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Falzone PV, Vazquez-Calvo S, Roca-Luque I. Catheter Ablation of Ventricular Tachycardia in Ischemic Heart Disease: What Is Known and New Perspectives. Curr Heart Fail Rep 2024; 21:174-185. [PMID: 38536648 DOI: 10.1007/s11897-024-00656-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 05/14/2024]
Abstract
PURPOSE OF THE REVIEW This review aims to evaluate current evidence regarding ventricular tachycardia ablation in patients with ischemic heart disease and explore novel approaches currently developing to improve procedural and long-term outcomes. RECENT FINDINGS Recently published trials (PARTITA, PAUSE-SCD, and SURVIVE-VT) have demonstrated the prognostic benefit of prophylactic ventricular tachycardia ablation compared to current clinical practice. Advanced cardiac imaging provides a valuable pre-procedural evaluation of the arrhythmogenic substrate, identifying ablation targets non-invasively. Advanced cardiac mapping techniques allow to better characterize arrhythmogenic substrate during ablation procedure. Emerging technologies like pulsed field ablation and ultra-low temperature cryoablation show promise in ventricular tachycardia ablation. Advancements in mapping techniques, ablation technologies, and pre-procedural cardiac imaging offer promise for improving ventricular tachycardia ablation outcomes in ischemic heart disease.
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Affiliation(s)
- Pasquale Valerio Falzone
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Carrer de Villaroel 170, 08036, Barcelona, Catalonia, Spain
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Sara Vazquez-Calvo
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Carrer de Villaroel 170, 08036, Barcelona, Catalonia, Spain
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Ivo Roca-Luque
- Institut Clinic Cardiovascular, Hospital Clínic, Universitat de Barcelona, Carrer de Villaroel 170, 08036, Barcelona, Catalonia, Spain.
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain.
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Roukoz H, Tholakanahalli V. Epicardial ablation of ventricular tachycardia in ischemic cardiomyopathy: A review and local experience. Indian Pacing Electrophysiol J 2024; 24:84-93. [PMID: 38340957 PMCID: PMC11010455 DOI: 10.1016/j.ipej.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 10/29/2023] [Accepted: 02/07/2024] [Indexed: 02/12/2024] Open
Abstract
Myocardial scar in ischemic cardiomyopathy is predominantly endocardial, however, between 5% and 15% of these patients have an arrhythmogenic epicardial substrate. Percutaneous epicardial ablation should be considered in patients with ICM and VT especially if they failed an endocardial ablation. Simultaneous epicardial and endocardial ablation of VT in ICM may reduce short- and medium-term VT recurrence compared with an endocardial only approach. Cardiac imaging could be used to help guide patient selection for a combined epi-endo approach. Complications related to epicardial access can happen in up to 7% of patients. Epicardial ablation in these patients should be referred to experienced tertiary centers. We review the literature and share interesting cases.
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Chen HS, van Roon L, Schoones J, Zeppenfeld K, DeRuiter MC, Jongbloed MRM. Cardiac sympathetic hyperinnervation after myocardial infarction: a systematic review and qualitative analysis. Ann Med 2023; 55:2283195. [PMID: 38065671 PMCID: PMC10836288 DOI: 10.1080/07853890.2023.2283195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 11/08/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Cardiac sympathetic hyperinnervation after myocardial infarction (MI) is associated with arrhythmogenesis and sudden cardiac death. The characteristics of cardiac sympathetic hyperinnervation remain underexposed. OBJECTIVE To provide a systematic review on cardiac sympathetic hyperinnervation after MI, taking into account: (1) definition, experimental model and quantification method and (2) location, amount and timing, in order to obtain an overview of current knowledge and to expose gaps in literature. METHODS References on cardiac sympathetic hyperinnervation were screened for inclusion. The included studies received a full-text review and quality appraisal. Relevant data on hyperinnervation were collected and qualitatively analysed. RESULTS Our literature search identified 60 eligible studies performed between 2000 and 2022. Cardiac hyperinnervation is generally defined as an increased sympathetic nerve density or increased number of nerves compared to another control group (100%). Studies were performed in a multitude of experimental models, but most commonly in male rats with permanent left anterior descending (LAD) artery ligation (male: 63%, rat: 68%, permanent ligation: 93%, LAD: 97%). Hyperinnervation seems to occur mainly in the borderzone. Quantification after MI was performed in regions of interest in µm2/mm2 (41%) or in percentage of nerve fibres (46%) and the reported amount showed a great variation ranging from 439 to 126,718 µm2/mm2. Hyperinnervation seems to start from three days onwards to >3 months without an evident peak, although studies on structural evaluation over time and in the chronic phase were scarce. CONCLUSIONS Cardiac sympathetic hyperinnervation after MI occurs mainly in the borderzone from three days onwards and remains present at later timepoints, for at least 3 months. It is most commonly studied in male rats with permanent LAD ligation. The amount of hyperinnervation differs greatly between studies, possibly due to differential quantification methods. Further studies are required that evaluate cardiac sympathetic hyperinnervation over time and in the chronic phase, in transmural sections, in the female sex, and in MI with reperfusion.
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Affiliation(s)
- H. Sophia Chen
- Department of Cardiology, Center of Congenital Heart Disease Amsterdam Leiden (CAHAL), Leiden University Medical Center, Leiden, The Netherlands
- Department of Anatomy & Embryology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lieke van Roon
- Department of Anatomy & Embryology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan Schoones
- Dictorate of Research Policy, Leiden University Medical Center, Leiden, The Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology, Center of Congenital Heart Disease Amsterdam Leiden (CAHAL), Leiden University Medical Center, Leiden, The Netherlands
| | - Marco C. DeRuiter
- Department of Anatomy & Embryology, Leiden University Medical Center, Leiden, The Netherlands
| | - Monique R. M. Jongbloed
- Department of Cardiology, Center of Congenital Heart Disease Amsterdam Leiden (CAHAL), Leiden University Medical Center, Leiden, The Netherlands
- Department of Anatomy & Embryology, Leiden University Medical Center, Leiden, The Netherlands
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Chen HS, Voortman LM, van Munsteren JC, Wisse LJ, Tofig BJ, Kristiansen SB, Glashan CA, DeRuiter MC, Zeppenfeld K, Jongbloed MRM. Quantification of Large Transmural Biopsies Reveals Heterogeneity in Innervation Patterns in Chronic Myocardial Infarction. JACC Clin Electrophysiol 2023; 9:1652-1664. [PMID: 37480856 DOI: 10.1016/j.jacep.2023.04.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 04/05/2023] [Accepted: 04/21/2023] [Indexed: 07/24/2023]
Abstract
BACKGROUND Abnormal cardiac innervation plays an important role in arrhythmogenicity after myocardial infarction (MI). Data regarding reperfusion models and innervation abnormalities in the medium to long term after MI are sparse. Histologic quantification of the small-sized cardiac nerves is challenging, and transmural analysis has not been performed. OBJECTIVES This study sought to assess cardiac innervation patterns in transmural biopsy sections in a porcine reperfusion model of MI (MI-R) using a novel method for nerve quantification. METHODS Transmural biopsy sections from 4 swine (n = 83) at 3 months after MI-R and 3 controls (n = 38) were stained with picrosirius red (fibrosis) and beta-III-tubulin (autonomic nerves). Biopsy sections were classified as infarct core, border zone, or remote zone. Each biopsy section was analyzed with a custom software pipeline, allowing calculation of nerve density and classification into innervation types at the 1 × 1-mm resolution level. Relocation of the classified squares to the original biopsy position enabled transmural quantification and innervation heterogeneity assessment. RESULTS Coexisting hyperinnervation, hypoinnervation, and denervation were present in all transmural MI-R biopsy sections. The innervation heterogeneity was greatest in the infarct core (median: 0.14; IQR: 0.12-0.15), followed by the border zone (median: 0.05; IQR: 0.04-0.07; P = 0.02) and remote zone (median: 0.02; IQR: 0.02-0.03; P < 0.0001). Only in the border zone was a positive linear relation between fibrosis and innervation heterogeneity observed (R = 0.79; P < 0.0001). CONCLUSIONS This novel method allows quantification of nerve density and heterogeneity in large transmural biopsy sections. In the chronic phase after MI-R, alternating innervation patterns were identified within the same biopsy section. Persistent innervation heterogeneity, in particular in the border zone biopsy sections, may contribute to late arrhythmogenicity.
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Affiliation(s)
- H Sophia Chen
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands; Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, the Netherlands
| | - Lenard M Voortman
- Department of Cell and Chemical Biology, Leiden University Medical Center, Leiden, the Netherlands
| | - J Conny van Munsteren
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, the Netherlands
| | - Lambertus J Wisse
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, the Netherlands
| | - Bawer J Tofig
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Aarhus University Hospital, Aarhus, Denmark
| | - Steen B Kristiansen
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Aarhus University Hospital, Aarhus, Denmark
| | - Claire A Glashan
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands; Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marco C DeRuiter
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, the Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands; Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, the Netherlands.
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Chatterjee NA. Septal Substrate in Ventricular Tachycardia Storm: Bellwether of Risk. JACC Clin Electrophysiol 2023:S2405-500X(23)00211-6. [PMID: 37227352 DOI: 10.1016/j.jacep.2023.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 05/26/2023]
Affiliation(s)
- Neal A Chatterjee
- Electrophysiology Section, Cardiology Division, University of Washington Medicine Heart Institute, University of Washington, Seattle, Washington, USA.
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Pandozi C, Mariani MV, Chimenti C, Maestrini V, Filomena D, Magnocavallo M, Straito M, Piro A, Russo M, Galeazzi M, Ficili S, Colivicchi F, Severino P, Mancone M, Fedele F, Lavalle C. The scar: the wind in the perfect storm-insights into the mysterious living tissue originating ventricular arrhythmias. J Interv Card Electrophysiol 2023; 66:27-38. [PMID: 35072829 PMCID: PMC9931863 DOI: 10.1007/s10840-021-01104-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 12/27/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Arrhythmic death is very common among patients with structural heart disease, and it is estimated that in European countries, 1 per 1000 inhabitants yearly dies for sudden cardiac death (SCD), mainly as a result of ventricular arrhythmias (VA). The scar is the result of cardiac remodelling process that occurs in several cardiomyopathies, both ischemic and non-ischemic, and is considered the perfect substrate for re-entrant and non-re-entrant arrhythmias. METHODS Our aim was to review published evidence on the histological and electrophysiological properties of myocardial scar and to review the central role of cardiac magnetic resonance (CMR) in assessing ventricular arrhythmias substrate and its potential implication in risk stratification of SCD. RESULTS Scarring process affects both structural and electrical myocardial properties and paves the background for enhanced arrhythmogenicity. Non-uniform anisotropic conduction, gap junctions remodelling, source to sink mismatch and refractoriness dispersion are some of the underlining mechanisms contributing to arrhythmic potential of the scar. All these mechanisms lead to the initiation and maintenance of VA. CMR has a crucial role in the evaluation of patients suffering from VA, as it is considered the gold standard imaging test for scar characterization. Mounting evidences support the use of CMR not only for the definition of gross scar features, as size, localization and transmurality, but also for the identification of possible conducting channels suitable of discrete ablation. Moreover, several studies call out the CMR-based scar characterization as a stratification tool useful in selecting patients at risk of SCD and amenable to implantable cardioverter-defibrillator (ICD) implantation. CONCLUSIONS Scar represents the substrate of ventricular arrhythmias. CMR, defining scar presence and its features, may be a useful tool for guiding ablation procedures and for identifying patients at risk of SCD amenable to ICD therapy.
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Affiliation(s)
- C. Pandozi
- grid.416357.2Department of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - Marco Valerio Mariani
- Department of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences "Sapienza" University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - C. Chimenti
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - V. Maestrini
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - D. Filomena
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - M. Magnocavallo
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - M. Straito
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - A. Piro
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - M. Russo
- grid.416357.2Department of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - M. Galeazzi
- grid.416357.2Department of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - S. Ficili
- ASP, Ragusa Maggiore Hospital, Modica, Italy
| | - F. Colivicchi
- grid.416357.2Department of Cardiology, San Filippo Neri Hospital, Rome, Italy
| | - P. Severino
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - M. Mancone
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - F. Fedele
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
| | - C. Lavalle
- grid.7841.aDepartment of Cardiovascular, Respiratory, Nephrological, Aenesthesiological and Geriatric Sciences “Sapienza” University of Rome, Viale del Policlinico 155, 00161 Rome, Italy
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Vakil RM, Marine JE, Kolandaivelu A, Dickfeld T, Weiss RG, Tomaselli GF, Chrispin J, Wu KC. The Association of Clustered Ventricular Arrhythmia and Cycle Length With Scar Burden in Cardiomyopathy. JACC Clin Electrophysiol 2022; 8:957-966. [PMID: 35981800 PMCID: PMC10111293 DOI: 10.1016/j.jacep.2022.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 05/13/2022] [Accepted: 05/18/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Patients with ≥2 ventricular arrhythmia (VA) events within 3 months (clustered VA) have increased risk for mortality. OBJECTIVES The aim of this study was to examine the association of risk factors including scar characteristics on cardiovascular magnetic resonance imaging with clustered VA and VA cycle length in nonischemic cardiomyopathy (NICM) and ischemic cardiomyopathy (ICM). METHODS Data from 329 primary prevention implantable cardioverter-defibrillator recipients (mean age 57 years, 26% women) were analyzed from the Left Ventricular Structural Predictors of Sudden Cardiac Death study. RESULTS Twenty-one patients developed clustered VA (median time 2.7 years after implantable cardioverter-defibrillator placement). Men had the greatest risk for recurrent VA. Patients with NICM and scar had the highest incidence rate of clustered VA. In patients with NICM, each 1-g increase in core scar correlated with greater clustered VA risk (HR: 1.19; 95% CI: 1.07-1.32). Gray scar was similar among subgroups. Patients with NICM with clustered VA had the longest mean VA cycle length (297 ± 40 milliseconds). Higher core scar burden correlated with longer VA cycle length in patients with NICM (P = 0.002), and higher body mass index correlated with shorter VA cycle length in those with ICM (P = 0.02). Type of VA was similar between cardiomyopathy subgroups, and no scar pattern predominated. CONCLUSIONS Clustered VA was most common in patients with NICM and scar, with greatest risk among those with larger core scar. Core scar correlated with slower VA in patients with NICM, and higher body mass index correlated with faster VA in those with ICM. Type of VA was similar by cardiomyopathy etiology, and no dominant scar pattern was associated with clustered VA.
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Multielectrode Unipolar Voltage Mapping and Electrogram Morphology to Identify Post-Infarct Scar Geometry: Validation by Histology. JACC Clin Electrophysiol 2022; 8:437-449. [PMID: 35450598 DOI: 10.1016/j.jacep.2021.11.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 10/27/2021] [Accepted: 11/17/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES This study sought to evaluate the ability of uni- and bipolar electrograms collected with a multielectrode catheter with smaller electrodes to: 1) delineate scar; and 2) determine local scar complexity. BACKGROUND Early reperfusion results in variable endocardial scar, often overlaid with surviving viable myocardium. Although bipolar voltage (BV) mapping is considered the pillar of substrate-based ablation, the role of unipolar voltage (UV) mapping has not been sufficiently explored. It has been suggested that bipolar electrograms collected with small electrode catheters can better identify complex scar geometries. METHODS Twelve swine with early reperfusion infarctions were mapped with the 48-electrode OctaRay catheter and a conventional catheter during sinus rhythm. BV electrograms with double components were identified. Transmural (n = 933) biopsy specimens corresponding to mapping points were obtained, histologically assessed, and classified by scar geometry. RESULTS OctaRay UV (UVOcta) and BV (BVOcta) amplitude were associated with the amount of viable myocardium at a given location, with a stronger association for UVOcta (R2 = 0.767 vs 0.473). Cutoff values of 3.7 mV and 1.0 mV could delineate scar (area under the curve: 0.803 and 0.728 for UVOcta and BVOcta, respectively). The morphology of bipolar electrograms collected with the OctaRay catheter more frequently identified areas with 2 layers of surviving myocardium than electrograms collected with the conventional catheter (84% vs 71%). CONCLUSIONS UV mapping can generate a map to delineate the area of interest when using a multielectrode catheter. Within this area of interest, the morphology of bipolar electrograms can identify areas in which a surviving epicardial layer may overlay a poorly coupled, potentially arrhythmogenic, endocardium.
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Primo J. Ischemic heart disease management and prognosis: Focus on the details at onset for results in the future. Rev Port Cardiol 2022; 41:337-339. [DOI: 10.1016/j.repc.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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10
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John RM, Stevenson W. Interventricular septal substrates for scar-related monomorphic ventricular tachycardia. Indian Pacing Electrophysiol J 2022; 22:10-11. [PMID: 35101203 PMCID: PMC8811287 DOI: 10.1016/j.ipej.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Roy M John
- Stanford School of Medicine, Palo Alto, CA, USA.
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Aktaş MK, Younis A, Zareba W, Kutyifa V, Klein H, Daubert JP, Estes M, McNitt S, Polonsky B, Goldenberg I. Survival After Implantable Cardioverter-Defibrillator Shocks. J Am Coll Cardiol 2021; 77:2453-2462. [PMID: 34016257 DOI: 10.1016/j.jacc.2021.03.329] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND There are conflicting data on the impact of implantable cardioverter-defibrillator (ICD) shocks on subsequent mortality. OBJECTIVES The aim of this study was to determine whether the arrhythmic substrate leading to ICD therapy or the therapy itself increases mortality. METHODS The study cohort included 5,516 ICD recipients who were enrolled in 5 landmark ICD trials (MADIT-II, MADIT-RISK, MADIT-CRT, MADIT-RIT, RAID). The authors evaluated the association of device therapy with subsequent mortality in 4 separate time-dependent models: model I, type of ICD therapy; model II, type of arrhythmia for which ICD therapy was delivered; model III, combined assessment of all arrhythmia and therapy types during follow-up; and model IV, incremental risk associated with repeated ICD shocks. RESULTS When analyzed by the type of ICD therapy (model I), a first appropriate ICD shock was associated with increased risk of subsequent mortality with or without concomitant occurrence of inappropriate shock during follow-up (hazard ratio [HR]: 2.78 and 2.31; p < 0.001 and p = 0.12), whereas inappropriate shock alone was not associated with mortality risk (HR: 1.23; p = 0.42). Similarly, ICD therapy for ventricular tachycardia (VT) ≥200 beats/min or ventricular fibrillation (VF) (model II) was associated with increased risk of death with or without concomitant therapy for VT <200 beats/min (HRs: 2.25 and 2.62; both p < 0.001), whereas appropriate therapy for VT <200 beats/min or inappropriate therapy (regardless of etiology) did not reach statistical significance (all p > 0.10). Combined assessment of all therapy and arrhythmia types during follow-up (model III) showed that appropriate ICD shocks for VF, shocks for fast VT (≥200 beats/min) without prior antitachycardia pacing (ATP), as well as shocks for fast VT delivered after failed ATP, were associated with the highest risk of subsequent death (HR: all >2.8; p < 0.001). Finally, 2 or more ICD appropriate shocks were not associated with incremental risk to the first appropriate ICD shock (model IV). CONCLUSION The combined data from 5 landmark ICD trials suggest that the underlying arrhythmic substrate rather than the ICD therapy is the more important determinant of mortality in ICD recipients.
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Affiliation(s)
- Mehmet K Aktaş
- Clinical Cardiovascular Research Center, University of Rochester, Rochester, New York, USA.
| | - Arwa Younis
- Clinical Cardiovascular Research Center, University of Rochester, Rochester, New York, USA. https://twitter.com/arwayounis2
| | - Wojciech Zareba
- Clinical Cardiovascular Research Center, University of Rochester, Rochester, New York, USA
| | - Valentina Kutyifa
- Clinical Cardiovascular Research Center, University of Rochester, Rochester, New York, USA
| | - Helmut Klein
- Clinical Cardiovascular Research Center, University of Rochester, Rochester, New York, USA
| | - James P Daubert
- Division of Cardiology, Duke University, Durham, North Carolina, USA
| | - Mark Estes
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Scott McNitt
- Clinical Cardiovascular Research Center, University of Rochester, Rochester, New York, USA
| | - Bronislava Polonsky
- Clinical Cardiovascular Research Center, University of Rochester, Rochester, New York, USA
| | - Ilan Goldenberg
- Clinical Cardiovascular Research Center, University of Rochester, Rochester, New York, USA
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Tung R, Raiman M, Liao H, Zhan X, Chung FP, Nagel R, Hu H, Jian J, Shatz DY, Besser SA, Aziz ZA, Beaser AD, Upadhyay GA, Nayak HM, Nishimura T, Xue Y, Wu S. Simultaneous Endocardial and Epicardial Delineation of 3D Reentrant Ventricular Tachycardia. J Am Coll Cardiol 2020; 75:884-897. [PMID: 32130924 DOI: 10.1016/j.jacc.2019.12.044] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 12/12/2019] [Accepted: 12/16/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Mechanisms of scar-related ventricular tachycardia (VT) are largely based on computational and animal models that portray a 2-dimensional view. OBJECTIVES The authors sought to delineate the human VT circuit with a 3-dimensional perspective from recordings obtained by simultaneous endocardial and epicardial mapping. METHODS High-resolution mapping was performed during 97 procedures in 89 patients with structural heart disease. Circuits were characterized by systematic isochronal analysis to estimate the dimensions of the isthmus and extent of the exit region recorded on both myocardial surfaces. RESULTS A total of 151 VT morphologies were mapped, of which 83 underwent simultaneous endocardial and epicardial mapping; 17% of circuits activated in a 2-dimensional plane, restricted to 1 myocardial surface. Three-dimensional activation patterns with nonuniform transmural propagation were observed in 61% of circuits with only 4% showing transmurally uniform activation, and 18% exhibiting focal activation patterns consistent with mid-myocardial reentry. The dimensions of the central isthmus were 17 mm (12 to 28 mm) × 10 mm (9 to 19 mm) with 55% exhibiting a minimal dimension of <1.5 cm. QRS activation was transmural in 63% and located 43 mm (34 to 52 mm) from the central isthmus. On the basis of 6 proposed definitions for epicardial VT, the prevalence of an epicardial circuit ranged from 21% to 80% in ischemic cardiomyopathy and 28% to 77% in nonischemic cardiomyopathy. CONCLUSIONS A 2D perspective oversimplifies the electrophysiological circuit responsible for reentrant human VT and simultaneous endocardial and epicardial mapping facilitates inferences about mid-myocardial activation. Intricate activation patterns are frequently observed on both myocardial surfaces, and the epicardium is functionally involved in the majority of circuits. Human reentry may exist within isthmus dimensions smaller than 1 cm, whereas QRS activation is often transmural and remote from the critical isthmus target. A 3-dimensional perspective of the VT circuit may enhance the precision of ablative therapy and may support a greater role for adjunctive strategies and technology to address arrhythmogenic tissue harbored in the mid-myocardium and subepicardium.
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Affiliation(s)
- Roderick Tung
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois; Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
| | | | - Hongtao Liao
- Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xianzhang Zhan
- Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Fa Po Chung
- Taipei Veterans General Hospital, Taipei, Taiwan
| | | | - Hongde Hu
- West China Hospital, Sichuan University, Chengdu, China
| | - Jiang Jian
- West China Hospital, Sichuan University, Chengdu, China
| | - Dalise Y Shatz
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois
| | - Stephanie A Besser
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois
| | - Zaid A Aziz
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois
| | - Andrew D Beaser
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois
| | - Gaurav A Upadhyay
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois
| | - Hemal M Nayak
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois
| | - Takuro Nishimura
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois
| | - Yumei Xue
- Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shulin Wu
- Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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13
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Sáenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Europace 2020; 21:1143-1144. [PMID: 31075787 DOI: 10.1093/europace/euz132] [Citation(s) in RCA: 222] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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14
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Nishimura T, Upadhyay GA, Aziz ZA, Beaser AD, Shatz DY, Nayak HM, Tung R. Circuit Determinants of Ventricular Tachycardia Cycle Length: Characterization of Fast and Unstable Human Ventricular Tachycardia. Circulation 2020; 143:212-226. [PMID: 33169628 DOI: 10.1161/circulationaha.120.050363] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Fast ventricular tachycardias (VTs) have historically been attributed to shorter path lengths with smaller reentrant circuit dimensions in animal models. The relationship between the dimensions of the reentrant VT circuit and tachycardia cycle length (TCL) has not been examined in humans. This study aimed to analyze the determinants of the rate of human VT with comparison of circuit dimensions and conduction velocity (CV) across a wide range of both stable and unstable VTs delineated by high-resolution mapping. METHODS Fifty-four VTs with complete circuit delineation (>90% TCL) by high-resolution multielectrode mapping were analyzed in 49 patients (men, 88%; age, 65 years [58-71 years]; nonischemic, 47%). Fast VT was defined as TCL <333 milliseconds (rate >180 bpm). Unstable VT was defined by hemodynamic deterioration with an intrinsic mean arterial pressure <60 mm Hg during a sustained episode. RESULTS The median TCL of VT was 365 milliseconds (306-443 milliseconds), and 24 fast VTs were characterized. A wide range of CVs was observed within the entrance (0.03-0.55 m/s), common pathway (0.03-0.77 m/s), exit (0.03-0.53 m/s), and outer loop (0.17-1.13 m/s). There were no significant differences in the median dimensions of the isthmus and path length between fast and slow VTs and between unstable and stable VTs. The outer loop CV was the only circuit component that correlated with TCL in both ischemic cardiomyopathy (r=-0.5, P=0.006) and nonischemic cardiomyopathy (r=-0.45, P=0.028). The duration of the longest diastolic electrogram was inversely correlated with the dimensions of common pathway (length: r=-0.46, P=0.001, width: r=-0.3, P=0.047) and predictive of rapid VT termination by a single radiofrequency application (r=-0.41, P=0.023). CONCLUSIONS Because of a wide spectrum of CV observed within the reentrant path during human VT, the dimensions of the circuit were not predictive of VT cycle length. For the first time, we demonstrate that the CV of the outer loop, rather than isthmus, is the principal determinant of the rate of VT. The size of the circuit was similar between fast and slow VTs and between unstable and stable VTs. Long, continuous electrograms were indicative of spatially confined isthmus dimensions, confirmed by rapid termination of VT during radiofrequency delivery.
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Affiliation(s)
- Takuro Nishimura
- The University of Chicago Medicine, Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Section of Cardiology, IL
| | - Gaurav A Upadhyay
- The University of Chicago Medicine, Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Section of Cardiology, IL
| | - Zaid A Aziz
- The University of Chicago Medicine, Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Section of Cardiology, IL
| | - Andrew D Beaser
- The University of Chicago Medicine, Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Section of Cardiology, IL
| | - Dalise Y Shatz
- The University of Chicago Medicine, Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Section of Cardiology, IL
| | - Hemal M Nayak
- The University of Chicago Medicine, Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Section of Cardiology, IL
| | - Roderick Tung
- The University of Chicago Medicine, Center for Arrhythmia Care, Pritzker School of Medicine, Department of Medicine, Section of Cardiology, IL
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15
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Glashan CA, Beukers HKC, Tofig BJ, Tao Q, Blom S, Mertens B, Kristiansen SB, Zeppenfeld K. Mini-, Micro-, and Conventional Electrodes: An in Vivo Electrophysiology and Ex Vivo Histology Head-to-Head Comparison. JACC Clin Electrophysiol 2020; 7:197-205. [PMID: 33602400 DOI: 10.1016/j.jacep.2020.08.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 08/11/2020] [Accepted: 08/12/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES This study sought to assess the relative effect of catheter, tissue, and catheter-tissue parameters, on the ability to determine the amount of viable myocardium in vivo. BACKGROUND Although multiple variables impact bipolar voltages (BVs), electrode size, interelectrode spacing, and directional dependency are of particular interest with the development of catheters incorporating mini and microelectrodes. METHODS Nine swine with early reperfusion myocardial infarctions were mapped using the QDot catheter and then remapped using a Pentaray catheter. All QDot points were matched with Pentaray points within 5 mm. The swine were sacrificed, and mapping data projected onto the heart. Transmural biopsies corresponding to mapping points were obtained, allowing a comparison of electrograms recorded by mini, micro-, and conventional electrodes with histology. RESULTS The conventional BV of 2,322 QDot points was 1.9 ± 1.3 mV. The largest of the 3 microelectrode BVs (BVµMax) average 4.8 ± 3.1 mV. The difference between the largest (BVμMax) and smallest (BVμMin) at a given location was 53.7 ± 18.1%. The relationships between both BVμMax and BVμMin and between the conventional BV and BVμMax were positively related but with a significant spread in data, which was more pronounced for the latter. Pentaray points positively related to the BVμMax with poor fit. On histology, increasing viable myocardium increased voltage, but both the slope coefficient and fit were best for BVμMax. CONCLUSIONS Using histology, we could demonstrate that BVμMax is superior to identify viable myocardium compared with BVC and BV using the Pentaray catheter. The ability to simultaneously record 3 BVμs with different orientations, for the same beat, with controllable contact and selecting BVμMax for local BV may partially compensate for wave front direction.
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Affiliation(s)
- Claire A Glashan
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Hans K C Beukers
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Bawer J Tofig
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Qian Tao
- Division of Image Processing, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Sira Blom
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Bart Mertens
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands.
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16
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Bella PD, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. J Interv Card Electrophysiol 2020; 59:145-298. [PMID: 31984466 PMCID: PMC7223859 DOI: 10.1007/s10840-019-00663-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, IN, USA
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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Deshmukh T, Zaman S, Narayan A, Kovoor P. Duration of Inducible Ventricular Tachycardia Early After ST-Segment-Elevation Myocardial Infarction and Its Impact on Mortality and Ventricular Tachycardia Recurrence. J Am Heart Assoc 2020; 9:e015204. [PMID: 32573328 PMCID: PMC7670508 DOI: 10.1161/jaha.119.015204] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Background The clinical significance of the duration of inducible ventricular tachycardia (VT) at electrophysiology study (EPS) in patients soon after ST‐segment–elevation myocardial infarction and its predictive utility for VT recurrence are not known. Methods and Results Consecutive ST‐segment–elevation myocardial infarction patients with day 3 to 5 left ventricular ejection fraction ≤40% underwent EPS. A positive EPS was defined as sustained monomorphic VT with cycle length ≥200 ms. The induced VT was terminated by overdrive pacing or direct current shock at 30 s or earlier if hemodynamic decompensation occurred. Patients with inducible VT duration 2 to 10 s were compared with patients with inducible VT >10 s. The primary end point was survival free of VT or cardiac mortality. From 384 consecutive ST‐segment–elevation myocardial infarction patients who underwent EPS, 29% had inducible VT (n=112, 87% men). After mean follow‐up of 5.9±3.9 years, primary end point occurred in 35% of patients with induced VT 2 to 10 s duration (n=68) and in 22% of patients with induced VT >10 s (n=41) (P=0.61). This was significantly different from the noninducible VT group, in which primary end point occurred in 3% of patients (n=272) (P=0.001). Conclusions This study is the first to show that in patients who undergo EPS early after myocardial infarction, inducible VT of short duration (2–10 s) has similar predictive utility for ventricular tachyarrhythmia as longer duration (>10 s) inducible VT, which was significantly different to those without inducible VT. It is possible that immediate cardioversion of rapid VT might have contributed to some of the short durations of inducible VT.
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Affiliation(s)
- Tejas Deshmukh
- Department of Cardiology Westmead Hospital Sydney Australia.,University of Sydney Australia
| | - Sarah Zaman
- Monash University Melbourne Australia.,Monash Cardiovascular Research Centre Monash Heart Melbourne Australia
| | - Arun Narayan
- Department of Cardiology Westmead Hospital Sydney Australia
| | - Pramesh Kovoor
- Department of Cardiology Westmead Hospital Sydney Australia.,University of Sydney Australia
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18
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Bhaskaran A, Nayyar S, Porta-Sánchez A, Jons C, Massé S, Magtibay K, Aukhojee P, Ha A, Bokhari M, Tung R, Downar E, Nanthakumar K. Direct and indirect mapping of intramural space in ventricular tachycardia. Heart Rhythm 2020; 17:439-446. [DOI: 10.1016/j.hrthm.2019.10.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Indexed: 12/01/2022]
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19
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Amin M, Kella D, Killu AM, Padmanabhan D, Hodge DO, Golafshar MA, Chamberlain AM, Lee JZ, Shen WK, Friedman PA, Asirvatham SJ, Roger VL, Gersh BJ, Mulpuru SK. Sudden cardiac arrest and ventricular arrhythmias following first type I myocardial infarction in the contemporary era. J Cardiovasc Electrophysiol 2019; 30:2869-2876. [PMID: 31588605 PMCID: PMC8276850 DOI: 10.1111/jce.14218] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 09/18/2019] [Accepted: 10/02/2019] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Myocardial infarction (MI) is associated with an increase in subsequent heart failure (HF), recurrent ischemic events, sudden cardiac arrest, and ventricular arrhythmias (SCA-VA). The primary objective of the study to determine the role of intercurrent HF and ischemic events on the development of SCA-VA following first type I MI. METHODS AND RESULTS A retrospective cohort study of patients experiencing first type 1 MI in Olmsted County, Minnesota (2002-2012) was conducted by identifying patients using the medical records linkage system (Rochester epidemiology project). Patients aged ≥18 years were followed from the time of MI till death or 31 July, 2017. Intercurrent HF and ischemic events were the primary exposures following MI and their association with outcome SCA-VA was assessed. Eight hundred and sixty-seven patients (mean age was 63 ± 14.5 years; 69% male; 49.8% ST-elevation myocardial infarction) who had their first type I MI during the study period were included. Majority of acute MI patients were revascularized using percutaneous coronary intervention and bypass surgery (628 [72.43%] and 87 [10.03%] respectively). During a mean follow-up of 7.69 ± 4.17 years, HF, recurrent ischemic events and SCA-VA occurred in 155 (17.9%), 245 (28.3%), and 40 (4.61%) patients respectively. Low ejection fraction (adjusted hazard ratio [HR] 0.95; 95% confidence interval [CI], 0.93-0.98; P < .001), intercurrent HF (adjusted HR 3.11; 95% CI, 1.39-6.95; P = .006) and recurrent ischemic events (adjusted HR 3.47; 95% CI, 1.68-7.18; P < .001) were associated with subsequent SCA-VA. CONCLUSION SCA-VA occurred in a small proportion of patients after MI and is associated with intercurrent HF and recurrent ischemic events.
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Affiliation(s)
- Mustapha Amin
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Danesh Kella
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Ammar M. Killu
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | | | | | | | - Justin Z. Lee
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ, USA
| | - Win-Kuang Shen
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ, USA
| | - Paul A. Friedman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | - Véronique L. Roger
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
- Department of Epidemiology, Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | - Siva K. Mulpuru
- Department of Cardiovascular Diseases, Mayo Clinic, Phoenix, AZ, USA
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20
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Glashan CA, Tofig BJ, Tao Q, Blom SA, Jongbloed MR, Nielsen JC, Lukac P, Kristiansen SB, Zeppenfeld K. Multisize Electrodes for Substrate Identification in Ischemic Cardiomyopathy. JACC Clin Electrophysiol 2019; 5:1130-1140. [DOI: 10.1016/j.jacep.2019.06.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 05/10/2019] [Accepted: 06/06/2019] [Indexed: 11/30/2022]
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21
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Nelson T, Garg P, Clayton RH, Lee J. The Role of Cardiac MRI in the Management of Ventricular Arrhythmias in Ischaemic and Non-ischaemic Dilated Cardiomyopathy. Arrhythm Electrophysiol Rev 2019; 8:191-201. [PMID: 31463057 PMCID: PMC6702467 DOI: 10.15420/aer.2019.5.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 04/25/2019] [Indexed: 02/07/2023] Open
Abstract
Ventricular tachycardia (VT) and VF account for the majority of sudden cardiac deaths worldwide. Treatments for VT/VF include anti-arrhythmic drugs, ICDs and catheter ablation, but these treatments vary in effectiveness and carry substantial risks and/or expense. Current methods of selecting patients for ICD implantation are imprecise and fail to identify some at-risk patients, while leading to others being overtreated. In this article, the authors discuss the current role and future direction of cardiac MRI (CMRI) in refining diagnosis and personalising ventricular arrhythmia management. The capability of CMRI with gadolinium contrast delayed-enhancement patterns and, more recently, T1 mapping to determine the aetiology of patients presenting with heart failure is well established. Although CMRI imaging in patients with ICDs can be challenging, recent technical developments have started to overcome this. CMRI can contribute to risk stratification, with precise and reproducible assessment of ejection fraction, quantification of scar and 'border zone' volumes, and other indices. Detailed tissue characterisation has begun to enable creation of personalised computer models to predict an individual patient's arrhythmia risk. When patients require VT ablation, a substrate-based approach is frequently employed as haemodynamic instability may limit electrophysiological activation mapping. Beyond accurate localisation of substrate, CMRI could be used to predict the location of re-entrant circuits within the scar to guide ablation.
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Affiliation(s)
- Tom Nelson
- Sheffield Teaching Hospitals NHS Foundation TrustSheffield, UK
- Department of Immunity, Infection and Cardiovascular Disease, University of SheffieldSheffield, UK
| | - Pankaj Garg
- Sheffield Teaching Hospitals NHS Foundation TrustSheffield, UK
- Department of Immunity, Infection and Cardiovascular Disease, University of SheffieldSheffield, UK
| | - Richard H Clayton
- INSIGNEO Institute for In-Silico Medicine, University of SheffieldSheffield, UK
- Department of Computer Science, University of SheffieldSheffield, UK
| | - Justin Lee
- Sheffield Teaching Hospitals NHS Foundation TrustSheffield, UK
- Department of Immunity, Infection and Cardiovascular Disease, University of SheffieldSheffield, UK
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22
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Heart Rhythm 2019; 17:e2-e154. [PMID: 31085023 PMCID: PMC8453449 DOI: 10.1016/j.hrthm.2019.03.002] [Citation(s) in RCA: 186] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Indexed: 01/10/2023]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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Bazan V, Frankel DS, Santangeli P, Garcia FC, Tschabrunn CM, Marchlinski FE. Three-dimensional myocardial scar characterization from the endocardium: Usefulness of endocardial unipolar electroanatomic mapping. J Cardiovasc Electrophysiol 2019; 30:427-437. [PMID: 30614100 DOI: 10.1111/jce.13842] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/26/2018] [Accepted: 12/30/2018] [Indexed: 11/29/2022]
Abstract
Epicardial ablation may be required to eliminate ventricular tachycardia (VT) in patients with underlying structural heart disease. The decision to gain epicardial access is frequently based on the suspicion of an epicardial origin for the VT and/or presence of an arrhythmogenic substrate. Epicardial pathology and VT is frequently present in patients with nonischemic right and/or left cardiomyopathies even in the setting of modest or no endocardial bipolar voltage substrate. In this setting, unipolar voltage mapping from the endocardium serves to help identify midmyocardial and/or epicardial VT substrate. The additional value of endocardial unipolar mapping includes its usefulness to predict the clinical outcome after VT ablation, to determine the irreversibility of myocardial disease, and to guide endomyocardial biopsy procedures to specific areas of intramural scarring. In this review, we aim to provide a guide to the use of endocardial unipolar mapping and its appropriate interpretation in a variety of clinical situations.
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Affiliation(s)
| | - David S Frankel
- Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pasquale Santangeli
- Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Fermin C Garcia
- Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Cory M Tschabrunn
- Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Francis E Marchlinski
- Electrophysiology Section, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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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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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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Targeting the Hidden Substrate Unmasked by Right Ventricular Extrastimulation Improves Ventricular Tachycardia Ablation Outcome After Myocardial Infarction. JACC Clin Electrophysiol 2018; 4:316-327. [DOI: 10.1016/j.jacep.2018.01.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/28/2018] [Accepted: 01/29/2018] [Indexed: 11/24/2022]
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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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Abstract
Ventricular arrhythmias are a significant cause of morbidity and mortality in patients with ischemic structural heart disease. Endocardial and epicardial mapping strategies include scar characterization channel identification, and recording and ablation of late potentials and local abnormal ventricular activities. Catheter ablation along with new technology and techniques of bipolar ablation, needle catheter, and autonomic modulation may increase efficacy in difficult to ablate ventricular arrhythmias. Catheter ablation of ventricular arrhythmias seem to confer mortality and morbidity benefits in patients with ischemic heart disease.
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Affiliation(s)
- Ronald Lo
- Electrophysiology and Arrhythmia Service, Veterans Administration Medical Center, Loma Linda University, Mail Code 111C, 11201 Benton Street, Loma Linda, CA 92357, USA
| | - Karin K M Chia
- Department of Cardiology, Royal North Shore Hospital, The University of Sydney, Level 5, Acute Service Building, St Leonards, Sydney, North South Wales 2065, Australia
| | - Henry H Hsia
- Arrhythmia Service, Veterans Administration Medical Center-San Francisco, MC 111C-6, 4150 Clement Street, San Francisco, CA 94121, USA.
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Steven D, van den Bruck JH, Lüker J, Plenge T, Sultan A. [3-D mapping of ventricular tachycardia in patients with dilative cardiomyopathy]. Herzschrittmacherther Elektrophysiol 2017; 28:206-211. [PMID: 28597213 DOI: 10.1007/s00399-017-0511-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Catheter ablation of ventricular tachycardia (VT) is gaining in importance. The current guidelines suggest considering catheter ablation for VT even in patients with a single sustained and documented episode. This is also underlined by recent data indicating that absence of VT predicts lower mortality and longer transplant-free survival. The majority of patients with VTs have a history of prior myocardial infarction; in a smaller proportion, patients present with dilated cardiomyopathy. The latter has a less structured scar pattern which makes it more complicated to apply efficient ablation strategies. Data have shown that the probability of VT recurrence after catheter ablation is higher and an epicardial access more frequently required. Algorithms and strategies to improve catheter ablation results have been developed and evaluated especially on patients with dilated cardiomyopathy (DCM) to further improve outcomes. The present article will strive to acquaint the reader with the current strategies and state of knowledge.
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Affiliation(s)
- Daniel Steven
- Abt. für Elektrophysiologie, Herzzentrum Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | | | - Jakob Lüker
- Abt. für Elektrophysiologie, Herzzentrum Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Tobias Plenge
- Abt. für Elektrophysiologie, Herzzentrum Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Arian Sultan
- Abt. für Elektrophysiologie, Herzzentrum Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland
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Graham AJ, Orini M, Lambiase PD. Limitations and Challenges in Mapping Ventricular Tachycardia: New Technologies and Future Directions. Arrhythm Electrophysiol Rev 2017; 6:118-124. [PMID: 29018519 DOI: 10.15420/aer.2017.20.1] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Recurrent episodes of ventricular tachycardia in patients with structural heart disease are associated with increased mortality and morbidity, despite the life-saving benefits of implantable cardiac defibrillators. Reducing implantable cardiac defibrillator therapies is important, as recurrent shocks can cause increased myocardial damage and stunning, despite the conversion of ventricular tachycardia/ventricular fibrillation. Catheter ablation has emerged as a potential therapeutic option either for primary or secondary prevention of these arrhythmias, particularly in post-myocardial infarction cases where the substrate is well defined. However, the outcomes of catheter ablation of ventricular tachycardia in structural heart disease remain unsatisfactory in comparison with other electrophysiological procedures. The disappointing efficacy of ventricular tachycardia ablation in structural heart disease is multifactorial. In this review, we discuss the issues surrounding this and examine the limitations of current mapping approaches, as well as newer technologies that might help address them.
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Affiliation(s)
| | - Michele Orini
- Barts Heart Centre, London.,Institute of Cardiovascular Science, UCL, London, United Kingdom
| | - Pier D Lambiase
- Barts Heart Centre, London.,Institute of Cardiovascular Science, UCL, London, United Kingdom
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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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Pijnappels DA. Chatty Cells: Not Cardiac Regeneration, But Segregation for Rhythm Preservation? JACC Clin Electrophysiol 2016; 2:583-586. [PMID: 29759577 DOI: 10.1016/j.jacep.2016.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 07/21/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Daniël A Pijnappels
- Laboratory of Experimental Cardiology, Department of Cardiology, Heart Lung Center Leiden, Leiden University Medical Center, Leiden, the Netherlands.
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Tung R, Kim S, Yagishita D, Vaseghi M, Ennis DB, Ouadah S, Ajijola OA, Bradfield JS, Mahapatra S, Finn P, Shivkumar K. Scar voltage threshold determination using ex vivo magnetic resonance imaging integration in a porcine infarct model: Influence of interelectrode distances and three-dimensional spatial effects of scar. Heart Rhythm 2016; 13:1993-2002. [PMID: 27392944 DOI: 10.1016/j.hrthm.2016.07.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Studies analyzing optimal voltage thresholds for scar detection with electroanatomic mapping frequently lack a gold standard for comparison. OBJECTIVE The purpose of this study was to use a porcine infarct model with ex vivo magnetic resonance imaging (MRI) integration to characterize the relationship between interelectrode spacing and bipolar voltage thresholds and examine the influence of 3-dimensional scar on unipolar voltages. METHODS Thirty-two combined endocardial-epicardial electroanatomic maps were created in 8 postinfarct porcine subjects (bipolar 2-mm, 5-mm, and 8-mm interelectrode spacing and unipolar) for comparison with ex vivo MRI. Two thresholds were compared: (1) 95% normal distribution and (2) best fit to MRI. Direct electrogram analysis was performed in regions across from MRI-defined scar and adjacent to scar border zone. RESULTS A linear increase in optimal thresholds was observed with wider bipole spacing. The 95% thresholds for scar were lower than MRI-matched thresholds with moderate sensitivity for nontransmural scar (54% endo, 63% epi). Unipolar endocardial scar area exceeded MRI-defined scar, resulting in mismatched false scar in 5 of 8 (63%). Endocardial and epicardial unipolar voltages were lower than normal in regions adjacent and across from scar. CONCLUSION Variations in interelectrode spacing necessitate tailored bipolar voltage thresholds to optimize scar detection. Statistical 95% thresholds appear to be conservative and not fully sensitive for the detection of scar defined by high-resolution ex vivo MRI. In the presence of endocardial scar, unipolar mapping to quantitatively characterize epicardial scar may be overly sensitive due to 3-dimensional spatial averaging.
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Affiliation(s)
- Roderick Tung
- UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California.
| | - Steve Kim
- St. Jude Medical, Minneapolis, Minnesota
| | - Daigo Yagishita
- UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California
| | - Marmar Vaseghi
- UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California
| | - Daniel B Ennis
- Department of Radiological Sciences, University of California, Los Angeles, California,; Department of Bioengineering, University of California, Los Angeles, California
| | - Sarah Ouadah
- Department of Bioengineering, University of California, Los Angeles, California
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California
| | | | - Paul Finn
- Department of Radiological Sciences, University of California, Los Angeles, California
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, UCLA Health System, Los Angeles, California; Department of Radiological Sciences, University of California, Los Angeles, California,; Department of Bioengineering, University of California, Los Angeles, California
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Affiliation(s)
- Christine M Albert
- From Harvard Medical School, Center for Arrhythmia Prevention, Division of Cardiovascular and Preventive Medicine (C.M.A.), and Department of Medicine, Harvard Medical School, Cardiac Arrhythmia Program, Division of Cardiovascular Medicine (W.G.S.), Brigham and Women's Hospital, Boston, MA.
| | - William G Stevenson
- From Harvard Medical School, Center for Arrhythmia Prevention, Division of Cardiovascular and Preventive Medicine (C.M.A.), and Department of Medicine, Harvard Medical School, Cardiac Arrhythmia Program, Division of Cardiovascular Medicine (W.G.S.), Brigham and Women's Hospital, Boston, MA
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Álvarez-Álvarez B, Bouzas-Cruz N, Abu-Assi E, Raposeiras-Roubin S, López-López A, González Cambeiro MC, Peña-Gil C, García-Acuña JM, González-Juanatey JR. Impacto de la fibrilación ventricular que complica el curso de un síndrome coronario agudo en la incidencia a largo plazo de muerte súbita cardiaca. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2014.11.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Álvarez-Álvarez B, Bouzas-Cruz N, Abu-Assi E, Raposeiras-Roubin S, López-López A, González Cambeiro MC, Peña-Gil C, García-Acuña JM, González-Juanatey JR. Impact of Acute Coronary Syndrome Complicated by Ventricular Fibrillation on Long-term Incidence of Sudden Cardiac Death. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2015; 68:878-884. [PMID: 25800166 DOI: 10.1016/j.rec.2014.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 11/03/2014] [Indexed: 06/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES There is little information on the effect of acute coronary syndrome complicated by ventricular fibrillation on the long-term incidence of sudden cardiac death. We analyzed this effect in a contemporary cohort of patients with acute coronary syndrome. METHODS We studied 5302 consecutive patients with acute coronary syndrome between December 2003 and December 2012. We compared mortality during and after hospitalization according to the presence or absence of ventricular fibrillation. RESULTS Ventricular fibrillation was observed in 163 (3.1%) patients, and was early onset in 72.4% of these patients. In-hospital mortality was 36.2% in the group with ventricular fibrillation and 4.7% in the group without (p<.001). After a mean follow-up of 4.7 years (standard deviation, 2.6 years), mortality was 30.7% in the ventricular fibrillation group and 24.7% in the other group (P=.23). After adjusting for confounding variables, the presence of ventricular fibrillation was not associated with an increased risk of death in the follow-up period (hazard ratio=1.29; 95% confidence interval, 0.90-1.87). The cause of death was established in 72% of patients. The incidence of sudden death was 12.9% in the ventricular fibrillation group and 11.9% in the other group (P=.71). Cardiovascular-cause mortality was also similar between the 2 groups (35.5% and 34.4%, respectively. CONCLUSIONS Patients with acute coronary syndrome complicated by ventricular fibrillation who survive the in-hospital phase do not appear to be at an increased risk of sudden cardiac death or other cardiovascular-cause death.
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Affiliation(s)
- Belén Álvarez-Álvarez
- Servicio de Cardiología y Unidad Coronaria, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain.
| | - Noelia Bouzas-Cruz
- Servicio de Cardiología y Unidad Coronaria, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Emad Abu-Assi
- Servicio de Cardiología y Unidad Coronaria, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Sergio Raposeiras-Roubin
- Servicio de Cardiología y Unidad Coronaria, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Andrea López-López
- Servicio de Cardiología y Unidad Coronaria, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - María Cristina González Cambeiro
- Servicio de Cardiología y Unidad Coronaria, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Carlos Peña-Gil
- Servicio de Cardiología y Unidad Coronaria, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - José María García-Acuña
- Servicio de Cardiología y Unidad Coronaria, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - José Ramón González-Juanatey
- Servicio de Cardiología y Unidad Coronaria, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
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Denost Q, Adam JP, Pontallier A, Montembault A, Bareille R, Siadous R, Delmond S, Rullier E, David L, Bordenave L. Colorectal tissue engineering: A comparative study between porcine small intestinal submucosa (SIS) and chitosan hydrogel patches. Surgery 2015; 158:1714-23. [PMID: 26275832 DOI: 10.1016/j.surg.2015.06.040] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 05/14/2015] [Accepted: 06/03/2015] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Tissue engineering may provide new operative tools for colorectal surgery in elective indications. The aim of this study was to define a suitable bioscaffold for colorectal tissue engineering. METHODS We compared 2 bioscaffolds with in vitro and in vivo experiments: porcine small intestinal submucosa (SIS) versus chitosan hydrogel matrix. We assessed nontoxicity of the scaffold in vitro by using human adipose-derived stem cells (hADSC). In vivo, a 1 × 2-cm colonic wall defect was created in 16 rabbits. Animals were divided randomly into 2 groups according to the graft used, SIS or chitosan hydrogel. Graft area was explanted at 4 and 8 weeks. The end points of in vivo experiments were technical feasibility, behavior of the scaffold, in situ putative inflammatory effect, and the quality of tissue regeneration, in particular smooth muscle layer regeneration. RESULTS In vitro, hADSC attachment and proliferation occurred on both scaffolds without a substantial difference. After proliferation, hADSCs kept their mesenchymal stem cell characteristics. In vivo, one animal died in each group. Eight weeks after implantation, the chitosan scaffold allowed better wound healing compared with the SIS scaffold, with more effective control of inflammatory activity and an integral regeneration of the colonic wall including the smooth muscle cell layer. CONCLUSION The outcomes of in vitro experiments did not differ greatly between the 2 groups. Macroscopic and histologic findings, however, revealed better wound healing of the colonic wall in the chitosan group suggesting that the chitosan hydrogel could serve as a better scaffold for colorectal tissue engineering.
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Affiliation(s)
- Quentin Denost
- Department of Digestive Surgery, CHU de Bordeaux, University of Bordeaux, Bordeaux, France; Bioingénierie tissulaire, University of Bordeaux, Bordeaux, France; INSERM, Bioingenierie tissulaire, U1026, Bordeaux, France; CHU de Bordeaux, CIC 1401, Bordeaux, France.
| | - Jean-Philippe Adam
- Department of Digestive Surgery, CHU de Bordeaux, University of Bordeaux, Bordeaux, France; Bioingénierie tissulaire, University of Bordeaux, Bordeaux, France; INSERM, Bioingenierie tissulaire, U1026, Bordeaux, France
| | - Arnaud Pontallier
- Department of Digestive Surgery, CHU de Bordeaux, University of Bordeaux, Bordeaux, France; Bioingénierie tissulaire, University of Bordeaux, Bordeaux, France; INSERM, Bioingenierie tissulaire, U1026, Bordeaux, France
| | | | - Reine Bareille
- Bioingénierie tissulaire, University of Bordeaux, Bordeaux, France; INSERM, Bioingenierie tissulaire, U1026, Bordeaux, France
| | - Robin Siadous
- Bioingénierie tissulaire, University of Bordeaux, Bordeaux, France; INSERM, Bioingenierie tissulaire, U1026, Bordeaux, France
| | | | - Eric Rullier
- Department of Digestive Surgery, CHU de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Laurent David
- Université de Lyon, Université Claude Bernard Lyon 1, Villeurbanne Cedex, France
| | - Laurence Bordenave
- Bioingénierie tissulaire, University of Bordeaux, Bordeaux, France; INSERM, Bioingenierie tissulaire, U1026, Bordeaux, France; CHU de Bordeaux, CIC 1401, Bordeaux, France
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Tsiachris D, Silberbauer J, Maccabelli G, Oloriz T, Baratto F, Mizuno H, Bisceglia C, Vergara P, Marzi A, Sora N, Guarracini F, Radinovic A, Cireddu M, Sala S, Gulletta S, Paglino G, Mazzone P, Trevisi N, Della Bella P. Electroanatomical voltage and morphology characteristics in postinfarction patients undergoing ventricular tachycardia ablation: pragmatic approach favoring late potentials abolition. Circ Arrhythm Electrophysiol 2015; 8:863-73. [PMID: 26022186 DOI: 10.1161/circep.114.002551] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 05/13/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND Catheter ablation is an important therapeutic option in postmyocardial infarction patients with ventricular tachycardia (VT). We analyzed the endo-epicardial electroanatomical mapping (EAM) voltage and morphology characteristics, their association with clinical data and their prognostic value in a large cohort of postmyocardial infarction patients. METHODS AND RESULTS We performed total and segmental analysis of voltage (bipolar dense scar [DS] and low voltage areas, unipolar low voltage and penumbra areas) and morphology characteristics (presence of abnormal late potentials [LPs] and early potentials [EPs]) in 100 postmyocardial infarction patients undergoing electroanatomical mapping-based VT ablation (26 endo-epicardial procedures) from 2010-2012. All patients had unipolar low voltage areas, whereas 18% had no identifiable endocardial bipolar DS areas. Endocardial bipolar DS area >22.5 cm(2) best predicted scar transmurality. Endo-epicardial LPs were recorded in 2/3 patients, more frequently in nonseptal myocardial segments and were abolished in 51%. Endocardial bipolar DS area >7 cm(2) and endocardial bipolar scar density >0.35 predicted epicardial LPs. Isolated LPs are located mainly epicardially and EPs endocardially. As a primary strategy, LPs and VT-mapping ablation occurred in 48%, only VT-mapping ablation in 27%, only LPs ablation in 17%, and EPs ablation in 6%. Endocardial LP abolition was associated with reduced VT recurrence and increased unipolar penumbra area predicted cardiac death. CONCLUSIONS Endocardial scar extension and density predict scar transmurality and endo-epicardial presence of LPs, although DS is not always identified in postmyocardial infarction patients. LPs, most frequently located in nonseptal myocardial segments, were abolished in 51% resulting in improved outcome.
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Affiliation(s)
- Dimitris Tsiachris
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - John Silberbauer
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Giuseppe Maccabelli
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Teresa Oloriz
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Francesca Baratto
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Hiroya Mizuno
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Caterina Bisceglia
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Pasquale Vergara
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Alessandra Marzi
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Nicoleta Sora
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Fabrizio Guarracini
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Andrea Radinovic
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Manuela Cireddu
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Simone Sala
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Simone Gulletta
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Gabriele Paglino
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Patrizio Mazzone
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Nicola Trevisi
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy
| | - Paolo Della Bella
- From the Arrhythmia Unit and Electrophysiology Laboratories, Ospedale San Raffaele, Milan, Italy.
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Ringenberg J, Deo M, Filgueiras-Rama D, Pizarro G, Ibañez B, Peinado R, Merino JL, Berenfeld O, Devabhaktuni V. Effects of fibrosis morphology on reentrant ventricular tachycardia inducibility and simulation fidelity in patient-derived models. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2014; 8:1-13. [PMID: 25368538 PMCID: PMC4210189 DOI: 10.4137/cmc.s15712] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 06/22/2014] [Accepted: 06/24/2014] [Indexed: 12/21/2022]
Abstract
Myocardial fibrosis detected via delayed-enhanced magnetic resonance imaging (MRI) has been shown to be a strong indicator for ventricular tachycardia (VT) inducibility. However, little is known regarding how inducibility is affected by the details of the fibrosis extent, morphology, and border zone configuration. The objective of this article is to systematically study the arrhythmogenic effects of fibrosis geometry and extent, specifically on VT inducibility and maintenance. We present a set of methods for constructing patient-specific computational models of human ventricles using in vivo MRI data for patients suffering from hypertension, hypercholesterolemia, and chronic myocardial infarction. Additional synthesized models with morphologically varied extents of fibrosis and gray zone (GZ) distribution were derived to study the alterations in the arrhythmia induction and reentry patterns. Detailed electrophysiological simulations demonstrated that (1) VT morphology was highly dependent on the extent of fibrosis, which acts as a structural substrate, (2) reentry tended to be anchored to the fibrosis edges and showed transmural conduction of activations through narrow channels formed within fibrosis, and (3) increasing the extent of GZ within fibrosis tended to destabilize the structural reentry sites and aggravate the VT as compared to fibrotic regions of the same size and shape but with lower or no GZ. The approach and findings represent a significant step toward patient-specific cardiac modeling as a reliable tool for VT prediction and management of the patient. Sensitivities to approximation nuances in the modeling of structural pathology by image-based reconstruction techniques are also implicated.
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Affiliation(s)
- Jordan Ringenberg
- EECS Department, College of Engineering, University of Toledo, Toledo, OH, USA
| | - Makarand Deo
- Department of Engineering, Norfolk State University, Norfolk, VA, USA
| | - David Filgueiras-Rama
- Cardiac Electrophysiology Unit, Hospital Clínico San Carlos, Madrid, Spain
- Atherothrombosis, Imaging and Epidemiology Department, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Gonzalo Pizarro
- Atherothrombosis, Imaging and Epidemiology Department, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
- Department of Cardiology, Hospital Universitario Quirón, Universidad Europea de Madrid, Madrid, Spain
| | - Borja Ibañez
- Atherothrombosis, Imaging and Epidemiology Department, Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Rafael Peinado
- Cardiology Department, Hospital Universitario La Paz, Madrid, Spain
| | - José L Merino
- Cardiology Department, Hospital Universitario La Paz, Madrid, Spain
| | - Omer Berenfeld
- Center for Arrhythmia Research, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Vijay Devabhaktuni
- EECS Department, College of Engineering, University of Toledo, Toledo, OH, USA
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Ávila P, Arenal Á. Ablación de sustrato de las taquicardias ventriculares en pacientes con infarto de miocardio antiguo. Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2013.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Substrate ablation of post-infarction ventricular tachycardias. ACTA ACUST UNITED AC 2014; 67:514-8. [PMID: 24952389 DOI: 10.1016/j.rec.2013.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 08/16/2013] [Indexed: 11/23/2022]
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Tilz RR, Makimoto H, Lin T, Rillig A, Deiss S, Wissner E, Mathew S, Metzner A, Rausch P, Kuck KH, Ouyang F. Electrical isolation of a substrate after myocardial infarction: a novel ablation strategy for unmappable ventricular tachycardias--feasibility and clinical outcome. Europace 2014; 16:1040-52. [DOI: 10.1093/europace/eut419] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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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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Bougouin W, Marijon E, Puymirat E, Defaye P, Celermajer DS, Le Heuzey JY, Boveda S, Kacet S, Mabo P, Barnay C, Da Costa A, Deharo JC, Daubert JC, Ferrieres J, Simon T, Danchin N. Incidence of sudden cardiac death after ventricular fibrillation complicating acute myocardial infarction: a 5-year cause-of-death analysis of the FAST-MI 2005 registry. Eur Heart J 2013; 35:116-22. [DOI: 10.1093/eurheartj/eht453] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Nalliah CJ, Zaman S, Narayan A, Sullivan J, Kovoor P. Coronary artery reperfusion for ST elevation myocardial infarction is associated with shorter cycle length ventricular tachycardia and fewer spontaneous arrhythmias. Europace 2013; 16:1053-60. [DOI: 10.1093/europace/eut307] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Zaman S, Kumar S, Sullivan J, Narayan A, Thiagalingam A, Ross DL, Kovoor P. Significance of Inducible Very Fast Ventricular Tachycardia (Cycle Length 200–230 ms) After Early Reperfusion for ST-Segment–Elevation Myocardial Infarction. Circ Arrhythm Electrophysiol 2013; 6:884-90. [DOI: 10.1161/circep.113.000213] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sarah Zaman
- From the Department of Cardiology, Westmead Hospital, Sydney, Australia (S.Z., J.S., A.N., A.T., D.L.R., P.K.); Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Australia (S.K.); and Department of Medicine, University of Sydney, Sydney, Australia (S.Z., P.K.)
| | - Saurabh Kumar
- From the Department of Cardiology, Westmead Hospital, Sydney, Australia (S.Z., J.S., A.N., A.T., D.L.R., P.K.); Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Australia (S.K.); and Department of Medicine, University of Sydney, Sydney, Australia (S.Z., P.K.)
| | - Janice Sullivan
- From the Department of Cardiology, Westmead Hospital, Sydney, Australia (S.Z., J.S., A.N., A.T., D.L.R., P.K.); Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Australia (S.K.); and Department of Medicine, University of Sydney, Sydney, Australia (S.Z., P.K.)
| | - Arun Narayan
- From the Department of Cardiology, Westmead Hospital, Sydney, Australia (S.Z., J.S., A.N., A.T., D.L.R., P.K.); Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Australia (S.K.); and Department of Medicine, University of Sydney, Sydney, Australia (S.Z., P.K.)
| | - Aravinda Thiagalingam
- From the Department of Cardiology, Westmead Hospital, Sydney, Australia (S.Z., J.S., A.N., A.T., D.L.R., P.K.); Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Australia (S.K.); and Department of Medicine, University of Sydney, Sydney, Australia (S.Z., P.K.)
| | - David L. Ross
- From the Department of Cardiology, Westmead Hospital, Sydney, Australia (S.Z., J.S., A.N., A.T., D.L.R., P.K.); Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Australia (S.K.); and Department of Medicine, University of Sydney, Sydney, Australia (S.Z., P.K.)
| | - Pramesh Kovoor
- From the Department of Cardiology, Westmead Hospital, Sydney, Australia (S.Z., J.S., A.N., A.T., D.L.R., P.K.); Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Australia (S.K.); and Department of Medicine, University of Sydney, Sydney, Australia (S.Z., P.K.)
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KAPA SURAJ, HUTCHINSON MATHEWD. Bipolar Mapping, Revisited Or: These Aren't the Electrograms You're Looking For. J Cardiovasc Electrophysiol 2013; 24:655-7. [DOI: 10.1111/jce.12118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- SURAJ KAPA
- Division of Cardiology, Department of Medicine, Perelman School of Medicine; University of Pennsylvania; Philadelphia Pennsylvania USA
| | - MATHEW D. HUTCHINSON
- Division of Cardiology, Department of Medicine, Perelman School of Medicine; University of Pennsylvania; Philadelphia Pennsylvania USA
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