, University of Bordeaux, Talence, France (A.P., E.V.); and LIRYC Cardiac Electrophysiology and Heart Modelling Institute, University of Bordeaux Foundation, Pessac, France (A.P., E.V.)
| | - Edward Vigmond
- From the Toronto General Hospital, Toronto, Ontario, Canada (N.J., S.G., K.V., B.K., S.M., M.K., A.P.-S., J.R.J., F.K., M.D., A.C.T.H., E.D., K.N.); Laboratory IMB, University of Bordeaux, Talence, France (A.P., E.V.); and LIRYC Cardiac Electrophysiology and Heart Modelling Institute, University of Bordeaux Foundation, Pessac, France (A.P., E.V.)
| | - Eugene Downar
- From the Toronto General Hospital, Toronto, Ontario, Canada (N.J., S.G., K.V., B.K., S.M., M.K., A.P.-S., J.R.J., F.K., M.D., A.C.T.H., E.D., K.N.); Laboratory IMB, University of Bordeaux, Talence, France (A.P., E.V.); and LIRYC Cardiac Electrophysiology and Heart Modelling Institute, University of Bordeaux Foundation, Pessac, France (A.P., E.V.)
| | - Kumaraswamy Nanthakumar
- From the Toronto General Hospital, Toronto, Ontario, Canada (N.J., S.G., K.V., B.K., S.M., M.K., A.P.-S., J.R.J., F.K., M.D., A.C.T.H., E.D., K.N.); Laboratory IMB, University of Bordeaux, Talence, France (A.P., E.V.); and LIRYC Cardiac Electrophysiology and Heart Modelling Institute, University of Bordeaux Foundation, Pessac, France (A.P., E.V.).
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Deng D, Arevalo H, Pashakhanloo F, Prakosa A, Ashikaga H, McVeigh E, Halperin H, Trayanova N. Accuracy of prediction of infarct-related arrhythmic circuits from image-based models reconstructed from low and high resolution MRI. Front Physiol 2015; 6:282. [PMID: 26528188 PMCID: PMC4602125 DOI: 10.3389/fphys.2015.00282] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 09/22/2015] [Indexed: 11/13/2022] Open
Abstract
Identification of optimal ablation sites in hearts with infarct-related ventricular tachycardia (VT) remains difficult to achieve with the current catheter-based mapping techniques. Limitations arise from the ambiguities in determining the reentrant pathways location(s). The goal of this study was to develop experimentally validated, individualized computer models of infarcted swine hearts, reconstructed from high-resolution ex-vivo MRI and to examine the accuracy of the reentrant circuit location prediction when models of the same hearts are instead reconstructed from low clinical-resolution MRI scans. To achieve this goal, we utilized retrospective data obtained from four pigs ~10 weeks post infarction that underwent VT induction via programmed stimulation and epicardial activation mapping via a multielectrode epicardial sock. After the experiment, high-resolution ex-vivo MRI with late gadolinium enhancement was acquired. The Hi-res images were downsampled into two lower resolutions (Med-res and Low-res) in order to replicate image quality obtainable in the clinic. The images were segmented and models were reconstructed from the three image stacks for each pig heart. VT induction similar to what was performed in the experiment was simulated. Results of the reconstructions showed that the geometry of the ventricles including the infarct could be accurately obtained from Med-res and Low-res images. Simulation results demonstrated that induced VTs in the Med-res and Low-res models were located close to those in Hi-res models. Importantly, all models, regardless of image resolution, accurately predicted the VT morphology and circuit location induced in the experiment. These results demonstrate that MRI-based computer models of hearts with ischemic cardiomyopathy could provide a unique opportunity to predict and analyze VT resulting for from specific infarct architecture, and thus may assist in clinical decisions to identify and ablate the reentrant circuit(s).
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Affiliation(s)
- Dongdong Deng
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University Baltimore, MD, USA
| | - Hermenegild Arevalo
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University Baltimore, MD, USA
| | - Farhad Pashakhanloo
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University Baltimore, MD, USA
| | - Adityo Prakosa
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University Baltimore, MD, USA
| | - Hiroshi Ashikaga
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institute Baltimore, MD, USA ; Department of Biomedical Engineering, Johns Hopkins University Baltimore, MD, USA
| | - Elliot McVeigh
- Department of Biomedical Engineering, Johns Hopkins University Baltimore, MD, USA
| | - Henry Halperin
- Division of Cardiology, Department of Medicine, Johns Hopkins Medical Institute Baltimore, MD, USA
| | - Natalia Trayanova
- Department of Biomedical Engineering, Institute for Computational Medicine, Johns Hopkins University Baltimore, MD, USA
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Berte B, Relan J, Sacher F, Pillois X, Appetiti A, Yamashita S, Mahida S, Casassus F, Hooks D, Sellal JM, Amraoui S, Denis A, Derval N, Cochet H, Hocini M, Haïssaguerre M, Weerasooriya R, Jaïs P. Impact of Electrode Type on Mapping of Scar-Related VT. J Cardiovasc Electrophysiol 2015. [PMID: 26198475 DOI: 10.1111/jce.12761] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Substrate-based VT ablation is mostly based on maps acquired with ablation catheters. We hypothesized that multipolar mapping catheters are more effective for identification of scar and local abnormal ventricular activity (LAVA). METHODS AND RESULTS Phase1: In a sheep infarction model (2 months postinfarction), substrate mapping and LAVA tagging (CARTO® 3) was performed, using a Navistar (NAV) versus a PentaRay (PR) catheter (Biosense Webster). Phase2: Consecutive VT ablation patients from a single center underwent NAV versus PR mapping. Point pairs were defined as a PR and a NAV point located within a 3D-distance of ≤3 mm. Agreement was defined as both points in a pair being manually tagged as normal or LAVA. Four sheep (4 years, 50 ± 4.8 kg) and 9 patients were included (53 ± 14 years, 8 male, 6 ischemic cardiomyopathy). Mapping density was higher within the scar with PR versus NAV (3.2 vs. 0.7 points/cm2 , P = 0.001) with larger bipolar scar area (68 ± 55 cm2 vs. 58 ± 48 cm2 , P = 0.001). In total, 818 point pairs were analyzed. Using PR, far-field voltages were smaller (PR vs. NAV; bipolar: 1.43 ± 1.84 mV vs. 1.64 ± 2.04 mV, P = 0.001; unipolar; 4.28 ± 3.02 mV vs. 4.59 ± 3.67 mV, P < 0.001). More LAVA were also detected with PR (PR vs. NAV; 126 ± 113 vs. 36 ± 29, P = 0.001). When agreement on LAVA was reached (overall: 72%; both LAVA, 40%; both normal, 82%) higher LAVA voltages were recorded on PR (0.48 ± 0.33 mV vs. 0.31 ± 0.21 mV, P = 0.0001). CONCLUSION Multipolar mapping catheters with small electrodes provide more accurate and higher density maps, with a higher sensitivity to near-field signals. Agreement between PR and NAV is low.
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Affiliation(s)
- Benjamin Berte
- Hôpital Cardiologique du Haut-L'évêque, Université de Bordeaux, LIRYC Institute, Bordeaux, France
| | - Jatin Relan
- Hôpital Cardiologique du Haut-L'évêque, Université de Bordeaux, LIRYC Institute, Bordeaux, France
| | - Frederic Sacher
- Hôpital Cardiologique du Haut-L'évêque, Université de Bordeaux, LIRYC Institute, Bordeaux, France
| | - Xavier Pillois
- Hôpital Cardiologique du Haut-L'évêque, Université de Bordeaux, LIRYC Institute, Bordeaux, France
| | - Anthony Appetiti
- Hôpital Cardiologique du Haut-L'évêque, Université de Bordeaux, LIRYC Institute, Bordeaux, France
| | - Seigo Yamashita
- Hôpital Cardiologique du Haut-L'évêque, Université de Bordeaux, LIRYC Institute, Bordeaux, France
| | - Saagar Mahida
- Hôpital Cardiologique du Haut-L'évêque, Université de Bordeaux, LIRYC Institute, Bordeaux, France
| | - Frederic Casassus
- Hôpital Cardiologique du Haut-L'évêque, Université de Bordeaux, LIRYC Institute, Bordeaux, France
| | - Darren Hooks
- Hôpital Cardiologique du Haut-L'évêque, Université de Bordeaux, LIRYC Institute, Bordeaux, France
| | - Jean-Marc Sellal
- Hôpital Cardiologique du Haut-L'évêque, Université de Bordeaux, LIRYC Institute, Bordeaux, France
| | - Sana Amraoui
- Hôpital Cardiologique du Haut-L'évêque, Université de Bordeaux, LIRYC Institute, Bordeaux, France
| | - Arnaud Denis
- Hôpital Cardiologique du Haut-L'évêque, Université de Bordeaux, LIRYC Institute, Bordeaux, France
| | - Nicolas Derval
- Hôpital Cardiologique du Haut-L'évêque, Université de Bordeaux, LIRYC Institute, Bordeaux, France
| | - Hubert Cochet
- Hôpital Cardiologique du Haut-L'évêque, Université de Bordeaux, LIRYC Institute, Bordeaux, France
| | - Mélèze Hocini
- Hôpital Cardiologique du Haut-L'évêque, Université de Bordeaux, LIRYC Institute, Bordeaux, France
| | - Michel Haïssaguerre
- Hôpital Cardiologique du Haut-L'évêque, Université de Bordeaux, LIRYC Institute, Bordeaux, France
| | - Rukshen Weerasooriya
- Hôpital Cardiologique du Haut-L'évêque, Université de Bordeaux, LIRYC Institute, Bordeaux, France
| | - Pierre Jaïs
- Hôpital Cardiologique du Haut-L'évêque, Université de Bordeaux, LIRYC Institute, Bordeaux, France
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Letsas KP, Efremidis M, Sgouros NP, Vlachos K, Asvestas D, Sideris A. Catheter ablation of persistent atrial fibrillation: The importance of substrate modification. World J Cardiol 2015; 7:111-118. [PMID: 25810810 PMCID: PMC4365304 DOI: 10.4330/wjc.v7.i3.111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Revised: 12/26/2014] [Accepted: 01/20/2015] [Indexed: 02/06/2023] Open
Abstract
Accumulating data have shown that elimination of atrial fibrillation (AF) sources should be the goal in persistent AF ablation. Pulmonary vein isolation, linear lesions and complex fractionated atrial electrograms (CFAEs) ablation have shown limited efficacy in patients with persistent AF. A combined approach using voltage, CFAEs and dominant frequency (DF) mapping may be helpful for the identification of AF sources and subsequent focal substrate modification. The fibrillatory activity is maintained by intramural reentry centered on fibrotic patches. Voltage mapping may assist in the identification of fibrotic areas. Stable rotors display the higher DF and possibly drive AF. Furthermore, the single rotor is usually consistent with organized AF electrograms without fractionation. It is therefore quite possible that rotors are located at relatively “healthy islands” within the patchy fibrosis. This is supported by the fact that high DF sites have been negatively correlated to the amount of fibrosis. CFAEs are located in areas adjacent to high DF. In conclusion, patchy fibrotic areas displaying the maximum DF along with high organization index and the lower fractionation index are potential targets of ablation. Prospective studies are required to validate the efficacy of substrate modification in left atrial ablation outcomes.
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Bradfield JS, Shivkumar K. Cardiac resynchronization therapy-induced proarrhythmia: understanding preferential conduction within myocardial scars. Circ Arrhythm Electrophysiol 2014; 7:1000-2. [PMID: 25516575 DOI: 10.1161/circep.114.002390] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jason S Bradfield
- From the UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, CA
| | - Kalyanam Shivkumar
- From the UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, CA.
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Sadek MM, Schaller RD, Supple GE, Frankel DS, Riley MP, Hutchinson MD, Garcia FC, Lin D, Dixit S, Zado ES, Callans DJ, Marchlinski FE. Ventricular Tachycardia Ablation - The Right Approach for the Right Patient. Arrhythm Electrophysiol Rev 2014; 3:161-7. [PMID: 26835085 DOI: 10.15420/aer.2014.3.3.161] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2014] [Accepted: 10/15/2014] [Indexed: 01/31/2023] Open
Abstract
Scar-related reentry is the most common mechanism of monomorphic ventricular tachycardia (VT) in patients with structural heart disease. Catheter ablation has assumed an increasingly important role in the management of VT in this setting, and has been shown to reduce VT recurrence and implantable cardioverter defibrillator (ICD) shocks. The approach to mapping and ablation will depend on the underlying heart disease etiology, VT inducibility and haemodynamic stability. This review explores pre-procedural planning, approach to ablation of both mappable and unmappable VT, and post-procedural testing. Future developments in techniques and technology that may improve outcomes are discussed.
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Affiliation(s)
- Mouhannad M Sadek
- Section of Cardiac Electrophysiology, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, US
| | - Robert D Schaller
- Section of Cardiac Electrophysiology, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, US
| | - Gregory E Supple
- Section of Cardiac Electrophysiology, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, US
| | - David S Frankel
- Section of Cardiac Electrophysiology, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, US
| | - Michael P Riley
- Section of Cardiac Electrophysiology, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, US
| | - Mathew D Hutchinson
- Section of Cardiac Electrophysiology, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, US
| | - Fermin C Garcia
- Section of Cardiac Electrophysiology, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, US
| | - David Lin
- Section of Cardiac Electrophysiology, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, US
| | - Sanjay Dixit
- Section of Cardiac Electrophysiology, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, US
| | - Erica S Zado
- Section of Cardiac Electrophysiology, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, US
| | - David J Callans
- Section of Cardiac Electrophysiology, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, US
| | - Francis E Marchlinski
- Section of Cardiac Electrophysiology, Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, US
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40
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Santangeli P, Frankel DS, Marchlinski FE. End Points for Ablation of Scar-Related Ventricular Tachycardia. Circ Arrhythm Electrophysiol 2014; 7:949-60. [DOI: 10.1161/circep.114.001585] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Pasquale Santangeli
- From the Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - David S. Frankel
- From the Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Francis E. Marchlinski
- From the Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
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41
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Sadek MM, Marchlinski FE. Ablation of ventricular arrhythmias. Trends Cardiovasc Med 2014; 24:296-304. [DOI: 10.1016/j.tcm.2014.07.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 07/09/2014] [Accepted: 07/09/2014] [Indexed: 11/25/2022]
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Kumar S, Stevenson WG, John RM. Catheter ablation for premature ventricular contractions and ventricular tachycardia in patients with heart failure. Curr Cardiol Rep 2014; 16:522. [PMID: 25059465 DOI: 10.1007/s11886-014-0522-3] [Citation(s) in RCA: 2] [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
Ventricular arrhythmias (VA) are a significant contributor to morbidity and mortality in patients with heart failure (HF). Implantable cardioverter defibrillators are effective in reducing mortality, but do not prevent arrhythmia recurrence. There is increasing recognition that frequent premature ventricular contractions or repetitive ventricular tachycardia may also lead to new onset ventricular dysfunction or deterioration of ventricular function in patients with pre-existing HF. Suppression of the arrhythmia may lead to recovery of ventricular function. Catheter ablation has emerged as a safe and effective treatment option for reducing arrhythmia recurrence and for suppression of PVCs but its efficacy is governed by the nature of the arrhythmias, the underlying HF substrate and the accessibility of the arrhythmia substrates to ablation.
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Affiliation(s)
- Saurabh Kumar
- Cardiac Arrhythmia Service, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
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Tedrow U, Stevenson WG. Sinus Rhythm Targeting of Channels for Ablation of Postinfarction Ventricular Tachycardia. Circ Arrhythm Electrophysiol 2014; 7:7-9. [DOI: 10.1161/circep.114.001422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Usha Tedrow
- From Arrhythmia Service of the Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA
| | - William G. Stevenson
- From Arrhythmia Service of the Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA
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