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Sapp JL, Tang ASL, Parkash R, Stevenson WG, Healey JS, Wells G. A Randomized Clinical Trial of Catheter Ablation and Antiarrhythmic Drug Therapy for Suppression of Ventricular Tachycardia in Ischemic Cardiomyopathy: The VANISH2 Trial. Am Heart J 2024:S0002-8703(24)00096-6. [PMID: 38649085 DOI: 10.1016/j.ahj.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/18/2024] [Accepted: 04/19/2024] [Indexed: 04/25/2024]
Abstract
Recurrent ventricular tachycardia (VT) in patients with prior myocardial infarction is associated with adverse quality of life and clinical outcomes, despite the presence of implanted defibrillators (ICDs). Suppression of recurrent VT can be accomplished with antiarrhythmic drug therapy or catheter ablation. The Ventricular Tachycardia Antiarrhythmics or Ablation In Structural Heart Disease 2 (VANISH2) trial is designed to determine whether ablation is superior to antiarrhythmic drug therapy as first line therapy for patients with ischemic cardiomyopathy and VT. The VANISH2 trial enrolls patients with prior myocardial infarction and VT (with one of: ≥1 ICD shock; ≥3 episodes treated with antitachycardia pacing (ATP) and symptoms; ≥5 episodes treated with ATP regardless of symptoms; ≥3 episodes within 24 hours; or sustained VT treated with electrical cardioversion or pharmacologic conversion). Enrolled patients are classified as either sotalol-eligible, or amiodarone-eligible, and then are randomized to either catheter ablation or to that antiarrhythmic drug therapy, with randomization stratified by drug-eligibility group. Drug therapy, catheter ablation procedures and ICD programming are standardized. All patients will be followed until two years after randomization. The primary endpoint is a composite of mortality at any time, appropriate ICD shock after 14 days, VT storm after 14 days, and treated sustained VT below detection of the ICD after 14 days. The outcomes will be analyzed according to the intention-to-treat principle using survival analysis techniques. The results of the VANISH2 trial are intended to provide data to support clinical decisions on how to suppress VT for patients with prior myocardial infarction. Clinicaltrials.gov registration NCT02830360.
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Affiliation(s)
- John L Sapp
- QEII Health Sciences Centre, Dalhousie University, Halifax, Canada.
| | | | - Ratika Parkash
- QEII Health Sciences Centre, Dalhousie University, Halifax, Canada
| | | | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - George Wells
- University of Ottawa Heart Institute, Ottawa Canada
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Sapp JL, Sivakumaran S, Tang ASL. Long-Term Outcomes of Resynchronization-Defibrillation for Heart Failure. Reply. N Engl J Med 2024; 390:1343-1345. [PMID: 38598810 DOI: 10.1056/nejmc2402048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
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Toloubidokhti M, Gharbia OA, Parkosa A, Trayanova N, Nazarian S, Sapp JL, Wang L. Understanding the Utility of Endocardial Electrocardiographic Imaging in Epi-Endocardial Mapping of 3D Reentrant Circuits. medRxiv 2024:2024.03.13.24304259. [PMID: 38559058 PMCID: PMC10980114 DOI: 10.1101/2024.03.13.24304259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background Studies of VT mechanisms are largely based on a 2D portrait of reentrant circuits on one surface of the heart. This oversimplifies the 3D circuit that involves the depth of the myocardium. Simultaneous epicardial and endocardial (epi-endo) mapping was shown to facilitate a 3D delineation of VT circuits, which is however difficult via invasive mapping. Objective This study investigates the capability of noninvasive epicardial-endocardial electrocardiographic imaging (ECGI) to elucidate the 3D construct of VT circuits, emphasizing the differentiation of epicardial, endocardial, and intramural circuits and to determine the proximity of mid-wall exits to the epicardial or endocardial surfaces. Methods 120-lead ECGs of VT in combination with subject-specific heart-torso geometry are used to compute unipolar electrograms (CEGM) on ventricular epicardium and endocardia. Activation isochrones are constructed, and the percentage of activation within VT cycle length is calculated on each surface. This classifies VT circuits into 2D (surface only), uniform transmural, nonuniform transmural, and mid-myocardial (focal on surfaces). Furthermore, the endocardial breakthrough time was accurately measured using Laplacian eigenmaps, and by correlating the delay time of the epi-endo breakthroughs, the relative distance of a mid-wall exit to the epicardium or the endocardium surfaces was identified. Results We analyzed 23 simulated and in-vivo VT circuits on post-infarction porcine hearts. In simulated circuits, ECGI classified 21% as 2D and 78% as 3D: 82.6% of these were correctly classified. The relative timing between epicardial and endocardial breakthroughs was correctly captured across all cases. In in-vivo circuits, ECGI classified 25% as 2D and 75% as 3D: in all cases, circuit exits and entrances were consistent with potential critical isthmus delineated from combined LGE-MRI and catheter mapping data. Conclusions ECGI epi-endo mapping has the potential for fast delineation of 3D VT circuits, which may augment detailed catheter mapping for VT ablation.
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Affiliation(s)
- Maryam Toloubidokhti
- College of Computing and Information Sciences, Rochester Institute of Technology, Rochester, NY, USA
| | - Omar A Gharbia
- Department of Otolaryngology, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Adityo Parkosa
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Natalia Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Saman Nazarian
- School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - John L Sapp
- Department of Medicine, QEII Health Sciences Centre, Halifax, NS, Canada
| | - Linwei Wang
- College of Computing and Information Sciences, Rochester Institute of Technology, Rochester, NY, USA
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Sapp JL, Sivakumaran S, Redpath CJ, Khan H, Parkash R, Exner DV, Healey JS, Thibault B, Sterns LD, Lam NHN, Manlucu J, Mokhtar A, Sumner G, McKinlay S, Kimber S, Mondesert B, Talajic M, Rouleau J, McCarron CE, Wells G, Tang ASL. Long-Term Outcomes of Resynchronization-Defibrillation for Heart Failure. N Engl J Med 2024; 390:212-220. [PMID: 38231622 DOI: 10.1056/nejmoa2304542] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
BACKGROUND The Resynchronization-Defibrillation for Ambulatory Heart Failure Trial (RAFT) showed a greater benefit with respect to mortality at 5 years among patients who received cardiac-resynchronization therapy (CRT) than among those who received implantable cardioverter-defibrillators (ICDs). However, the effect of CRT on long-term survival is not known. METHODS We randomly assigned patients with New York Heart Association (NYHA) class II or III heart failure, a left ventricular ejection fraction of 30% or less, and an intrinsic QRS duration of 120 msec or more (or a paced QRS duration of 200 msec or more) to receive either an ICD alone or a CRT defibrillator (CRT-D). We assessed long-term outcomes among patients at the eight highest-enrolling participating sites. The primary outcome was death from any cause; the secondary outcome was a composite of death from any cause, heart transplantation, or implantation of a ventricular assist device. RESULTS The trial enrolled 1798 patients, of whom 1050 were included in the long-term survival trial; the median duration of follow-up for the 1050 patients was 7.7 years (interquartile range, 3.9 to 12.8), and the median duration of follow-up for those who survived was 13.9 years (interquartile range, 12.8 to 15.7). Death occurred in 405 of 530 patients (76.4%) assigned to the ICD group and in 370 of 520 patients (71.2%) assigned to the CRT-D group. The time until death appeared to be longer for those assigned to receive a CRT-D than for those assigned to receive an ICD (acceleration factor, 0.80; 95% confidence interval, 0.69 to 0.92; P = 0.002). A secondary-outcome event occurred in 412 patients (77.7%) in the ICD group and in 392 (75.4%) in the CRT-D group. CONCLUSIONS Among patients with a reduced ejection fraction, a widened QRS complex, and NYHA class II or III heart failure, the survival benefit associated with receipt of a CRT-D as compared with ICD appeared to be sustained during a median of nearly 14 years of follow-up. (RAFT ClinicalTrials.gov number, NCT00251251.).
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Affiliation(s)
- John L Sapp
- From QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P.), the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton (S.S., S.K.), the University of Ottawa Heart Institute, Ottawa (C.J.R., N.H.N.L., G.W.), Schulich School of Medicine and Dentistry, Western University, London, ON (H.K., J.M., C.E.M., A.S.L.T.), Libin Cardiovascular Institute, Calgary, AB (D.V.E., G.S.), McMaster University, Hamilton, ON (J.S.H.), Montreal Heart Institute, Montreal (B.T., B.M., M.T., J.R.), Royal Jubilee Hospital, Victoria, BC (L.D.S.), and the University of Toronto, Toronto (S.M.) - all in Canada; and King Abdulaziz University, Jeddah, Saudi Arabia (A.M.)
| | - Soori Sivakumaran
- From QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P.), the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton (S.S., S.K.), the University of Ottawa Heart Institute, Ottawa (C.J.R., N.H.N.L., G.W.), Schulich School of Medicine and Dentistry, Western University, London, ON (H.K., J.M., C.E.M., A.S.L.T.), Libin Cardiovascular Institute, Calgary, AB (D.V.E., G.S.), McMaster University, Hamilton, ON (J.S.H.), Montreal Heart Institute, Montreal (B.T., B.M., M.T., J.R.), Royal Jubilee Hospital, Victoria, BC (L.D.S.), and the University of Toronto, Toronto (S.M.) - all in Canada; and King Abdulaziz University, Jeddah, Saudi Arabia (A.M.)
| | - Calum J Redpath
- From QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P.), the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton (S.S., S.K.), the University of Ottawa Heart Institute, Ottawa (C.J.R., N.H.N.L., G.W.), Schulich School of Medicine and Dentistry, Western University, London, ON (H.K., J.M., C.E.M., A.S.L.T.), Libin Cardiovascular Institute, Calgary, AB (D.V.E., G.S.), McMaster University, Hamilton, ON (J.S.H.), Montreal Heart Institute, Montreal (B.T., B.M., M.T., J.R.), Royal Jubilee Hospital, Victoria, BC (L.D.S.), and the University of Toronto, Toronto (S.M.) - all in Canada; and King Abdulaziz University, Jeddah, Saudi Arabia (A.M.)
| | - Habib Khan
- From QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P.), the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton (S.S., S.K.), the University of Ottawa Heart Institute, Ottawa (C.J.R., N.H.N.L., G.W.), Schulich School of Medicine and Dentistry, Western University, London, ON (H.K., J.M., C.E.M., A.S.L.T.), Libin Cardiovascular Institute, Calgary, AB (D.V.E., G.S.), McMaster University, Hamilton, ON (J.S.H.), Montreal Heart Institute, Montreal (B.T., B.M., M.T., J.R.), Royal Jubilee Hospital, Victoria, BC (L.D.S.), and the University of Toronto, Toronto (S.M.) - all in Canada; and King Abdulaziz University, Jeddah, Saudi Arabia (A.M.)
| | - Ratika Parkash
- From QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P.), the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton (S.S., S.K.), the University of Ottawa Heart Institute, Ottawa (C.J.R., N.H.N.L., G.W.), Schulich School of Medicine and Dentistry, Western University, London, ON (H.K., J.M., C.E.M., A.S.L.T.), Libin Cardiovascular Institute, Calgary, AB (D.V.E., G.S.), McMaster University, Hamilton, ON (J.S.H.), Montreal Heart Institute, Montreal (B.T., B.M., M.T., J.R.), Royal Jubilee Hospital, Victoria, BC (L.D.S.), and the University of Toronto, Toronto (S.M.) - all in Canada; and King Abdulaziz University, Jeddah, Saudi Arabia (A.M.)
| | - Derek V Exner
- From QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P.), the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton (S.S., S.K.), the University of Ottawa Heart Institute, Ottawa (C.J.R., N.H.N.L., G.W.), Schulich School of Medicine and Dentistry, Western University, London, ON (H.K., J.M., C.E.M., A.S.L.T.), Libin Cardiovascular Institute, Calgary, AB (D.V.E., G.S.), McMaster University, Hamilton, ON (J.S.H.), Montreal Heart Institute, Montreal (B.T., B.M., M.T., J.R.), Royal Jubilee Hospital, Victoria, BC (L.D.S.), and the University of Toronto, Toronto (S.M.) - all in Canada; and King Abdulaziz University, Jeddah, Saudi Arabia (A.M.)
| | - Jeff S Healey
- From QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P.), the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton (S.S., S.K.), the University of Ottawa Heart Institute, Ottawa (C.J.R., N.H.N.L., G.W.), Schulich School of Medicine and Dentistry, Western University, London, ON (H.K., J.M., C.E.M., A.S.L.T.), Libin Cardiovascular Institute, Calgary, AB (D.V.E., G.S.), McMaster University, Hamilton, ON (J.S.H.), Montreal Heart Institute, Montreal (B.T., B.M., M.T., J.R.), Royal Jubilee Hospital, Victoria, BC (L.D.S.), and the University of Toronto, Toronto (S.M.) - all in Canada; and King Abdulaziz University, Jeddah, Saudi Arabia (A.M.)
| | - Bernard Thibault
- From QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P.), the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton (S.S., S.K.), the University of Ottawa Heart Institute, Ottawa (C.J.R., N.H.N.L., G.W.), Schulich School of Medicine and Dentistry, Western University, London, ON (H.K., J.M., C.E.M., A.S.L.T.), Libin Cardiovascular Institute, Calgary, AB (D.V.E., G.S.), McMaster University, Hamilton, ON (J.S.H.), Montreal Heart Institute, Montreal (B.T., B.M., M.T., J.R.), Royal Jubilee Hospital, Victoria, BC (L.D.S.), and the University of Toronto, Toronto (S.M.) - all in Canada; and King Abdulaziz University, Jeddah, Saudi Arabia (A.M.)
| | - Laurence D Sterns
- From QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P.), the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton (S.S., S.K.), the University of Ottawa Heart Institute, Ottawa (C.J.R., N.H.N.L., G.W.), Schulich School of Medicine and Dentistry, Western University, London, ON (H.K., J.M., C.E.M., A.S.L.T.), Libin Cardiovascular Institute, Calgary, AB (D.V.E., G.S.), McMaster University, Hamilton, ON (J.S.H.), Montreal Heart Institute, Montreal (B.T., B.M., M.T., J.R.), Royal Jubilee Hospital, Victoria, BC (L.D.S.), and the University of Toronto, Toronto (S.M.) - all in Canada; and King Abdulaziz University, Jeddah, Saudi Arabia (A.M.)
| | - Nhat Hung N Lam
- From QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P.), the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton (S.S., S.K.), the University of Ottawa Heart Institute, Ottawa (C.J.R., N.H.N.L., G.W.), Schulich School of Medicine and Dentistry, Western University, London, ON (H.K., J.M., C.E.M., A.S.L.T.), Libin Cardiovascular Institute, Calgary, AB (D.V.E., G.S.), McMaster University, Hamilton, ON (J.S.H.), Montreal Heart Institute, Montreal (B.T., B.M., M.T., J.R.), Royal Jubilee Hospital, Victoria, BC (L.D.S.), and the University of Toronto, Toronto (S.M.) - all in Canada; and King Abdulaziz University, Jeddah, Saudi Arabia (A.M.)
| | - Jaimie Manlucu
- From QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P.), the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton (S.S., S.K.), the University of Ottawa Heart Institute, Ottawa (C.J.R., N.H.N.L., G.W.), Schulich School of Medicine and Dentistry, Western University, London, ON (H.K., J.M., C.E.M., A.S.L.T.), Libin Cardiovascular Institute, Calgary, AB (D.V.E., G.S.), McMaster University, Hamilton, ON (J.S.H.), Montreal Heart Institute, Montreal (B.T., B.M., M.T., J.R.), Royal Jubilee Hospital, Victoria, BC (L.D.S.), and the University of Toronto, Toronto (S.M.) - all in Canada; and King Abdulaziz University, Jeddah, Saudi Arabia (A.M.)
| | - Ahmed Mokhtar
- From QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P.), the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton (S.S., S.K.), the University of Ottawa Heart Institute, Ottawa (C.J.R., N.H.N.L., G.W.), Schulich School of Medicine and Dentistry, Western University, London, ON (H.K., J.M., C.E.M., A.S.L.T.), Libin Cardiovascular Institute, Calgary, AB (D.V.E., G.S.), McMaster University, Hamilton, ON (J.S.H.), Montreal Heart Institute, Montreal (B.T., B.M., M.T., J.R.), Royal Jubilee Hospital, Victoria, BC (L.D.S.), and the University of Toronto, Toronto (S.M.) - all in Canada; and King Abdulaziz University, Jeddah, Saudi Arabia (A.M.)
| | - Glen Sumner
- From QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P.), the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton (S.S., S.K.), the University of Ottawa Heart Institute, Ottawa (C.J.R., N.H.N.L., G.W.), Schulich School of Medicine and Dentistry, Western University, London, ON (H.K., J.M., C.E.M., A.S.L.T.), Libin Cardiovascular Institute, Calgary, AB (D.V.E., G.S.), McMaster University, Hamilton, ON (J.S.H.), Montreal Heart Institute, Montreal (B.T., B.M., M.T., J.R.), Royal Jubilee Hospital, Victoria, BC (L.D.S.), and the University of Toronto, Toronto (S.M.) - all in Canada; and King Abdulaziz University, Jeddah, Saudi Arabia (A.M.)
| | - Stuart McKinlay
- From QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P.), the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton (S.S., S.K.), the University of Ottawa Heart Institute, Ottawa (C.J.R., N.H.N.L., G.W.), Schulich School of Medicine and Dentistry, Western University, London, ON (H.K., J.M., C.E.M., A.S.L.T.), Libin Cardiovascular Institute, Calgary, AB (D.V.E., G.S.), McMaster University, Hamilton, ON (J.S.H.), Montreal Heart Institute, Montreal (B.T., B.M., M.T., J.R.), Royal Jubilee Hospital, Victoria, BC (L.D.S.), and the University of Toronto, Toronto (S.M.) - all in Canada; and King Abdulaziz University, Jeddah, Saudi Arabia (A.M.)
| | - Shane Kimber
- From QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P.), the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton (S.S., S.K.), the University of Ottawa Heart Institute, Ottawa (C.J.R., N.H.N.L., G.W.), Schulich School of Medicine and Dentistry, Western University, London, ON (H.K., J.M., C.E.M., A.S.L.T.), Libin Cardiovascular Institute, Calgary, AB (D.V.E., G.S.), McMaster University, Hamilton, ON (J.S.H.), Montreal Heart Institute, Montreal (B.T., B.M., M.T., J.R.), Royal Jubilee Hospital, Victoria, BC (L.D.S.), and the University of Toronto, Toronto (S.M.) - all in Canada; and King Abdulaziz University, Jeddah, Saudi Arabia (A.M.)
| | - Blandine Mondesert
- From QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P.), the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton (S.S., S.K.), the University of Ottawa Heart Institute, Ottawa (C.J.R., N.H.N.L., G.W.), Schulich School of Medicine and Dentistry, Western University, London, ON (H.K., J.M., C.E.M., A.S.L.T.), Libin Cardiovascular Institute, Calgary, AB (D.V.E., G.S.), McMaster University, Hamilton, ON (J.S.H.), Montreal Heart Institute, Montreal (B.T., B.M., M.T., J.R.), Royal Jubilee Hospital, Victoria, BC (L.D.S.), and the University of Toronto, Toronto (S.M.) - all in Canada; and King Abdulaziz University, Jeddah, Saudi Arabia (A.M.)
| | - Mario Talajic
- From QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P.), the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton (S.S., S.K.), the University of Ottawa Heart Institute, Ottawa (C.J.R., N.H.N.L., G.W.), Schulich School of Medicine and Dentistry, Western University, London, ON (H.K., J.M., C.E.M., A.S.L.T.), Libin Cardiovascular Institute, Calgary, AB (D.V.E., G.S.), McMaster University, Hamilton, ON (J.S.H.), Montreal Heart Institute, Montreal (B.T., B.M., M.T., J.R.), Royal Jubilee Hospital, Victoria, BC (L.D.S.), and the University of Toronto, Toronto (S.M.) - all in Canada; and King Abdulaziz University, Jeddah, Saudi Arabia (A.M.)
| | - Jean Rouleau
- From QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P.), the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton (S.S., S.K.), the University of Ottawa Heart Institute, Ottawa (C.J.R., N.H.N.L., G.W.), Schulich School of Medicine and Dentistry, Western University, London, ON (H.K., J.M., C.E.M., A.S.L.T.), Libin Cardiovascular Institute, Calgary, AB (D.V.E., G.S.), McMaster University, Hamilton, ON (J.S.H.), Montreal Heart Institute, Montreal (B.T., B.M., M.T., J.R.), Royal Jubilee Hospital, Victoria, BC (L.D.S.), and the University of Toronto, Toronto (S.M.) - all in Canada; and King Abdulaziz University, Jeddah, Saudi Arabia (A.M.)
| | - C Elizabeth McCarron
- From QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P.), the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton (S.S., S.K.), the University of Ottawa Heart Institute, Ottawa (C.J.R., N.H.N.L., G.W.), Schulich School of Medicine and Dentistry, Western University, London, ON (H.K., J.M., C.E.M., A.S.L.T.), Libin Cardiovascular Institute, Calgary, AB (D.V.E., G.S.), McMaster University, Hamilton, ON (J.S.H.), Montreal Heart Institute, Montreal (B.T., B.M., M.T., J.R.), Royal Jubilee Hospital, Victoria, BC (L.D.S.), and the University of Toronto, Toronto (S.M.) - all in Canada; and King Abdulaziz University, Jeddah, Saudi Arabia (A.M.)
| | - George Wells
- From QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P.), the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton (S.S., S.K.), the University of Ottawa Heart Institute, Ottawa (C.J.R., N.H.N.L., G.W.), Schulich School of Medicine and Dentistry, Western University, London, ON (H.K., J.M., C.E.M., A.S.L.T.), Libin Cardiovascular Institute, Calgary, AB (D.V.E., G.S.), McMaster University, Hamilton, ON (J.S.H.), Montreal Heart Institute, Montreal (B.T., B.M., M.T., J.R.), Royal Jubilee Hospital, Victoria, BC (L.D.S.), and the University of Toronto, Toronto (S.M.) - all in Canada; and King Abdulaziz University, Jeddah, Saudi Arabia (A.M.)
| | - Anthony S L Tang
- From QEII Health Sciences Centre, Dalhousie University, Halifax, NS (J.L.S., R.P.), the Mazankowski Alberta Heart Institute, University of Alberta, Edmonton (S.S., S.K.), the University of Ottawa Heart Institute, Ottawa (C.J.R., N.H.N.L., G.W.), Schulich School of Medicine and Dentistry, Western University, London, ON (H.K., J.M., C.E.M., A.S.L.T.), Libin Cardiovascular Institute, Calgary, AB (D.V.E., G.S.), McMaster University, Hamilton, ON (J.S.H.), Montreal Heart Institute, Montreal (B.T., B.M., M.T., J.R.), Royal Jubilee Hospital, Victoria, BC (L.D.S.), and the University of Toronto, Toronto (S.M.) - all in Canada; and King Abdulaziz University, Jeddah, Saudi Arabia (A.M.)
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Boursalie S, MacIntyre C, Sapp JL, Gray C, Abdelwahab A, Gardner M, Lee D, Matheson K, Parkash R. Disparities in Referral and Utilization of Implantable Cardioverter-Defibrillators for Primary Prevention of Sudden Cardiac Death. Can J Cardiol 2023; 39:1610-1616. [PMID: 37423507 DOI: 10.1016/j.cjca.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/26/2023] [Accepted: 07/02/2023] [Indexed: 07/11/2023] Open
Abstract
BACKGROUND Implantable cardioverter-defibrillators (ICDs) reduce mortality in patients with reduced left ventricular ejection fraction (LVEF). We investigated sex disparities in a contemporary Canadian population for utilization of primary prevention ICDs. METHODS This was a retrospective cohort study on patients with reduced LVEF admitted to hospitals from 2010 to 2020 in Nova Scotia (population = 971,935). RESULTS There were 4406 patients eligible for ICDs: 3108 (71%) men and 1298 (29%) women. The mean follow-up time was 3.9 ± 3.0 years. Rates of coronary disease were similar between men and women (45.8% vs 44.0%; P = 0.28), but men had lower LVEF (26.6 ± 5.9% vs 27.2 ± 5.8%; P = 0.0017). The referral rate for ICD was 11% (n = 487), with 13% of men (n = 403) and 6.5% of women (n = 84) referred (P < 0.001). The ICD implantation rate in the population was 8% (n = 358), with 9.5% of men (n = 296) and 4.8% of women (n = 62) (P < 0.001) receiving the device. Men were more likely than women to receive an ICD (odds ratio 2.08, 95% confidence interval 1.61-2.70; P < 0.0001)). There was no significant difference in mortality between men and women (P = 0.2764). There was no significant difference in device therapies between men and women (43.8% vs 31.1%; P = 0.0685). CONCLUSIONS A significant disparity exists in the utilization of primary prevention ICDs between men and women in a contemporary Canadian population.
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Affiliation(s)
- Suzanne Boursalie
- Division of Cardiology, Department of Medicine, Dalhousie, University, Halifax, Nova Scotia, Canada
| | - Ciorsti MacIntyre
- Division of Cardiology, Department of Medicine, Dalhousie, University, Halifax, Nova Scotia, Canada
| | - John L Sapp
- Division of Cardiology, Department of Medicine, Dalhousie, University, Halifax, Nova Scotia, Canada
| | - Chris Gray
- Division of Cardiology, Department of Medicine, Dalhousie, University, Halifax, Nova Scotia, Canada
| | - Amir Abdelwahab
- Division of Cardiology, Department of Medicine, Dalhousie, University, Halifax, Nova Scotia, Canada
| | - Martin Gardner
- Division of Cardiology, Department of Medicine, Dalhousie, University, Halifax, Nova Scotia, Canada
| | - David Lee
- Division of Cardiology, Department of Medicine, Dalhousie, University, Halifax, Nova Scotia, Canada
| | - Kara Matheson
- Research Methods Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Ratika Parkash
- Division of Cardiology, Department of Medicine, Dalhousie, University, Halifax, Nova Scotia, Canada.
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Zhou S, AbdelWahab A, Wang R, Dang H, Warren JW, Sapp JL. Optimization of a 12-Lead Electrocardiography Subset for Automated Early Left Ventricular Activation Localization Approach Based on Pace-Mapping Technology. Can J Cardiol 2023; 39:1410-1416. [PMID: 37270167 DOI: 10.1016/j.cjca.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 05/15/2023] [Accepted: 05/25/2023] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND We previously developed an automated approach based on pace mapping to localise early left ventricular (LV) activation origin. To avoid a singular system, we require pacing from at least 2 more known sites than the number of electrocardiography (ECG) leads used. Fewer leads used means fewer pacing sites required. We sought to identify an optimal minimal ECG lead set for the automated approach. METHODS We used 1715 LV endocardial pacing sites to create derivation and testing data sets. The derivation data set, consisting of 1012 known pacing sites pooled from 38 patients, was used to identify an optimal 3-lead set by means of random forest regression (RFR), and a second 3-lead set by means of exhaustive search. The performance of these sets and the calculated Frank leads was compared within the testing data set with 703 pacing sites pooled from 25 patients. RESULTS The RFR yielded III, V1, and V4, whereas the exhaustive search identified leads II, V2 and V6. Comparison of these sets and the calculated Frank leads demonstrated similar performance when using 5 or more known pacing sites. Accuracy improved with additional pacing sites, achieving mean accuracy of < 5 mm, after including up to 9 pacing sites when they were focused on a suspected area of ventricular activation origin (radius < 10 mm). CONCLUSIONS The RFR identified the quasi-orthogonal leads set to localise the source of LV activation, minimizing the training set of pacing sites. Localization accuracy was high with the use of these leads and was not significantly different from using leads identified by exhaustive search or empiric use of Frank leads.
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Affiliation(s)
- Shijie Zhou
- Department of Chemical, Paper, and Biomedical Engineering, College of Engineering and Computing, Miami University, Oxford, Ohio, USA; Department of Electrical and Computer Engineering, College of Engineering and Computing, Miami University, Oxford, Ohio, USA.
| | - Amir AbdelWahab
- Cardiology Division, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | | | - Huan Dang
- Department of Electrical and Computer Engineering, College of Engineering and Computing, Miami University, Oxford, Ohio, USA
| | - James W Warren
- Department of Physiology and Biophysics, Dalhousie University, Halifax, Nova Scotia, Canada
| | - John L Sapp
- Cardiology Division, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
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Zhou S, Wang R, Seagren A, Emmert N, Warren JW, MacInnis PJ, AbdelWahab A, Sapp JL. Improving localization accuracy for non-invasive automated early left ventricular origin localization approach. Front Physiol 2023; 14:1183280. [PMID: 37435305 PMCID: PMC10330701 DOI: 10.3389/fphys.2023.1183280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/02/2023] [Indexed: 07/13/2023] Open
Abstract
Background: We previously developed a non-invasive approach to localize the site of early left ventricular activation origin in real time using 12-lead ECG, and to project the predicted site onto a generic LV endocardial surface using the smallest angle between two vectors algorithm (SA). Objectives: To improve the localization accuracy of the non-invasive approach by utilizing the K-nearest neighbors algorithm (KNN) to reduce projection errors. Methods: Two datasets were used. Dataset #1 had 1012 LV endocardial pacing sites with known coordinates on the generic LV surface and corresponding ECGs, while dataset #2 included 25 clinically-identified VT exit sites and corresponding ECGs. The non-invasive approach used "population" regression coefficients to predict the target coordinates of a pacing site or VT exit site from the initial 120-m QRS integrals of the pacing site/VT ECG. The predicted site coordinates were then projected onto the generic LV surface using either the KNN or SA projection algorithm. Results: The non-invasive approach using the KNN had a significantly lower mean localization error than the SA in both dataset #1 (9.4 vs. 12.5 mm, p < 0.05) and dataset #2 (7.2 vs. 9.5 mm, p < 0.05). The bootstrap method with 1,000 trials confirmed that using KNN had significantly higher predictive accuracy than using the SA in the bootstrap assessment with the left-out sample (p < 0.05). Conclusion: The KNN significantly reduces the projection error and improves the localization accuracy of the non-invasive approach, which shows promise as a tool to identify the site of origin of ventricular arrhythmia in non-invasive clinical modalities.
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Affiliation(s)
- Shijie Zhou
- The Department of Chemical, Paper and Biomedical Engineering, Miami University, Oxford, OH, United States
- The Department of Computer Science and Software Engineering, Miami University, Oxford, OH, United States
| | | | - Avery Seagren
- The Department of Chemical, Paper and Biomedical Engineering, Miami University, Oxford, OH, United States
| | - Noah Emmert
- The Department of Computer Science and Software Engineering, Miami University, Oxford, OH, United States
| | - James W. Warren
- The Department of Physiology and Biophysics, Dalhousie University, Halifax, NS, Canada
| | - Paul J. MacInnis
- The Department of Physiology and Biophysics, Dalhousie University, Halifax, NS, Canada
| | - Amir AbdelWahab
- Cardiology Division, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | - John L. Sapp
- Cardiology Division, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
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Samuel M, Healey JS, Nault I, Sterns LD, Essebag V, Gray C, Hruczkowski T, Gardner M, Parkash R, Sapp JL. Ventricular Tachycardia and ICD Therapy Burden With Catheter Ablation Versus Escalated Antiarrhythmic Drug Therapy. JACC Clin Electrophysiol 2023; 9:808-821. [PMID: 37380314 DOI: 10.1016/j.jacep.2023.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Catheter ablation improves ventricular tachycardia (VT) event-free (time to event) survival in patients with antiarrhythmic drug (AAD)-refractory VT and previous myocardial infarction (MI). The effects of ablation on recurrent VT and implantable cardioverter-defibrillator (ICD) therapy (burden) have yet to be investigated. OBJECTIVES This study sought to compare the VT and ICD therapy burden following treatment with either ablation or escalated AAD therapy among patients with VT and previous MI in the VANISH (Ventricular tachycardia AblatioN versus escalated antiarrhythmic drug therapy in ISchemic Heart disease) trial. METHODS The VANISH trial randomized patients with previous MI and VT despite initial AAD therapy to either escalated AAD treatment or catheter ablation. VT burden was defined as the total number of VT events treated with ≥1 appropriate ICD therapy. Appropriate ICD therapy burden was defined as the total number of appropriate shocks or antitachycardia pacing therapies (ATPs) delivered. The Anderson-Gill recurrent event model was used to compare burden between the treatment arms. RESULTS Of the 259 enrolled patients (median age, 69.8 years; 7.0% women), 132 patients were randomized to ablation and 129 patients were randomized to escalated AAD therapy. Over 23.4 months of follow-up, ablation-treated patients had a 40% lower shock-treated VT event burden and a 39% lower appropriate shock burden compared with patients who received escalated AAD therapy (P <0.05 for all). A reduction in VT burden, ATP-treated VT event burden, and appropriate ATP burden among ablation patients was only demonstrated in the stratum of patients with amiodarone-refractory VT (P <0.05 for all). CONCLUSIONS Among patients with AAD-refractory VT and a previous MI, catheter ablation reduced shock-treated VT event burden and appropriate shock burden compared with escalated AAD therapy. There was also lower VT burden, ATP-treated VT event burden, and appropriate ATP burden among ablation-treated patients; however, the effect was limited to patients with amiodarone-refractory VT.
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Affiliation(s)
- Michelle Samuel
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | | | - Isabelle Nault
- Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
| | | | - Vidal Essebag
- McGill University Health Centre, Montreal, Quebec, Canada; Hôpital Sacré-Coeur de Montréal, Montreal, Quebec, Canada
| | - Christopher Gray
- Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | | | - Martin Gardner
- Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ratika Parkash
- Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - John L Sapp
- Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada.
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9
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Healey JS, Krahn AD, Bashir J, Amit G, Philippon F, McIntyre WF, Tsang B, Joza J, Exner DV, Birnie DH, Sadek M, Leong DP, Sikkel M, Korley V, Sapp JL, Roux JF, Lee SF, Wong G, Djuric A, Spears D, Carroll S, Crystal E, Hruczkowski T, Connolly SJ, Mondesert B. Perioperative Safety and Early Patient and Device Outcomes Among Subcutaneous Versus Transvenous Implantable Cardioverter Defibrillator Implantations : A Randomized, Multicenter Trial. Ann Intern Med 2022; 175:1658-1665. [PMID: 36343346 DOI: 10.7326/m22-1566] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Implantable cardioverter defibrillators (ICDs) improve survival in patients at risk for cardiac arrest, but are associated with intravascular lead-related complications. The subcutaneous ICD (S-ICD), with no intravascular components, was developed to minimize lead-related complications. OBJECTIVE To assess key ICD performance measures related to delivery of ICD therapy, including inappropriate ICD shocks (delivered in absence of life-threatening arrhythmia) and failed ICD shocks (which did not terminate ventricular arrhythmia). DESIGN Randomized, multicenter trial. (ClinicalTrials.gov: NCT02881255). SETTING The ATLAS trial. PATIENTS 544 eligible patients (141 female) with a primary or secondary prevention indication for an ICD who were younger than age 60 years, had a cardiogenetic phenotype, or had prespecified risk factors for lead complications were electrocardiographically screened and 503 randomly assigned to S-ICD (251 patients) or transvenous ICD (TV-ICD) (252 patients). Mean follow-up was 2.5 years (SD, 1.1). Mean age was 49.0 years (SD, 11.5). MEASUREMENTS The primary outcome was perioperative major lead-related complications. RESULTS There was a statistically significant reduction in perioperative, lead-related complications, which occurred in 1 patient (0.4%) with an S-ICD and in 12 patients (4.8%) with TV-ICD (-4.4%; 95% CI, -6.9 to -1.9; P = 0.001). There was a trend for more inappropriate shocks with the S-ICD (hazard ratio [HR], 2.37; 95% CI, 0.98 to 5.77), but no increase in failed appropriate ICD shocks (HR, 0.61 (0.15 to 2.57). Patients in the S-ICD group had more ICD site pain, measured on a 10-point numeric rating scale, on the day of implant (4.2 ± 2.8 vs. 2.9 ± 2.2; P < 0.001) and 1 month later (1.3 ± 1.8 vs. 0.9 ± 1.5; P = 0.035). LIMITATION At present, the ATLAS trial is underpowered to detect differences in clinical shock outcomes; however, extended follow-up is ongoing. CONCLUSION The S-ICD reduces perioperative, lead-related complications without significantly compromising the effectiveness of ICD shocks, but with more early postoperative pain and a trend for more inappropriate shocks. PRIMARY FUNDING SOURCE Boston Scientific.
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Affiliation(s)
- Jeff S Healey
- Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., W.F.M., D.P.L., S.F.L., G.W., A.D., S.J.C.)
| | - Andrew D Krahn
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada (A.D.K., J.B.)
| | - Jamil Bashir
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada (A.D.K., J.B.)
| | - Guy Amit
- McMaster University, Hamilton, Ontario, Canada (G.A.)
| | - François Philippon
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Quebec, Canada (F.P.)
| | - William F McIntyre
- Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., W.F.M., D.P.L., S.F.L., G.W., A.D., S.J.C.)
| | - Bernice Tsang
- Southlake Regional Hospital, Newmarket, Ontario, Canada (B.T.)
| | | | - Derek V Exner
- University of Calgary, Calgary, Alberta, Canada (D.V.E.)
| | - David H Birnie
- University of Ottawa, Ottawa, Ontario, Canada (D.H.B., M.S.)
| | - Mouhannad Sadek
- University of Ottawa, Ottawa, Ontario, Canada (D.H.B., M.S.)
| | - Darryl P Leong
- Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., W.F.M., D.P.L., S.F.L., G.W., A.D., S.J.C.)
| | - Markus Sikkel
- University of Victoria, Victoria, British Columbia, Canada (M.S.)
| | - Victoria Korley
- University of Toronto, Toronto, Ontario, Canada (V.K., E.C.)
| | - John L Sapp
- Dalhousie University and QEII Health Sciences Centre, Halifax, Nova Scotia, Canada (J.L.S.)
| | | | - Shun Fu Lee
- Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., W.F.M., D.P.L., S.F.L., G.W., A.D., S.J.C.)
| | - Gloria Wong
- Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., W.F.M., D.P.L., S.F.L., G.W., A.D., S.J.C.)
| | - Angie Djuric
- Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., W.F.M., D.P.L., S.F.L., G.W., A.D., S.J.C.)
| | - Danna Spears
- University Health Network, University of Toronto, Toronto, Ontario, Canada (D.S.)
| | - Sandra Carroll
- Population Health Research Institute, Hamilton, and School of Nursing, McMaster University, Hamilton, Ontario, Canada (S.C.)
| | - Eugene Crystal
- University of Toronto, Toronto, Ontario, Canada (V.K., E.C.)
| | | | - Stuart J Connolly
- Population Health Research Institute, Hamilton, Ontario, Canada (J.S.H., W.F.M., D.P.L., S.F.L., G.W., A.D., S.J.C.)
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Sapp JL. Myocardial Scar and Clustered Ventricular Arrhythmias: Imaging Is Part of the Picture. JACC Clin Electrophysiol 2022; 8:967-969. [PMID: 35981801 DOI: 10.1016/j.jacep.2022.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/29/2022] [Indexed: 10/15/2022]
Affiliation(s)
- John L Sapp
- Department of Medicine, Dalhousie University and QEII Health Sciences Centre, Halifax, Nova Scotia, Canada.
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11
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Sapp JL. Needle Ablation for Ventricular Tachycardia: From Bench to Bedside. Can J Cardiol 2022; 38:1150-1152. [PMID: 35781012 DOI: 10.1016/j.cjca.2022.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 11/02/2022] Open
Affiliation(s)
- John L Sapp
- QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada.
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12
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Samuel M, Healey J, Nault I, Sterns LD, Essebag V, Gray C, Hruczkowski T, Gardner M, Parkash R, Sapp JL. Reduction in shock burden with catheter ablation versus escalated antiarrhythmic drug therapy: Insights from the VANISH trial. Europace 2022. [DOI: 10.1093/europace/euac053.364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): 1. Canadian Institutes of Health Research (CIHR)
2. Additional financial support from St. Jude Medical and Biosense Webster
Background
Recurrent shocks for ventricular tachycardia (VT) are associated with an increased risk of heart failure and mortality and have a negative influence on quality of life. Catheter ablation has been shown to improve VT event-free survival in patients with antiarrhythmic drug (AAD)-refractory VT and prior myocardial infarction (MI); however, the effects of ablation on shock burden has yet to be investigated.
Purpose
Our primary objectives were to compare the shock-treated VT event burden and appropriate shock burden following randomization to treatment with either catheter ablation or escalated AAD therapy among VT patients with prior MI in the Ventricular tachycardia AblatioN versus escalated antiarrhythmic drug therapy in Ischemic Heart disease (VANISH) randomized trial.
Methods
Recurrent event analyses were performed using the intention-to-treat population of the VANISH trial. Shock-treated VT event burden was defined as the total number of VT events treated with ≥1 appropriate internal or external shocks. Appropriate shock burden was defined as the total number of appropriate internal and external shocks delivered, regardless of the number of VT events. All VT events and implantable cardioverter defibrillator (ICD) therapies were adjudicated by reviewers blinded to the treatment allocation. Three recurrent event models were used to compare the shock burden between treatment arms (Anderson-Gill (AG), Frailty, and Prentice, Williams, and Peterson Total Time (PWP-TT). Each model clustered by patient and accounted for competing risk of death with the Fine and Gray sub-distributions hazards model.
Results
Of the 259 patients enrolled in the VANISH trial [median age 69.8 (IQR 63.0-74.2) years, 7.0% women], 132 patients were randomized to ablation and 129 patients to escalated AAD therapy. Over a median follow-up of 23.4 (IQR 14.7-40.4) months, there were 138 shock-treated VT events [39.07 (95% CI 33.14-46.07) shock-treated VT events per 100 person-years] in the ablation arm and 218 shock-treated VT events [64.60 (95% CI 56.49–73.84) shock-treated VT events per 100 person-years] in the escalated AAD therapy arm (Figure 1). Ablation patients had a 40% lower shock-treated VT event burden (ie. number of shock-treated VT events) compared to patients randomized to escalated AAD therapy [Figure 1; AG HR 0.60 (95% 0.38-0.95)]. Further, there was also a statistically significant reduction in the appropriate shock burden (i.e. number of appropriate shocks) among ablation patients (169 appropriate shocks) compared to escalated AAD therapy patients (266 appropriate shocks) [Figure 1; AG HR 0.61 (95% CI 0.37-0.96)]. All results were consistent between the 3 recurrent event models.
Conclusion
Among patients with AAD-refractory VT and a prior MI, catheter ablation reduced shock-treated VT event burden and appropriate shock burden compared to escalated AAD therapy.
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Affiliation(s)
- M Samuel
- Montreal Heart Institute, University of Montreal, Montreal, Canada
| | - J Healey
- McMaster University, Hamilton, Canada
| | - I Nault
- Quebec Heart and Lung Institute, Quebec, Canada
| | - LD Sterns
- Royal Jubilee Hospital, Victoria, Canada
| | - V Essebag
- McGill University Health Centre, Montreal, Canada
| | - C Gray
- QE II Health Sciences Center, Halifax, Canada
| | - T Hruczkowski
- Mazankowski Alberta Heart Institute, Edmonton, Canada
| | - M Gardner
- QE II Health Sciences Center, Halifax, Canada
| | - R Parkash
- QE II Health Sciences Center, Halifax, Canada
| | - JL Sapp
- QE II Health Sciences Center, Halifax, Canada
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Suszko AM, Chakraborty P, Viswanathan K, Barichello S, Sapp JL, Talajic M, Laksman Z, Yee R, Spears DA, Adler A, Chauhan VS. PO-668-06 AUTOMATED QUANTIFICATION OF ABNORMAL LOW-AMPLITUDE QRS PEAKS FROM HIGH-RESOLUTION ECGS PREDICTS LATE VENTRICULAR ARRHYTHMIAS IN HYPERTROPHIC CARDIOMYOPATHY: A 5-YEAR PROSPECTIVE MULTICENTER STUDY. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Dukkipati SR, Nakamura T, Nakajima I, Oates C, Narui R, Tanigawa S, Sljapic T, Whang W, Koruth JS, Choudry S, Schaeffer B, Fujii A, Tedrow UB, Sapp JL, Stevenson WG, Reddy VY. Intramural Needle Ablation for Refractory Premature Ventricular Contractions. Circ Arrhythm Electrophysiol 2022; 15:e010020. [PMID: 35476455 DOI: 10.1161/circep.121.010020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Frequent premature ventricular contractions (PVCs) are often amenable to catheter ablation. However, a deep intramural focus may lead to failure due to inability of standard ablation techniques to penetrate the focus. We sought to assess the efficacy and safety of infusion needle ablation (INA) for PVCs that are refractory to standard radiofrequency ablation. METHODS Under 2 Food and Drug Administration approved protocols, INA was evaluated in patients with frequent PVCs that were refractory to standard ablation. Initial targets for ablation were selected by standard mapping techniques. INA was performed with a deflectable catheter equipped with an extendable/retractable needle at the tip that can be extended up to 12 mm into the myocardium and is capable of pacing and recording. After contrast injection for location assessment, radiofrequency ablation was performed with the needle tip using a temperature-controlled mode (maximum temperature 60 °C) with saline infusion from the needle. The primary end point was a decrease in PVC burden to <5000/24 hours at 6 months. The primary safety end point was incidence of procedure- or device-related serious adverse events. RESULTS At 4 centers, 35 patients (age 55.3±16.9 years, 74.2% male) underwent INA. The baseline median PVC burden was 25.4% (interquartile range, 18.4%-33.9%) and mean left ventricular ejection fraction was 37.7±12.3%. Delivering 10.3±8.0 INA lesions/patient (91% had adjunctive standard radiofrequency ablation also) resulted in acute PVC elimination in 71.4%. After a mean follow-up of 156±109 days, the primary efficacy end point was met in 73.3%. The median PVC burden decreased to 0.8% (interquartile range, 0.1%-6.0%; P<0.001). The primary safety end point occurred in 14.3% consisting of 1 (2.9%) heart block, 1 (2.9%) femoral artery dissection, and 3 (8.6%) pericardial effusions (all treated percutaneously). CONCLUSIONS INA is effective for the elimination of frequent PVCs that are refractory to conventional ablation and is associated with an acceptable safety profile. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01791543 and NCT03204981.
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Affiliation(s)
- Srinivas R Dukkipati
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, NY (S.R.D., C.O., T.S., W.W., J.S.K., S.C., V.Y.R.)
| | - Tomofumi Nakamura
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (T.N., I.N., R.N., W.G.S.)
| | - Ikutaro Nakajima
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (T.N., I.N., R.N., W.G.S.)
| | - Connor Oates
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, NY (S.R.D., C.O., T.S., W.W., J.S.K., S.C., V.Y.R.)
| | - Ryohsuke Narui
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (T.N., I.N., R.N., W.G.S.)
| | - Shinichi Tanigawa
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (S.T., B.S., A.F., U.B.T.)
| | - Tatjana Sljapic
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, NY (S.R.D., C.O., T.S., W.W., J.S.K., S.C., V.Y.R.)
| | - William Whang
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, NY (S.R.D., C.O., T.S., W.W., J.S.K., S.C., V.Y.R.)
| | - Jacob S Koruth
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, NY (S.R.D., C.O., T.S., W.W., J.S.K., S.C., V.Y.R.)
| | - Subbarao Choudry
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, NY (S.R.D., C.O., T.S., W.W., J.S.K., S.C., V.Y.R.)
| | - Benjamin Schaeffer
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (S.T., B.S., A.F., U.B.T.)
| | - Akira Fujii
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (S.T., B.S., A.F., U.B.T.)
| | - Usha B Tedrow
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (S.T., B.S., A.F., U.B.T.)
| | - John L Sapp
- Heart Rhythm Service, Division of Cardiology, Department of Medicine, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada (J.L.S.)
| | - William G Stevenson
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (T.N., I.N., R.N., W.G.S.)
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, NY (S.R.D., C.O., T.S., W.W., J.S.K., S.C., V.Y.R.)
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Hindi M, Schwab K, Sandhu JK, Singh S, Tang AS, Healey JS, Thibault B, Sapp JL, Essebag V, Nery PB, Sterns LD, Birnie DH, Bennett MT. BS-400-20 COMPARISON OF THE EFFICACY OF BI-V VS RV BURST ATP IN TERMINATING VT IN PATIENTS WITH NON-ISCHEMIC VS ISCHEMIC CARDIOMYOPATHY. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.1212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Batnyam U, Tokutake K, AbdelWahab AM, Richardson TD, Kanagasundram AN, Sapp JL, Stevenson WG, Tedrow UB. PO-635-02 FACTORS ASSOCIATED WITH INFUSION NEEDLE RADIOFREQUENCY ABLATION FAILURE IN PATIENTS WITH REFRACTORY VENTRICULAR TACHYCARDIA. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Hindi M, Sandhu JK, Schwab K, Singh S, Tang AS, Healey JS, Thibault B, Sapp JL, Essebag V, Nery PB, Sterns LD, Birnie DH, Bennett MT. CE-540-01 EFFICACY OF BURST VS RAMP ATP FOR SLOW VT. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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18
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Enriquez AA, Bode WD, Futyma P, Liang JJ, Wrzos A, Zarebski L, Adams C, Tapias CA, Saenz Morales LC, Vidal VN, Sadek M, Sapp JL, AbdelWahab AM, Muser D, Baranchuk A, Garcia FC, Marchlinski FE, Santangeli P. PO-666-01 CATHETER ABLATION OF INTRAMURAL OUTFLOW TRACT VENTRICULAR ARRHYTHMIAS: A MULTICENTER STUDY. Heart Rhythm 2022. [DOI: 10.1016/j.hrthm.2022.03.369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Parkash R, Wells GA, Rouleau J, Talajic M, Essebag V, Skanes A, Wilton SB, Verma A, Healey JS, Sterns L, Bennett M, Roux JF, Rivard L, Leong-Sit P, Jensen-Urstad M, Jolly U, Philippon F, Sapp JL, Tang ASL. Randomized Ablation-Based Rhythm-Control Versus Rate-Control Trial in Patients with Heart Failure and Atrial Fibrillation: Results from the RAFT-AF trial. Circulation 2022; 145:1693-1704. [PMID: 35313733 DOI: 10.1161/circulationaha.121.057095] [Citation(s) in RCA: 44] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Atrial fibrillation (AF) and heart failure (HF) frequently coexist and can be challenging to treat. Pharmacologic based rhythm-control of AF has not proven to be superior to rate-control. Ablation-based rhythm-control was compared to rate-control to evaluate if clinical outcomes in patients with HF and AF could be improved. Methods: This was a multicenter, open-label trial with blinded outcome evaluation using a central adjudication committee. Patients with high burden paroxysmal (>4 episodes in six months) or persistent (duration < three years) AF, New York Heart Association class II-III HF, and elevated NT-proBNP were randomized to ablation-based rhythm-control or rate-control. The primary outcome was a composite of all-cause mortality and all HF events, with a minimum follow up of two years. Secondary outcomes included left ventricular ejection fraction (LVEF), six-minute walk test and NT-proBNP. Quality of life was measured using the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the AF Effect on quality of life (AFEQT). The primary analysis was time-to-event using Cox proportional hazards modeling. The trial was stopped early due to a determination of apparent futility by the Data Safety Monitoring Committee. Results: From December 1, 2011, to January 20, 2018, 411 patients were randomized to ablation-based rhythm-control (n=214) or rate-control (n=197). The primary outcome occurred in 50 (23.4%) patients in the ablation-based rhythm-control group and 64 (32.5%) patients in the rate-control group (hazard ratio 0.71 95% CI (0.49, 1.03), p=0.066). LVEF increased in the ablation-based group (10.1±1.2% vs 3.8±1.2%, p=0.017); six-minute walk distance improved (44.9±9.1 meters 27.5±9.7 meters, p=0.025) and NT-proBNP demonstrated a decrease (mean change -77.1% vs -39.2%, p<0.0001). MLHFQ demonstrated greater improvement in the ablation-based rhythm-control group (LSMD of -5.4, 95%CI (-10.5, -0.3), p=0.0036), as did the AFEQT score (LSMD of 6.2, 95%CI (1.7, 10.7), p=0.0005). Serious adverse events were observed in 50% of patients in both treatment groups. Conclusions: In patients with high burden AF and HF, there was no statistical difference in all-cause mortality or HF events with ablation-based rhythm-control versus rate-control, however, there was a non-significant trend for improved outcomes with ablation-based rhythm control over rate-control.
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Affiliation(s)
- Ratika Parkash
- Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - George A Wells
- University of Ottawa Cardiovascular Research Methods Centre, Ottawa, ON, Canada
| | - Jean Rouleau
- Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - Mario Talajic
- Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - Vidal Essebag
- McGill University Health Centre, Montreal, QC, Canada
| | - Allan Skanes
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Stephen B Wilton
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Atul Verma
- Southlake Regional Health Centre, ON, Canada
| | | | - Laurence Sterns
- Royal Jubilee Hospital, Island Health Authority, Victoria, BC, Canada
| | - Matthew Bennett
- Centre for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, BC, Canada
| | | | - Lena Rivard
- Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - Peter Leong-Sit
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | | | - Umjeet Jolly
- St. Mary's General Hospital, Kitchener, ON, Canada
| | - François Philippon
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, QC, Canada
| | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Anthony S L Tang
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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Gyawali PK, Murkute JV, Toloubidokhti M, Jiang X, Horacek BM, Sapp JL, Wang L. Learning to Disentangle Inter-Subject Anatomical Variations in Electrocardiographic Data. IEEE Trans Biomed Eng 2022; 69:860-870. [PMID: 34460360 PMCID: PMC8858595 DOI: 10.1109/tbme.2021.3108164] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This work investigates the possibility of disentangled representation learning of inter-subject anatomical variations within electrocardiographic (ECG) data. METHODS Since ground truth anatomical factors are generally not known in clinical ECG for assessing the disentangling ability of the models, the presented work first proposes the SimECG data set, a 12-lead ECG data set procedurally generated with a controlled set of anatomical generative factors. Second, to perform such disentanglement, the presented method evaluates and compares deep generative models with latent density modeled by nonparametric Indian Buffet Process to account for the complex generative process of ECG data. RESULTS In the simulated data, the experiments demonstrate, for the first time, concrete evidence of the possibility to disentangle key generative anatomical factors within ECG data in separation from task-relevant generative factors. We achieve a disentanglement score of 92.1% while disentangling five anatomical generative factors and the task-relevant generative factor. In both simulated and real-data experiments, this work further provides quantitative evidence for the benefit of disentanglement learning on the downstream clinical task of localizing the origin of ventricular activation. Overall, the presented method achieves an improvement of around 18.5%, and 11.3% for the simulated dataset, and around 7.2%, and 3.6% for the real dataset, over baseline CNN, and standard generative model, respectively. CONCLUSION These results demonstrate the importance as well as the feasibility of the disentangled representation learning of inter-subject anatomical variations within ECG data. SIGNIFICANCE This work suggests the important research direction to deal with the well-known challenge posed by the presence of significant inter-subject variations during an automated analysis of ECG data.
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21
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Deyell MW, Doucette S, Parkash R, Nault I, Gula L, Gray C, Gardner M, Sterns LD, Healey JS, Essebag V, Sapp JL. Ventricular tachycardia characteristics and outcomes with catheter ablation vs. antiarrhythmic therapy: insights from the VANISH trial. Europace 2022; 24:1112-1118. [PMID: 35030257 PMCID: PMC9301970 DOI: 10.1093/europace/euab328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/22/2021] [Indexed: 01/16/2023] Open
Abstract
AIMS Catheter ablation is superior to escalated antiarrhythmic drugs among patients with ventricular tachycardia (VT) and prior myocardial infarction (MI). However, it is uncertain whether clinical VT characteristics, should influence choice of therapy. The purpose of this study was to evaluate whether presentation with electrical storm and the clinical VT cycle length predicted response to ablation vs. escalated antiarrhythmic therapy. METHODS AND RESULTS All patients enrolled in the Ventricular Tachycardia Ablation vs. Escalated Antiarrhythmic Drug Therapy in Ischaemic Heart Disease (VANISH) trial were included. The association between VT cycle length and presentation with electrical storm and the primary outcome of death, subsequent VT storm or appropriate ICD shock was evaluated. Among the study population of 259 patients, escalated antiarrhythmic drug therapy had worse outcomes for those presenting with a VT cycle length >400 ms [<150 b.p.m., 89/259, hazard ratio (HR) 1.7 (1.02-3.13)]. This effect was more pronounced among those taking amiodarone at baseline [HR of 2.22 (1.19-4.16)]. Presentation with VT storm (32/259) did not affect the primary outcome between groups. However, those presenting with VT storm on amiodarone had a trend towards worse outcomes with escalated antiarrhythmic therapy [HR 4.31 (0.55-33.93)]. CONCLUSION The VT cycle length can influence response to either ablation or escalated drug therapy in patients with VT and prior MI. Those with slow VT had improved outcomes with ablation. Patients presenting with electrical storm demonstrated similar outcomes to the overall trial population, with a trend to benefit of catheter ablation, particularly in those on amiodarone.
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Affiliation(s)
- Marc W Deyell
- Corresponding author. Tel: +1 604 806 8256; fax: +1 604 806 8723. E-mail address:
| | - Steve Doucette
- Department of Medicine, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ratika Parkash
- Department of Medicine, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Isabelle Nault
- Department of Medicine, Université Laval, Québec City, Québec, Canada
| | - Lorne Gula
- Department of Medicine, Western University, London, Ontario, Canada
| | - Christopher Gray
- Department of Medicine, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Martin Gardner
- Department of Medicine, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Laurence D Sterns
- Department of Medicine, Royal Jubilee Hospital, Victoria, British Columbia, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Vidal Essebag
- Department of Medicine, McGill University Health Centre and Hôpital Sacré-Coeur de Montréal, Montreal, Québec, Canada
| | - John L Sapp
- Department of Medicine, QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada
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22
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Samuel M, Elsokkari I, Sapp JL. Ventricular tachycardia burden and mortality: association or causality? Can J Cardiol 2022; 38:454-464. [DOI: 10.1016/j.cjca.2022.01.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/15/2022] [Accepted: 01/17/2022] [Indexed: 12/24/2022] Open
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23
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Elsokkari I, Tsuji Y, Sapp JL, Nattel S. Recent insights into mechanisms and clinical approaches to electrical storm. Can J Cardiol 2021; 38:439-453. [PMID: 34979281 DOI: 10.1016/j.cjca.2021.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 12/21/2021] [Accepted: 12/30/2021] [Indexed: 12/14/2022] Open
Abstract
Electrical storm, characterized by repetitive ventricular tachycardia/fibrillation (VT/VF) over a short period, is becoming commoner with widespread use of implantable cardioverter-defibrillator (ICD) therapy. Electrical storm, sometimes called "arrhythmic storm" or "VT-storm", is usually a medical emergency requiring hospitalization and expert management, and significantly affects short- and long-term outcomes. This syndrome typically occurs in patients with underlying structural heart disease (ischemic or non-ischemic cardiomyopathy) or inherited channelopathies. Triggers for electrical storm should be sought but are often unidentifiable. Initial management is dictated by the hemodynamic status, while subsequent management typically involves ICD interrogation and reprogramming to reduce recurrent shocks, identification/management of triggers like electrolyte abnormalities, myocardial ischemia, or decompensated heart failure, and antiarrhythmic-drug therapy or catheter ablation. Sympathetic nervous system activation is central to the initiation and maintenance of arrhythmic storm, so autonomic modulation is a cornerstone of management. Sympathetic inhibition can be achieved with medications (particularly beta-adrenoreceptor blockers), deep sedation, or cardiac sympathetic denervation. More definitive management targets the underlying ventricular arrhythmia substrate to terminate and prevent recurrent arrhythmia. Arrhythmia targeting can be achieved with antiarrhythmic medications, catheter ablation or more novel therapies such as stereotactic radiation therapy that targets the arrhythmic substrate. Mechanistic studies point to adrenergic activation and other direct consequences of ICD-shocks in promoting further arrhythmogenesis and hypocontractility. Here, we review the pathophysiologic mechanisms, clinical features, prognosis, and therapeutic options for electrical storm. We also outline a clinical approach to this challenging and complex condition, along with its mechanistic basis.
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Affiliation(s)
- Ihab Elsokkari
- University of Sydney, Nepean Blue Mountains local health district, Australia
| | - Yukiomi Tsuji
- Department of Physiology of Visceral Function, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - John L Sapp
- Dalhousie University, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada.
| | - Stanley Nattel
- Departments of Medicine and Research Center, Montreal Heart Institute and Université de Montréal and Pharmacology and Therapeutics McGill University, Montreal, Quebec, Canada; Institute of Pharmacology, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany; IHU LIYRC Institute, Bordeaux, France.
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24
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Samuel M, Rivard L, Nault I, Gula L, Essebag V, Parkash R, Sterns LD, Khairy P, Sapp JL. Comparative effectiveness of ventricular tachycardia ablation vs. escalated antiarrhythmic drug therapy by location of myocardial infarction: a sub-study of the VANISH trial. Europace 2021; 24:948-958. [PMID: 34964475 PMCID: PMC9282915 DOI: 10.1093/europace/euab298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/16/2021] [Indexed: 12/31/2022] Open
Abstract
AIMS Complexity of the ventricular tachycardia (VT) substrate and the size and thickness of infarction area border zones differ based on location of myocardial infarctions (MIs). These differences may translate into heterogeneity in the effectiveness of treatments. This study aims to examine the influence of infarct location on the effectiveness of VT ablation in comparison with escalated pharmacological therapy in patients with prior MI and antiarrhythmic drug (AAD)-refractory VT. METHODS AND RESULTS VANISH trial participants were categorized based on the presence or absence of an inferior MI scar. Inverse probability of treatment weighted Cox models were calculated for each subgroup. Of 259 randomized patients (median age 69.8 years, 7.0% women), 135 had an inferior MI and 124 had a non-inferior MI. Among patients with an inferior MI, no statistically significant difference in the composite primary outcome of all-cause mortality, appropriate implantable cardioverter-defibrillator (ICD) shock, and VT storm was detected between treatment arms [adjusted hazard ratio (aHR) 0.80, 95% confidence interval (CI) 0.51-1.20]. In contrast, patients with non-inferior MIs had a statistically significant reduction in the incidence of the primary outcome with ablation (aHR 0.48, 95% CI 0.27-0.86). In a sensitivity analysis of anterior MI patients (n = 83), a trend towards a reduction in the primary outcome with ablation was detected (aHR 0.50, 95% CI 0.23-1.09). CONCLUSION The effectiveness of VT ablation versus escalated AADs varies based on the location of the MI. Patients with MI scars located only in non-inferior regions of the ventricles derive greater benefit from VT ablation in comparison to escalation of AADs in reducing VT-related events.
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Affiliation(s)
- Michelle Samuel
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Lena Rivard
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Isabelle Nault
- Department of Medicine, Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
| | - Lorne Gula
- Department of Medicine, Western University, London, Ontario, Canada
| | - Vidal Essebag
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Ratika Parkash
- Department of Medicine, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Room 2501B Halifax Infirmary, 1796 Summer St, Halifax, Nova Scotia B3H 3A7, Canada
| | - Laurence D Sterns
- Department of Medicine, Royal Jubilee Hospital, Victoria, British Columbia, Canada
| | - Paul Khairy
- Department of Medicine, Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - John L Sapp
- Corresponding author. Tel: +1 902 473 4272; fax: +1 902 473 3158. E-mail address:
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25
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Allan KS, O'Neil E, Currie MM, Lin S, Sapp JL, Dorian P. Responding to Cardiac Arrest in the Community in the Digital Age. Can J Cardiol 2021; 38:491-501. [PMID: 34954009 DOI: 10.1016/j.cjca.2021.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 12/14/2021] [Accepted: 12/14/2021] [Indexed: 01/25/2023] Open
Abstract
Sudden cardiac arrest (SCA) is a common event, affecting almost 400,000 individuals annually in North America. Initiation of cardiopulmonary resuscitation (CPR) and early defibrillation using an automated external defibrillator (AED) are critical for survival, yet many bystanders are reluctant to intervene. Digital technologies, including mobile devices, social media and crowdsourcing may help play a role to improve survival from SCA. In this article we review the current digital tools and strategies available to increase rates of bystander recognition of SCA, prompt immediate activation of Emergency Medical Services (EMS), initiate high quality CPR and to locate, retrieve and operate AEDs. Smartphones can help to both educate and connect bystanders with EMS dispatchers, through text messaging or video-calling, to encourage the initiation of CPR and retrieval of the closest AED. Wearable devices and household smartspeakers could play a future role in continuous vital signs monitoring in individuals at-risk of lethal arrhythmias and send an alert to either chosen contacts or EMS. Machine learning algorithms and mathematical modeling may aid EMS dispatchers with better recognition of SCA as well as policymakers with where to best place AEDs for optimal accessibility. There are challenges with the use of digital tech, including the need for government regulation and issues with data ownership, accessibility and interoperability. Future research will include smart cities, e-linkages, new technologies and using social media for mass education. Together or in combination, these emerging digital technologies may represent the next leap forward in SCA survival.
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Affiliation(s)
- Katherine S Allan
- Division of Cardiology, Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada.
| | - Emma O'Neil
- Department of Emergency Medicine, Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada
| | - Margaret M Currie
- Faculty of Science, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Steve Lin
- Department of Emergency Medicine, Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - John L Sapp
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Paul Dorian
- Division of Cardiology, Unity Health Toronto - St. Michael's Hospital, Toronto, Ontario, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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26
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Stevenson WG, Sapp JL. Newer Methods for VT Ablation and When to Use Them. Can J Cardiol 2021; 38:502-514. [PMID: 34942300 DOI: 10.1016/j.cjca.2021.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 12/03/2021] [Accepted: 12/11/2021] [Indexed: 02/07/2023] Open
Abstract
Radiofrequency (RF) catheter ablation has long been an important therapy for ventricular tachycardia and frequent symptomatic premature ventricular beats and nonsustained arrhythmias when antiarrhythmic drugs fail to suppress the arrhythmias. It is increasingly used in preference to antiarrhythmic drugs, sparing the patient drug adverse effects. Ablation success varies with the underlying heart disease and type of arrhythmia, being very effective for patients without structural heart disease, less in structural heart disease. Failure occurs when a target for ablation cannot be identified, or ablation lesions fail to reach and abolish the arrhythmia substrate that may be extensive, intramural or subepicardial in location. Approaches to improving ablation lesion creation are modifications to RF ablation and emerging investigational techniques. Easily implemented modifications to RF methods include manipulating the size and location of the cutaneous dispersive electrode, increasing RF delivery duration, and use of lower tonicity catheter irrigation (usually 0.45% saline). When catheters can be placed on either side of culprit substrate RF can be delivered in a bipolar or simultaneous unipolar configuration that can be successful. Catheters with extendable/retractable irrigated needles for RF delivery are under investigation in clinical trials. Cryoablation is potentially useful in specific situations when maintaining contact is difficult. Transvascular ethanol ablation and stereotactic radioablation have both shown promise for arrhythmias that fail other ablation strategies. Although substantial clinical progress has been achieved, further improvement is clearly needed. With ability to increase ablation lesion size, continued careful evaluation of safety, which has been excellent for standard RF ablation, remains important.
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Affiliation(s)
- William G Stevenson
- The Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; The Heart Rhythm Service, Department of Medicine, Division of Cardiology, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada.
| | - John L Sapp
- The Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee; The Heart Rhythm Service, Department of Medicine, Division of Cardiology, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
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27
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Connolly MS, Goldstein, PCP JP, Currie M, Carter AJ, Doucette SP, Giddens K, Allan KS, Travers AH, Ahrens B, Rainham D, Sapp JL. Urban-Rural differences in Cardiac Arrest outcomes: a retrospective population-based cohort study. CJC Open 2021; 4:383-389. [PMID: 35495857 PMCID: PMC9039571 DOI: 10.1016/j.cjco.2021.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/27/2021] [Indexed: 11/29/2022] Open
Abstract
Background Approximately 10% of people who suffer an out-of-hospital cardiac arrest (OHCA) treated by paramedics survive to hospital discharge. Survival differs by up to 19.2% between urban centres and rural areas. Our goal was to investigate the differences in OHCA survival between urban centres and rural areas. Methods This was a retrospective cohort study of OHCA patients treated by Nova Scotia Emergency Medical Services (EMS) in 2017. Cases of traumatic, expected, and noncardiac OHCA were excluded. Data were collected from the Emergency Health Service electronic patient care record system and the discharge abstract database. Geographic information system analysis classified cases as being in urban centres (population > 1000 people) or rural areas, using 2016 Canadian Census boundaries. The primary outcome was survival to hospital discharge. Multivariable logistic regression covariates were age, sex, bystander resuscitation, whether the arrest was witnessed, public location, and preceding symptoms. Results A total of 510 OHCAs treated by Nova Scotia Emergency Medical Services were included for analysis. A total of 12% (n = 62) survived to discharge. Patients with OHCAs in urban centres were 107% more likely to survive than those with OHCAs in rural areas (adjusted odds ratio = 2.1; 95% confidence interval = 1.1 to 3.8; P = 0.028). OHCAs in urban centres had a significantly shorter mean time to defibrillation of shockable rhythm (11.2 minutes ± 6.2) vs those in rural areas (17.5 minutes ± 17.3). Conclusions Nova Scotia has an urban vs rural disparity in OHCA care that is also seen in densely populated OHCA centres. Survival is improved in urban centres. Further improvements in overall survival, especially in rural areas, may arise from community engagement in OHCA recognition and optimized healthcare delivery.
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Affiliation(s)
| | - Judah P. Goldstein, PCP
- Department of Emergency Medicine, Division of EMS, Dalhousie University, Halifax, Nova Scotia, Canada
- EHS Nova Scotia, Halifax, Nova Scotia, Canada
- Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Margaret Currie
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Alix J.E. Carter
- Department of Emergency Medicine, Division of EMS, Dalhousie University, Halifax, Nova Scotia, Canada
- EHS Nova Scotia, Halifax, Nova Scotia, Canada
- Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Steve P. Doucette
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Karen Giddens
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Katherine S. Allan
- Division of Cardiology, St. Michael's Hospital, Halifax, Nova Scotia, Canada
| | - Andrew H. Travers
- Department of Emergency Medicine, Division of EMS, Dalhousie University, Halifax, Nova Scotia, Canada
- EHS Nova Scotia, Halifax, Nova Scotia, Canada
- Nova Scotia Health, Halifax, Nova Scotia, Canada
| | - Beau Ahrens
- Interdisciplinary PhD Program, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Daniel Rainham
- School of Health and Human Performance, Dalhousie University, Halifax, Nova Scotia, Canada
| | - John L. Sapp
- Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
- Nova Scotia Health, Halifax, Nova Scotia, Canada
- Corresponding author: Dr John L. Sapp, 1796 Summer St, Suite 2501B, Halifax Infirmary, QEII Health Sciences Centre, Halifax, Nova Scotia B3H 3A7, Canada. Tel.: +1-902-473-4272.
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Zaman MS, Dhamala J, Bajracharya P, Sapp JL, Horácek BM, Wu KC, Trayanova NA, Wang L. Fast Posterior Estimation of Cardiac Electrophysiological Model Parameters via Bayesian Active Learning. Front Physiol 2021; 12:740306. [PMID: 34759835 PMCID: PMC8573318 DOI: 10.3389/fphys.2021.740306] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/24/2021] [Indexed: 11/13/2022] Open
Abstract
Probabilistic estimation of cardiac electrophysiological model parameters serves an important step toward model personalization and uncertain quantification. The expensive computation associated with these model simulations, however, makes direct Markov Chain Monte Carlo (MCMC) sampling of the posterior probability density function (pdf) of model parameters computationally intensive. Approximated posterior pdfs resulting from replacing the simulation model with a computationally efficient surrogate, on the other hand, have seen limited accuracy. In this study, we present a Bayesian active learning method to directly approximate the posterior pdf function of cardiac model parameters, in which we intelligently select training points to query the simulation model in order to learn the posterior pdf using a small number of samples. We integrate a generative model into Bayesian active learning to allow approximating posterior pdf of high-dimensional model parameters at the resolution of the cardiac mesh. We further introduce new acquisition functions to focus the selection of training points on better approximating the shape rather than the modes of the posterior pdf of interest. We evaluated the presented method in estimating tissue excitability in a 3D cardiac electrophysiological model in a range of synthetic and real-data experiments. We demonstrated its improved accuracy in approximating the posterior pdf compared to Bayesian active learning using regular acquisition functions, and substantially reduced computational cost in comparison to existing standard or accelerated MCMC sampling.
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Affiliation(s)
- Md Shakil Zaman
- Rochester Institute of Technology, Rochester, NY, United States
| | - Jwala Dhamala
- Rochester Institute of Technology, Rochester, NY, United States
| | | | - John L Sapp
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - B Milan Horácek
- Department of Electrical and Computer Engineering, Halifax, NS, Canada
| | - Katherine C Wu
- Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Natalia A Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, United States
| | - Linwei Wang
- Rochester Institute of Technology, Rochester, NY, United States
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Zhou S, AbdelWahab A, Sapp JL, Sung E, Aronis KN, Warren JW, MacInnis PJ, Shah R, Horáček BM, Berger R, Tandri H, Trayanova NA, Chrispin J. Assessment of an ECG-Based System for Localizing Ventricular Arrhythmias in Patients With Structural Heart Disease. J Am Heart Assoc 2021; 10:e022217. [PMID: 34612085 PMCID: PMC8751877 DOI: 10.1161/jaha.121.022217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background We have previously developed an intraprocedural automatic arrhythmia‐origin localization (AAOL) system to identify idiopathic ventricular arrhythmia origins in real time using a 3‐lead ECG. The objective was to assess the localization accuracy of ventricular tachycardia (VT) exit and premature ventricular contraction (PVC) origin sites in patients with structural heart disease using the AAOL system. Methods and Results In retrospective and prospective case series studies, a total of 42 patients who underwent VT/PVC ablation in the setting of structural heart disease were recruited at 2 different centers. The AAOL system combines 120‐ms QRS integrals of 3 leads (III, V2, V6) with pace mapping to predict VT exit/PVC origin site and projects that site onto the patient‐specific electroanatomic mapping surface. VT exit/PVC origin sites were clinically identified by activation mapping and/or pace mapping. The localization error of the VT exit/PVC origin site was assessed by the distance between the clinically identified site and the estimated site. In the retrospective study of 19 patients with structural heart disease, the AAOL system achieved a mean localization accuracy of 6.5±2.6 mm for 25 induced VTs. In the prospective study with 23 patients, mean localization accuracy was 5.9±2.6 mm for 26 VT exit and PVC origin sites. There was no difference in mean localization error in epicardial sites compared with endocardial sites using the AAOL system (6.0 versus 5.8 mm, P=0.895). Conclusions The AAOL system achieved accurate localization of VT exit/PVC origin sites in patients with structural heart disease; its performance is superior to current systems, and thus, it promises to have potential clinical utility.
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Affiliation(s)
- Shijie Zhou
- Alliance for Cardiovascular Diagnostic and Treatment Innovation Johns Hopkins University Baltimore MD
| | - Amir AbdelWahab
- Department of Medicine Queen Elizabeth II Health Sciences Centre Halifax NS Canada
| | - John L Sapp
- Department of Medicine Queen Elizabeth II Health Sciences Centre Halifax NS Canada.,Department of Physiology and Biophysics Dalhousie University Halifax NS Canada
| | - Eric Sung
- Alliance for Cardiovascular Diagnostic and Treatment Innovation Johns Hopkins University Baltimore MD.,Department of Biomedical Engineering Johns Hopkins University Baltimore MD
| | - Konstantinos N Aronis
- Division of Cardiology Department of Medicine Section of Cardiac Electrophysiology Johns Hopkins Hospital Baltimore MD.,Department of Biomedical Engineering Johns Hopkins University Baltimore MD
| | - James W Warren
- Department of Physiology and Biophysics Dalhousie University Halifax NS Canada
| | - Paul J MacInnis
- Department of Physiology and Biophysics Dalhousie University Halifax NS Canada
| | - Rushil Shah
- Division of Cardiology Department of Medicine Section of Cardiac Electrophysiology Johns Hopkins Hospital Baltimore MD
| | - B Milan Horáček
- School of Biomedical Engineering Dalhousie University Halifax NS Canada
| | - Ronald Berger
- Alliance for Cardiovascular Diagnostic and Treatment Innovation Johns Hopkins University Baltimore MD.,Division of Cardiology Department of Medicine Section of Cardiac Electrophysiology Johns Hopkins Hospital Baltimore MD
| | - Harikrishna Tandri
- Alliance for Cardiovascular Diagnostic and Treatment Innovation Johns Hopkins University Baltimore MD.,Division of Cardiology Department of Medicine Section of Cardiac Electrophysiology Johns Hopkins Hospital Baltimore MD
| | - Natalia A Trayanova
- Alliance for Cardiovascular Diagnostic and Treatment Innovation Johns Hopkins University Baltimore MD.,Department of Biomedical Engineering Johns Hopkins University Baltimore MD
| | - Jonathan Chrispin
- Alliance for Cardiovascular Diagnostic and Treatment Innovation Johns Hopkins University Baltimore MD.,Division of Cardiology Department of Medicine Section of Cardiac Electrophysiology Johns Hopkins Hospital Baltimore MD
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Gharbia OA, Adityo Prakosa MT, Trayanova NA, Sapp JL, Wang L. B-PO03-122 DELINEATION OF 3D REENTRANT CIRCUITS USING EPICARDIAL-ENDOCARDIAL ELECTROCARDIOGRAPHIC IMAGING. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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31
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Zhou S, Sapp JL, Milan Horacek B, Warren J, MacInnis P, Davis JS, Lee D, Parkash R, Gray C, Gardner MJ, MacIntyre C, Trayanova NA, AbdelWahab AM. B-PO02-125 PROSPECTIVE ASSESSMENT OF A REAL-TIME INTRAPROCEDURAL RAPID-VT SYSTEM FOR LOCALIZING VT EXIT SITES ONTO PATIENT-SPECIFIC GEOMETRY. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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32
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Roberts H, MacIntyre C, Sapp JL, Gardner MJ, Gray C, AbdelWahab AM, Thompson K, Parkash R. B-PO05-057 ELECTRICAL LEAD ANOMALIES IN A POPULATION-BASED COHORT FROM 2012-2019. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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33
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Zhou S, AbdelWahab AM, Sapp JL, Sung E, Aronis KN, Nilesh Shah R, Warren J, MacInnis P, Berger RD, Tandri H, Milan Horacek B, Trayanova NA, Chrispin J. B-PO01-090 PROSPECTIVE ASSESSMENT OF AN AUTOMATED INTRAPROCEDURAL ECG-BASED SYSTEM FOR LOCALIZING VT EXIT SITES IN PATIENTS WITH STRUCTURAL HEART DISEASE (SHD). Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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34
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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: executive summary. Europace 2021; 22:450-495. [PMID: 31995197 DOI: 10.1093/europace/euz332] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] 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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35
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Samuel M, Rivard L, Nault I, Gula L, Essebag V, Parkash R, Sterns LD, Khairy P, Sapp JL. Comparative effectiveness of ventricular tachycardia ablation versus escalated antiarrhythmic drug therapy by location of myocardial infarction: A sub-study of the VANISH trial. Europace 2021. [DOI: 10.1093/europace/euab116.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Public Institution(s). Main funding source(s): Fonds de recherché du Québec-Santé (FRQS) [post doctoral award for Dr. Samuel)
BACKGROUND
Complexity of ventricular tachycardia (VT) substrate, efficiency of lesion formation, and the size and thickness of infarction area border zones differ based on location of myocardial infarctions (MI). These differences may translate into heterogeneity in risk of events and effectiveness of treatments for VT. Small observational studies suggest that VT from inferior infarctions have higher risk of early recurrence despite smaller infarct areas. However, differential effectiveness of VT treatments based on location of MI not been definitively established.
PURPOSE
The objective of this sub-study of the Ventricular tachycardia AblatioN versus escalated antiarrhythmic drug therapy in ISchemic Heart disease (VANISH) randomized trial was to compare the effectiveness of VT ablation by location of MI in reducing the composite endpoint of all-cause mortality, VT storm, or appropriate ICD therapy when compared to escalated pharmacological therapy in VT patients with a prior MI.
METHODS
VANISH participants were categorized into 3 subgroups based on MI location: 1. Inferior (may also have MI in other locations); 2. Non-inferior (no inferior MI, all patients not in group 1); and 3. Anterior (may also have MI in other locations). Inverse probability of treatment weighting was used to balance baseline characteristics (ie. age, sex, comorbidities, medications, and the location of additional infarctions) between patients randomized to ablation or escalated therapy within each subgroup. Weighted Cox proportional hazards models were calculated separately for each subgroup.
RESULTS
Of 259 patients enrolled in the VANISH trial [median age 69.8 (IQR 63.0-74.2) years, 7.0% women], 135 had an inferior MI, 124 a non-inferior MI, and 83 an anterior MI. Among patients with an inferior MI, no statistically significant difference in the primary outcome was detected between patients randomized to ablation or escalated therapy [aHR 0.78 (95% CI 0.51-1.20)]. In contrast, patients with non-inferior MIs had a statistically significant reduction in the incidence of the primary outcome with ablation [aHR 0.48 (95% CI 0.27-0.86)]; which was of greater magnitude than the reduction observed in the overall results of the VANISH trial [HR 0.72 (95% CI 0.53-0.98)]. In addition, a trend towards a reduction in the primary outcome with ablation was detected in patients with anterior MIs [aHR 0.50 (95% CI 0.23-1.09)].
CONCLUSION
The effectiveness of VT ablation versus escalated pharmacological therapy varies based on the location of the MI. Patients with MI scars located only in non-inferior regions of the ventricles derive greater benefit from VT ablation in reducing VT-related events. Further studies are required to explore reasons for this finding and to assess the impact of VT treatment strategies based on MI location in optimizing outcomes.
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Affiliation(s)
- M Samuel
- Montreal Heart Institute, University of Montreal, Montreal, Canada
| | - L Rivard
- Montreal Heart Institute, University of Montreal, Montreal, Canada
| | - I Nault
- Quebec Heart and Lung Institute, Quebec, Canada
| | - L Gula
- Western University, London, Canada
| | - V Essebag
- McGill University Health Centre, Cardiology, Montreal, Canada
| | - R Parkash
- QE II Health Sciences Center, Halifax, Canada
| | - LD Sterns
- Royal Jubilee Hospital, Victoria, Canada
| | - P Khairy
- Montreal Heart Institute, University of Montreal, Montreal, Canada
| | - JL Sapp
- QE II Health Sciences Center, Halifax, Canada
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Zhou S, Sung E, Prakosa A, Aronis KN, Chrispin J, Tandri H, AbdelWahab A, Horáček BM, Sapp JL, Trayanova NA. Feasibility study shows concordance between image-based virtual-heart ablation targets and predicted ECG-based arrhythmia exit-sites. Pacing Clin Electrophysiol 2021; 44:432-441. [PMID: 33527422 DOI: 10.1111/pace.14181] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/05/2021] [Accepted: 01/24/2021] [Indexed: 12/20/2022]
Abstract
INTRODUCTION We recently developed two noninvasive methodologies to help guide VT ablation: population-derived automated VT exit localization (PAVEL) and virtual-heart arrhythmia ablation targeting (VAAT). We hypothesized that while very different in their nature, limitations, and type of ablation targets (substrate-based vs. clinical VT), the image-based VAAT and the ECG-based PAVEL technologies would be spatially concordant in their predictions. OBJECTIVE The objective is to test this hypothesis in ischemic cardiomyopathy patients in a retrospective feasibility study. METHODS Four post-infarct patients who underwent LV VT ablation and had pre-procedural LGE-CMRs were enrolled. Virtual hearts with patient-specific scar and border zone identified potential VTs and ablation targets. Patient-specific PAVEL based on a population-derived statistical method localized VT exit sites onto a patient-specific 238-triangle LV endocardial surface. RESULTS Ten induced VTs were analyzed and 9-exit sites were localized by PAVEL onto the patient-specific LV endocardial surface. All nine predicted VT exit sites were in the scar border zone defined by voltage mapping and spatially correlated with successful clinical lesions. There were 2.3 ± 1.9 VTs per patient in the models. All five VAAT lesions fell within regions ablated clinically. VAAT targets correlated well with 6 PAVEL-predicted VT exit sites. The distance between the center of the predicted VT-exit-site triangle and nearest corresponding VAAT ablation lesion was 10.7 ± 7.3 mm. CONCLUSIONS VAAT targets are concordant with the patient-specific PAVEL-predicted VT exit sites. These findings support investigation into combining these two complementary technologies as a noninvasive, clinical tool for targeting clinically induced VTs and regions likely to harbor potential VTs.
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Affiliation(s)
- Shijie Zhou
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland, USA
| | - Eric Sung
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland, USA
| | - Adityo Prakosa
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland, USA
| | - Konstantinos N Aronis
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland, USA
| | - Jonathan Chrispin
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland, USA
| | - Harikrishna Tandri
- Section of Cardiac Electrophysiology, Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland, USA
| | - Amir AbdelWahab
- Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - B Milan Horáček
- School of Biomedical Engineering, Dalhousie University, Halifax, Nova Scotia, Canada
| | - John L Sapp
- Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Natalia A Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, Maryland, USA
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Weng W, Blanchard C, Reed JL, Matheson K, McIntyre C, Gray C, Sapp JL, Gardner M, AbdelWahab A, Yung J, Parkash R. A virtual platform to deliver ambulatory care for patients with atrial fibrillation. Cardiovascular Digital Health Journal 2021; 2:63-70. [PMID: 35265891 PMCID: PMC8890105 DOI: 10.1016/j.cvdhj.2020.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Background There are little data on the use of virtual care for patients with arrhythmia. We evaluated a virtual clinic platform, in conjunction with specialist care, for patients with symptomatic atrial fibrillation (AF). Methods This was a prospective, observational cohort study evaluating an online educational and treatment platform, with a randomized sub-study examining the use of an ambulatory single-lead electrocardiogram heart monitor (AHM). Follow-up was 6 months. The main outcome was patients’ platform use; success was defined as 90% of patients using the platform at least once, and 75% using it at least twice. The primary outcome in the AHM sub-study was Atrial Fibrillation Symptom Severity (AFSS) score. Other outcomes included patient satisfaction questionnaires, quality of life, emergency department visits, and hospitalizations for AF. Results We enrolled 94 patients between July 2018 and May 2019; 83% of patients logged in at least once and 54.3% more than once. Patients who were older, were male, or had new-onset AF were more likely to log in to the platform. Satisfaction scores were high; 70%–94% of patients responded favorably. Quality-of-life scores improved at 3 and 6 months. In the AHM sub-study (n = 71), those who received an AHM had lower AFSS scores (least square mean difference -2.52, 95% CI -4.48 to -0.25, P = .03). There was no difference in emergency department visits or hospitalizations. Conclusion The online platform did not reach our feasibility target but was well received. Allocation of an AHM was associated with improved quality of life. Virtual AF care shows promise and should be evaluated in further research.
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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: 208] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Alkharaza A, Al-Harbi M, El-Sokkari I, Doucette S, MacIntyre C, Gray C, Abdelwahab A, Sapp JL, Gardner M, Parkash R. The effect of revascularization on mortality and risk of ventricular arrhythmia in patients with ischemic cardiomyopathy. BMC Cardiovasc Disord 2020; 20:455. [PMID: 33087069 PMCID: PMC7576697 DOI: 10.1186/s12872-020-01726-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/04/2020] [Indexed: 11/17/2022] Open
Abstract
Background There is clear evidence that patients with prior myocardial infarction and a reduced ejection fraction benefit from implantation of a cardioverter-defibrillator (ICD). It is unclear whether this benefit is altered by whether or not revascularization is performed prior to ICD implantation. Methods This was a retrospective cohort study following patients who underwent ICD implantation from 2002 to 2014. Patients with ischemic cardiomyopathy and either primary or secondary prevention ICDs were selected for inclusion. Using the electronic medical record, cardiac catheterization data, revascularization status (percutaneous coronary intervention or coronary bypass surgery) were recorded. The outcomes were mortality and ventricular arrhythmia. Results There were 606 patients included in the analysis. The mean age was 66.3 ± 10.1 years, 11.9% were women, and the mean LVEF was 30.5 ± 12.0, 58.9% had a primary indication for ICD, 82.0% of the cohort had undergone coronary catheterization prior to ICD implantation. In the overall cohort, there were fewer mortality and ventricular arrhythmia events in patients who had undergone prior revascularization. In patients who had an ICD for secondary prevention, revascularization was associated with a decrease in mortality (HR 0.46, 95% CI (0.24, 0.85) p = 0.015), and a trend towards fewer ventricular arrhythmia (HR 0.62, 95% CI (0.38, 1.00) p = 0.051). There was no association between death or ventricular arrhythmia with revascularization in patients with primary prevention ICDs. Conclusion Revascularization may be beneficial in preventing recurrent ventricular arrhythmia, and should be considered as adjunctive therapy to ICD implantation to improve cardiovascular outcomes.
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Affiliation(s)
- Ahmad Alkharaza
- Queen Elizabeth II Health Sciences Center, HI Site, 1796 Summer Street, Room 2501D, Halifax, Nova Scotia, Canada
| | - Mousa Al-Harbi
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Ihab El-Sokkari
- Queen Elizabeth II Health Sciences Center, HI Site, 1796 Summer Street, Room 2501D, Halifax, Nova Scotia, Canada
| | - Steve Doucette
- Research Methods Unit, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Ciorsti MacIntyre
- Queen Elizabeth II Health Sciences Center, HI Site, 1796 Summer Street, Room 2501D, Halifax, Nova Scotia, Canada
| | - Christopher Gray
- Queen Elizabeth II Health Sciences Center, HI Site, 1796 Summer Street, Room 2501D, Halifax, Nova Scotia, Canada
| | - Amir Abdelwahab
- Queen Elizabeth II Health Sciences Center, HI Site, 1796 Summer Street, Room 2501D, Halifax, Nova Scotia, Canada
| | - John L Sapp
- Queen Elizabeth II Health Sciences Center, HI Site, 1796 Summer Street, Room 2501D, Halifax, Nova Scotia, Canada
| | - Martin Gardner
- Queen Elizabeth II Health Sciences Center, HI Site, 1796 Summer Street, Room 2501D, Halifax, Nova Scotia, Canada
| | - Ratika Parkash
- Queen Elizabeth II Health Sciences Center, HI Site, 1796 Summer Street, Room 2501D, Halifax, Nova Scotia, Canada.
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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: Executive summary. J Interv Card Electrophysiol 2020; 59:81-133. [PMID: 31960344 PMCID: PMC7508755 DOI: 10.1007/s10840-019-00664-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Qian PC, Oberfeld B, Schaeffer B, Nakamura T, John RM, Sapp JL, Stevenson WG, Tedrow UB. Frequency Content of Unipolar Electrograms May Predict Deep Intramural Excitable Substrate. JACC Clin Electrophysiol 2020; 6:760-769. [DOI: 10.1016/j.jacep.2020.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/04/2020] [Accepted: 03/10/2020] [Indexed: 11/29/2022]
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Zhou S, AbdelWahab A, Horáček BM, MacInnis PJ, Warren JW, Davis JS, Elsokkari I, Lee DC, MacIntyre CJ, Parkash R, Gray CJ, Gardner MJ, Marcoux C, Choudhury R, Trayanova NA, Sapp JL. Prospective Assessment of an Automated Intraprocedural 12-Lead ECG-Based System for Localization of Early Left Ventricular Activation. Circ Arrhythm Electrophysiol 2020; 13:e008262. [PMID: 32538133 DOI: 10.1161/circep.119.008262] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND To facilitate ablation of ventricular tachycardia (VT), an automated localization system to identify the site of origin of left ventricular activation in real time using the 12-lead ECG was developed. The objective of this study was to prospectively assess its accuracy. METHODS The automated site of origin localization system consists of 3 steps: (1) localization of ventricular segment based on population templates, (2) population-based localization within a segment, and (3) patient-specific site localization. Localization error was assessed by the distance between the known reference site and the estimated site. RESULTS In 19 patients undergoing 21 catheter ablation procedures of scar-related VT, site of origin localization accuracy was estimated using 552 left ventricular endocardial pacing sites pooled together and 25 VT-exit sites identified by contact mapping. For the 25 VT-exit sites, localization error of the population-based localization steps was within 10 mm. Patient-specific site localization achieved accuracy of within 3.5 mm after including up to 11 pacing (training) sites. Using 3 remotes (67.8±17.0 mm from the reference VT-exit site), and then 5 close pacing sites, resulted in localization error of 7.2±4.1 mm for the 25 identified VT-exit sites. In 2 emulated clinical procedure with 2 induced VTs, the site of origin localization system achieved accuracy within 4 mm. CONCLUSIONS In this prospective validation study, the automated localization system achieved estimated accuracy within 10 mm and could thus provide clinical utility.
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Affiliation(s)
- Shijie Zhou
- Department of Biomedical Engineering (S.Z., N.A.T.), Johns Hopkins University, Baltimore, MD.,Alliance for Cardiovascular Diagnostic and Treatment Innovation (S.Z., N.A.T.), Johns Hopkins University, Baltimore, MD.,Heart Rhythm Service, Cardiology Division, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (S.Z., A.A., J.S.D., I.E., D.C.L., C.J.M., R.P., C.J.G., M.J.G., C.M., R.C., J.L.S.)
| | - Amir AbdelWahab
- Heart Rhythm Service, Cardiology Division, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (S.Z., A.A., J.S.D., I.E., D.C.L., C.J.M., R.P., C.J.G., M.J.G., C.M., R.C., J.L.S.)
| | - B Milan Horáček
- School of Biomedical Engineering (B.M.H.), Dalhousie University, Halifax, NS, Canada
| | - Paul J MacInnis
- Departments of Physiology and Biophysics (P.J.M., J.W.W., J.L.S.), Dalhousie University, Halifax, NS, Canada
| | - James W Warren
- Departments of Physiology and Biophysics (P.J.M., J.W.W., J.L.S.), Dalhousie University, Halifax, NS, Canada
| | - Jason S Davis
- Heart Rhythm Service, Cardiology Division, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (S.Z., A.A., J.S.D., I.E., D.C.L., C.J.M., R.P., C.J.G., M.J.G., C.M., R.C., J.L.S.)
| | - Ihab Elsokkari
- Heart Rhythm Service, Cardiology Division, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (S.Z., A.A., J.S.D., I.E., D.C.L., C.J.M., R.P., C.J.G., M.J.G., C.M., R.C., J.L.S.)
| | - David C Lee
- Heart Rhythm Service, Cardiology Division, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (S.Z., A.A., J.S.D., I.E., D.C.L., C.J.M., R.P., C.J.G., M.J.G., C.M., R.C., J.L.S.)
| | - Ciorsti J MacIntyre
- Heart Rhythm Service, Cardiology Division, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (S.Z., A.A., J.S.D., I.E., D.C.L., C.J.M., R.P., C.J.G., M.J.G., C.M., R.C., J.L.S.)
| | - Ratika Parkash
- Heart Rhythm Service, Cardiology Division, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (S.Z., A.A., J.S.D., I.E., D.C.L., C.J.M., R.P., C.J.G., M.J.G., C.M., R.C., J.L.S.)
| | - Chris J Gray
- Heart Rhythm Service, Cardiology Division, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (S.Z., A.A., J.S.D., I.E., D.C.L., C.J.M., R.P., C.J.G., M.J.G., C.M., R.C., J.L.S.)
| | - Martin J Gardner
- Heart Rhythm Service, Cardiology Division, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (S.Z., A.A., J.S.D., I.E., D.C.L., C.J.M., R.P., C.J.G., M.J.G., C.M., R.C., J.L.S.)
| | - Curtis Marcoux
- Heart Rhythm Service, Cardiology Division, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (S.Z., A.A., J.S.D., I.E., D.C.L., C.J.M., R.P., C.J.G., M.J.G., C.M., R.C., J.L.S.)
| | - Rajin Choudhury
- Heart Rhythm Service, Cardiology Division, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (S.Z., A.A., J.S.D., I.E., D.C.L., C.J.M., R.P., C.J.G., M.J.G., C.M., R.C., J.L.S.)
| | - Natalia A Trayanova
- Department of Biomedical Engineering (S.Z., N.A.T.), Johns Hopkins University, Baltimore, MD.,Alliance for Cardiovascular Diagnostic and Treatment Innovation (S.Z., N.A.T.), Johns Hopkins University, Baltimore, MD
| | - John L Sapp
- Heart Rhythm Service, Cardiology Division, Department of Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada (S.Z., A.A., J.S.D., I.E., D.C.L., C.J.M., R.P., C.J.G., M.J.G., C.M., R.C., J.L.S.).,Departments of Physiology and Biophysics (P.J.M., J.W.W., J.L.S.), Dalhousie University, Halifax, NS, Canada.,Medicine (J.L.S.), Dalhousie University, Halifax, NS, Canada
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Deyell MW, AbdelWahab A, Angaran P, Essebag V, Glover B, Gula LJ, Khoo C, Lane C, Nault I, Nery PB, Rivard L, Slawnych MP, Tulloch HL, Sapp JL. 2020 Canadian Cardiovascular Society/Canadian Heart Rhythm Society Position Statement on the Management of Ventricular Tachycardia and Fibrillation in Patients With Structural Heart Disease. Can J Cardiol 2020; 36:822-836. [DOI: 10.1016/j.cjca.2020.04.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/29/2020] [Accepted: 04/05/2020] [Indexed: 10/24/2022] Open
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Sapp JL, Alqarawi W, MacIntyre CJ, Tadros R, Steinberg C, Roberts JD, Laksman Z, Healey JS, Krahn AD. Guidance on Minimizing Risk of Drug-Induced Ventricular Arrhythmia During Treatment of COVID-19: A Statement from the Canadian Heart Rhythm Society. Can J Cardiol 2020; 36:948-951. [PMID: 32299753 PMCID: PMC7195336 DOI: 10.1016/j.cjca.2020.04.003] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/02/2020] [Indexed: 12/27/2022] Open
Abstract
The COVID-19 pandemic has led to efforts at rapid investigation and application of drugs which may improve prognosis but for which safety and efficacy are not yet established. This document attempts to provide reasonable guidance for the use of antimicrobials which have uncertain benefit but may increase risk of QT interval prolongation and ventricular proarrhythmia, notably, chloroquine, hydroxychloroquine, azithromycin, and lopinavir/ritonavir. During the pandemic, efforts to reduce spread and minimize effects on health care resources mandate minimization of unnecessary medical procedures and testing. We recommend that the risk of drug proarrhythmia be minimized by 1) discontinuing unnecessary medications that may also increase the QT interval, 2) identifying outpatients who are likely to be at low risk and do not need further testing (no history of prolonged QT interval, unexplained syncope, or family history of premature sudden cardiac death, no medications that may prolong the QT interval, and/or a previous known normal corrected QT interval [QTc]), and 3) performing baseline testing in hospitalized patients or those who may be at higher risk. If baseline electrocardiographic testing reveals a moderately prolonged QTc, optimization of medications and electrolytes may permit therapy. If the QTc is markedly prolonged, drugs that further prolong it should be avoided, or expert consultation may permit administration with mitigating precautions. These recommendations are made while there are no known effective treatments for COVID-19 and should be revisited when further data on efficacy and safety become available.
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Affiliation(s)
- John L Sapp
- Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada.
| | - Wael Alqarawi
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Ciorsti J MacIntyre
- Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Rafik Tadros
- Cardiovascular Genetics Centre, Montréal Heart Institute, Montréal, Québec, Canada
| | - Christian Steinberg
- Institut Universitaire de Cardiologie et Pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | | | - Zachary Laksman
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Andrew D Krahn
- University of British Columbia, Vancouver, British Columbia, Canada
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Beca B, Sapp JL, Gardner MJ, Gray C, AbdelWahab A, MacIntyre C, Doucette S, Parkash R. Mortality and Heart Failure After Upgrade to Cardiac Resynchronization Therapy. CJC Open 2020; 1:93-99. [PMID: 32159089 PMCID: PMC7063653 DOI: 10.1016/j.cjco.2019.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 02/13/2019] [Indexed: 11/03/2022] Open
Abstract
Background Cardiac resynchronization therapy (CRT) is effective in treating advanced heart failure (HF), but data describing benefits and long-term outcomes for upgrades from a preexisting device are limited. This study sought to compare long-term outcomes in de novo CRT implants with those eligible for CRT with a prior device. Methods This is a retrospective cohort study using data from a provincial registry (2002-2015). Patients were included if they had mild-moderate HF, left ventricular ejection fraction ≤ 35%, and QRS duration ≥ 130 ms. Patients were classified as de novo CRT or upgraded to CRT from a prior device. Outcomes were mortality and composite mortality and HF hospitalization. Results There were 342 patients included in the study. In a multivariate model, patients in the upgraded cohort (n = 233) had a higher 5-year mortality rate (adjusted hazard ratio, 2.86; 95% confidence interval, 1.59-5.15; P = 0.0005) compared with the de novo cohort (n = 109) and higher composite mortality and HF hospitalization (adjusted hazard ratio, 2.60; 95% confidence interval, 1.54-4.37; P = 0.0003). Conclusions Implantation of de novo CRTs was associated with lower mortality and HF hospitalization compared with upgraded CRTs from preexisting devices. It is unknown whether these differences are due to the timing of CRT implementation or other clinical factors. Further work in this area may be helpful to determine how to improve outcomes for these patients.
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Affiliation(s)
- Bogdan Beca
- Division of Medical Education, Dalhousie University, Halifax, Nova Scotia, Canada
| | - John L Sapp
- Division of Cardiology, Department of Medicine, Queen Elizabeth II Health Centre, Halifax, Nova Scotia, Canada
| | - Martin J Gardner
- Division of Cardiology, Department of Medicine, Queen Elizabeth II Health Centre, Halifax, Nova Scotia, Canada
| | - Christopher Gray
- Division of Cardiology, Department of Medicine, Queen Elizabeth II Health Centre, Halifax, Nova Scotia, Canada
| | - Amir AbdelWahab
- Division of Cardiology, Department of Medicine, Queen Elizabeth II Health Centre, Halifax, Nova Scotia, Canada
| | - Ciorsti MacIntyre
- Division of Cardiology, Department of Medicine, Queen Elizabeth II Health Centre, Halifax, Nova Scotia, Canada
| | - Steve Doucette
- Research Methods Unit, Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Ratika Parkash
- Division of Cardiology, Department of Medicine, Queen Elizabeth II Health Centre, Halifax, Nova Scotia, Canada
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47
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Dhamala J, Bajracharya P, Arevalo HJ, Sapp JL, Horácek BM, Wu KC, Trayanova NA, Wang L. Embedding high-dimensional Bayesian optimization via generative modeling: Parameter personalization of cardiac electrophysiological models. Med Image Anal 2020; 62:101670. [PMID: 32171168 DOI: 10.1016/j.media.2020.101670] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 12/16/2019] [Accepted: 02/24/2020] [Indexed: 11/28/2022]
Abstract
The estimation of patient-specific tissue properties in the form of model parameters is important for personalized physiological models. Because tissue properties are spatially varying across the underlying geometrical model, it presents a significant challenge of high-dimensional (HD) optimization at the presence of limited measurement data. A common solution to reduce the dimension of the parameter space is to explicitly partition the geometrical mesh. In this paper, we present a novel concept that uses a generative variational auto-encoder (VAE) to embed HD Bayesian optimization into a low-dimensional (LD) latent space that represents the generative code of HD parameters. We further utilize VAE-encoded knowledge about the generative code to guide the exploration of the search space. The presented method is applied to estimating tissue excitability in a cardiac electrophysiological model in a range of synthetic and real-data experiments, through which we demonstrate its improved accuracy and substantially reduced computational cost in comparison to existing methods that rely on geometry-based reduction of the HD parameter space.
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Affiliation(s)
- Jwala Dhamala
- Rochester Institute of Technology, Rochester, NY, USA. http://www.jwaladhamala.com
| | | | | | | | | | | | | | - Linwei Wang
- Rochester Institute of Technology, Rochester, NY, USA.
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Affiliation(s)
- John L Sapp
- Department of Medicine, Dalhousie University, and the QEII Health Sciences Centre, Halifax, NS, Canada (J.L.S.)
| | - Shijie Zhou
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Institute of Computational Medicine, Johns Hopkins University, Baltimore, MD (S.Z.)
| | - Linwei Wang
- College of Computing and Information Sciences, Rochester Institute of Technology, Rochester, NY (L.W.)
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49
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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: Executive summary. J Arrhythm 2020; 36:1-58. [PMID: 32071620 PMCID: PMC7011820 DOI: 10.1002/joa3.12264] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] 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 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 Brisbane Qld Australia
| | - G Neal Kay
- University of Alabama at Birmingham Birmingham AL USA
| | | | | | - John M Miller
- Krannert Institute of Cardiology Indiana University School of Medicine 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 NS Canada
| | - Andrea Sarkozy
- University Hospital Antwerp University of Antwerp Antwerp Belgium
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Ghimire S, Sapp JL, Horacek BM, Wang L. Noninvasive Reconstruction of Transmural Transmembrane Potential With Simultaneous Estimation of Prior Model Error. IEEE Trans Med Imaging 2019; 38:2582-2595. [PMID: 30908200 PMCID: PMC6913037 DOI: 10.1109/tmi.2019.2906600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
To reconstruct electrical activity in the heart from body-surface electrocardiograms (ECGs) is an ill-posed inverse problem. Electrophysiological models have been found effective in regularizing these inverse problems by incorporating a priori knowledge about how the electrical potential in the heart propagates over time. However, these models suffer from model errors arising from, for example, parameters associated with tissue properties and the earliest sites of excitation. We present a Bayesian approach to simultaneously estimate transmembrane potential (TMP) signals and prior model errors, exploiting sparsity of the error in the gradient domain in the form of a novel sparse prior based on variational lower bound of the generalized Gaussian distribution. In synthetic and real-data experiments, we demonstrate the improvement of accuracy in TMP reconstruction brought by simultaneous model error estimation. We further provide theoretical and empirical justifications for the change of performances in the presented method at the presence of different model errors.
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