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Cardiac Electrophysiology Clinics Dec 2019Despite advances in our understanding of the relevant anatomy and mapping and catheter ablation techniques of idiopathic outflow tract ventricular arrhythmias,... (Review)
Review
Despite advances in our understanding of the relevant anatomy and mapping and catheter ablation techniques of idiopathic outflow tract ventricular arrhythmias, challenging sites for catheter ablation remain the aortic cusps, pulmonary artery, and notably the left ventricular summit. A systematic approach should be used to direct mapping efforts efficiently between endocardial, coronary venous, and epicardial sites. Foci at the left ventricular summit, particularly intraseptal and at the inaccessible epicardial region, remain difficult to reach and when percutaneous techniques fail, surgical ablation remains an option but with risk of late coronary artery stenosis.
Topics: Aorta; Arrhythmias, Cardiac; Cardiac Imaging Techniques; Catheter Ablation; Electrocardiography; Electrophysiologic Techniques, Cardiac; Heart Ventricles; Humans; Pulmonary Artery
PubMed: 31706473
DOI: 10.1016/j.ccep.2019.08.012 -
Cardiac Electrophysiology Clinics Mar 2023Challenging anatomic and morphologic conditions of the left ventricular (LV) summit architecture and its surrounding sites may prevent sufficient heating of the targeted... (Review)
Review
Challenging anatomic and morphologic conditions of the left ventricular (LV) summit architecture and its surrounding sites may prevent sufficient heating of the targeted area during standard radiofrequency catheter ablation. Bipolar ablation can result in higher likelihood of efficacy for ablation of LV summit arrhythmias from inaccessible regions and increase the chance of achieving a transmural lesion. In this review, the authors describe the present approaches for bipolar ablation of the LV summit arrhythmias refractory to standard approaches.
Topics: Humans; Tachycardia, Ventricular; Electrocardiography; Treatment Outcome; Heart Ventricles; Arrhythmias, Cardiac; Catheter Ablation
PubMed: 36774137
DOI: 10.1016/j.ccep.2022.07.001 -
Europace : European Pacing,... Dec 2023The electrocardiographic and electrophysiological characteristics of ventricular arrhythmia (VA) arising from the intramural basal inferior septum (BIS) have not been...
AIMS
The electrocardiographic and electrophysiological characteristics of ventricular arrhythmia (VA) arising from the intramural basal inferior septum (BIS) have not been specifically addressed to date. The aim of the current study was to characterize intramural BIS-VA and distinguish it from those with endocardial origins besides clarifying the anatomical configurations of the pyramidal space.
METHODS AND RESULTS
Fifty-five consecutive patients undergoing catheter ablation of VAs from BIS were identified and divided into three groups: the left ventricular (LV)-BIS group (n = 28), right ventricular (RV)-BIS group (n = 8), and intramural group (Intra, n = 19). Compared with the LV-BIS and RV-BIS groups, patients in the Intra group presented with no adequate earliest activation time at the two-sided BIS and epicardial coronary system [right: 7.79 ± 2.38 vs. left: 7.16 ± 2.59 vs. the middle cardiac vein (MCV): 6.26 ± 1.73 ms, P = 0.173] and poor-matched pacing-produced QRS at each site. Under the intracardiac echocardiography view, the pyramidal base was the broadest part of the septum and served as the division of the two-sided BIS. Focal ablation yielded promising acute-term and long-term procedural success in the LV-BIS and RV-BIS groups. But for the Intra group, VAs disappeared only after stepwise ablation successively targeted early preferential exit. After follow-up, three patients in the Intra group had recurrent VA, and all of them were treated well by a redo procedure or drug therapy.
CONCLUSION
Intramural VAs were relatively common in the BIS region in our series. Intra-procedural mapping was important to distinguish the intramural VAs from other VAs by comparing the local activation time and pacing mapping. Procedural success could be achieved by stepwise ablation on the counterpart sides of the BIS and within the MCV.
Topics: Humans; Treatment Outcome; Arrhythmias, Cardiac; Heart Ventricles; Electrocardiography; Ventricular Septum; Catheter Ablation; Tachycardia, Ventricular
PubMed: 38180948
DOI: 10.1093/europace/euae001 -
Cardiac Electrophysiology Clinics Mar 2023Prolonged use of fluoroscopy during catheter ablation (CA) of arrhythmias is associated with a significant exposure to ionizing radiation and risk of orthopedic injuries... (Review)
Review
Prolonged use of fluoroscopy during catheter ablation (CA) of arrhythmias is associated with a significant exposure to ionizing radiation and risk of orthopedic injuries given the need for heavy protective equipment. CA of ventricular arrhythmias (VAs) arising from the left ventricular (LV) summit is challenging, requiring a vast knowledge of the intricate cardiac anatomy of this area and careful imaging delineation of the different anatomical structures, which is frequently performed using fluoroscopic guidance. Certain techniques, including pericardial mapping and ablation, use of intracoronary wires, and mapping and ablation inside the coronary venous system have been proposed, further prolonging fluoroscopy time. Fluoroless CA procedures are feasible with currently available technology and appear to have similar safety and efficacy outcomes compared with conventional techniques. To successfully perform fluoroless CA of LV summit arrhythmias, it is important to be fully acquainted with intracardiac echocardiography (ICE) imaging and electroanatomic mapping (EAM). We will describe our approach to perform fluoroless CA in LV summit VAs.
Topics: Humans; Treatment Outcome; Arrhythmias, Cardiac; Heart Ventricles; Heart; Catheter Ablation
PubMed: 36774139
DOI: 10.1016/j.ccep.2022.10.002 -
Journal of Cardiovascular... Dec 2021While ventricular tachycardia (VT) in the setting of postmyocardial infarction left ventricular aneurysms (LVA) is not uncommonly encountered, there is a scarcity of...
BACKGROUND
While ventricular tachycardia (VT) in the setting of postmyocardial infarction left ventricular aneurysms (LVA) is not uncommonly encountered, there is a scarcity of data regarding the safety, efficacy, and outcomes of ablation of VT in this subset of patients.
METHODS
Our study included consecutive patients aged 18 years or older with postmyocardial infarction LVA who presented to Mayo Clinic for catheter ablation of VT between 2002 and 2018.
RESULTS
Of 34 patients, the mean age was 70.4 ± 9.1 years; 91% were male. Mean LVEF was 29 ± 9.7% and left ventricular end-diastolic dimension was 64.9 ± 6.6 mm. The site of the LVA was apical in 21 patients (62%). Fifteen patients (44%) presented with electrical storm or incessant VT. Nine patients (26%) had a history of intracardiac thrombus. All except for one patient had at least one VT originating from the aneurysm. The mean number of VTs was 2.9 ± 1.7. All patients underwent ablation at the site of the aneurysm. Ablation outside the aneurysm was performed in 13 patients (38%). Low-voltage fractionated potentials and/or late potentials at the aneurysmal site were present in all cases. Complete elimination of all VTs was achieved in 18 (53%), while the elimination of the clinical VT with continued inducibility of nonclinical VTs was achieved in a further 11 patients (32%). Two patients developed cardiac tamponade requiring pericardiocentesis. During a mean follow-up period of 2.3 ± 2.4 years, 11 patients (32%) experienced VT recurrence. Freedom from all-cause mortality at 1-year follow-up was 94%.
CONCLUSION
Radiofrequency catheter ablation targeting the aneurysmal site is a feasible and reasonably effective management strategy for clinical VTs in patients with postinfarction LVA.
Topics: Adolescent; Aged; Catheter Ablation; Heart Aneurysm; Heart Ventricles; Humans; Male; Middle Aged; Myocardial Infarction; Recurrence; Tachycardia, Ventricular; Treatment Outcome
PubMed: 34664765
DOI: 10.1111/jce.15273 -
Circulation Oct 2019We conducted a multicenter study to evaluate mapping and ablation of ventricular fibrillation (VF) substrates or VF triggers in early repolarization syndromes (ERS) or...
BACKGROUND
We conducted a multicenter study to evaluate mapping and ablation of ventricular fibrillation (VF) substrates or VF triggers in early repolarization syndromes (ERS) or J-wave syndrome (JWS).
METHODS
We studied 52 patients with ERS (4 women; median age, 35 years) with recurrent VF episodes. Body surface electrocardiographic imaging and endocardial and epicardial electroanatomical mapping of both ventricles were performed during sinus rhythm and VF for localization of triggers, substrates, and drivers. Ablations were performed on VF substrates, defined as areas that had late depolarization abnormalities characterized by low-voltage fractionated late potentials, and VF triggers.
RESULTS
Fifty-one of the 52 patients had detailed mapping that revealed 2 phenotypes: group 1 had late depolarization abnormalities predominantly at the right ventricular (RV) epicardium (n=40), and group 2 had no depolarization abnormalities (n=11). Group 1 can be subcategorized into 2 groups: Group 1A included 33 patients with ERS with Brugada electrocardiographic pattern, and group 1B included 7 patients with ERS without Brugada electrocardiographic pattern. Late depolarization areas colocalize with VF driver areas. The anterior RV outflow tract/RV epicardium and the RV inferior epicardium are the major substrate sites for group 1. The Purkinje network is the leading underlying VF trigger in group 2 that had no substrates. Ablations were performed in 43 patients: 31 and 5 group 1 patients had only VF substrate ablation and VF substrates plus VF trigger, respectively (mean, 1.4±0.6 sessions); 6 group 2 patients and 1 patient without group classification had only Purkinje VF trigger ablation (mean, 1.2±0.4 sessions). Ablations were successful in reducing VF recurrences (<0.0001). After follow-up of 31±26 months, 39 (91%) had no VF recurrences.
CONCLUSIONS
There are 2 phenotypes of ERS/J-wave syndrome: one with late depolarization abnormality as the underlying mechanism of high-amplitude J-wave elevation that predominantly resides in the RV outflow tract and RV inferolateral epicardium, serving as an excellent target for ablation, and the other with pure ERS devoid of VF substrates but with VF triggers that are associated with Purkinje sites. Ablation is effective in treating symptomatic patients with ERS/J-wave syndrome with frequent VF episodes.
Topics: Adult; Brugada Syndrome; Catheter Ablation; Electrocardiography; Electrophysiologic Techniques, Cardiac; Endocardium; Epicardial Mapping; Female; Heart Ventricles; Humans; Male; Middle Aged; Tachycardia, Ventricular; Ventricular Fibrillation; Young Adult
PubMed: 31542949
DOI: 10.1161/CIRCULATIONAHA.118.039022 -
International Journal of Molecular... Mar 2021Atrial fibrillation (AF) is one of the most common tachyarrhythmias observed in the clinic and is characterized by structural and electrical remodelling. Atrial...
Atrial fibrillation (AF) is one of the most common tachyarrhythmias observed in the clinic and is characterized by structural and electrical remodelling. Atrial fibrosis, an emblem of atrial structural remodelling, is a complex multifactorial and patient‑specific process involved in the occurrence and maintenance of AF. Whilst there is already considerable knowledge regarding the association between AF and fibrosis, this process is extremely complex, involving intricate neurohumoral and cellular and molecular interactions, and it is not limited to the atrium. Current technological advances have made the non‑invasive evaluation of fibrosis in the atria and ventricles possible, facilitating the selection of patient‑specific ablation strategies and upstream treatment regimens. An improved understanding of the mechanisms and roles of fibrosis in the context of AF is of great clinical significance for the development of treatment strategies targeting the fibrous region. In the present review, a focus was placed on the atrial fibrosis underlying AF, outlining its role in the occurrence and perpetuation of AF, by reviewing recent evaluations and potential treatment strategies targeting areas of fibrosis, with the aim of providing a novel perspective on the management and prevention of AF.
Topics: Atrial Fibrillation; Atrial Remodeling; Fibrosis; Heart Atria; Heart Ventricles; Humans
PubMed: 33448312
DOI: 10.3892/ijmm.2020.4842 -
Cardiology in Review 2015Heart failure is common and is associated with significant morbidity and mortality. Identifying potentially modifiable risk factors for the development of ventricular... (Review)
Review
Heart failure is common and is associated with significant morbidity and mortality. Identifying potentially modifiable risk factors for the development of ventricular dysfunction is important in both the prevention and the treatment of this condition. Arrhythmia disorders are increasingly recognized as contributory to the development of ventricular failure. Poorly controlled supraventricular tachyarrhythmias, altered left ventricular activation due to left bundle branch block or right ventricular pacing, and frequent premature ventricular contractions (PVCs) constitute the main subtypes of arrhythmia disorders that are associated with the development of ventricular dysfunction. PVCs are common and are considered benign in the absence of structural heart disease. Frequent PVCs, defined as greater than 20% of all QRS complexes on standard 24-hour Holter monitoring, are associated with the presence or subsequent development of left ventricular dilatation and dysfunction. Catheter ablation of frequent PVCs has been demonstrated to be effective at PVC suppression and is associated with improvement or normalization of ventricular function; thus defining a specific, reversible form of ventricular dysfunction termed PVC cardiomyopathy. In patients presenting with high burden PVCs, an assessment for symptoms and associated cardiomyopathy is warranted and, in the appropriate clinical setting, PVC catheter ablation may be a reasonable treatment option.
Topics: Catheter Ablation; Electrocardiography; Heart Conduction System; Heart Ventricles; Humans; Stroke Volume; Ventricular Premature Complexes
PubMed: 25741605
DOI: 10.1097/CRD.0000000000000063 -
JACC. Clinical Electrophysiology Jan 2019The left ventricular outflow tract (LVOT) is a frequent source of arrhythmias in patients with and without structural heart disease. An understanding of the anatomic... (Review)
Review
The left ventricular outflow tract (LVOT) is a frequent source of arrhythmias in patients with and without structural heart disease. An understanding of the anatomic relationship between the aortic valvar leaflets and their supporting sinuses, coronary vessels, pulmonary arterial root, right ventricular outflow tract, and LVOT is essential for successful treatment of arrhythmias arising from this region. The juxtaposition of aortic valvar leaflet insertion into the aortic root and the crescents of myocardial tissue incorporated within the aortic sinuses of Valsalva has implications for mapping and ablation above and below the aortic valve leaflets. The presence of epicardial fat, coronary arteries, and prominent myocardium in the anteroseptal aspect of the LVOT can present unique challenges for targeting LV summit and intramural ventricular arrhythmias. Advances in ablation techniques that achieve deeper transmural lesions, combined with the knowledge of the complex LVOT anatomy and its adjoining structures, have increased success rates in targeting challenging LVOT arrhythmias.
Topics: Aorta; Arrhythmias, Cardiac; Catheter Ablation; Heart Ventricles; Humans
PubMed: 30678772
DOI: 10.1016/j.jacep.2018.11.012 -
Circulation. Arrhythmia and... Jun 2019Idiopathic ventricular arrhythmias commonly originate from the right ventricular and left ventricular outflow tracts (OTs). Advances in real-time imaging have refined... (Review)
Review
Idiopathic ventricular arrhythmias commonly originate from the right ventricular and left ventricular outflow tracts (OTs). Advances in real-time imaging have refined our understanding of the intimate anatomic structures implicated in the genesis of OT arrhythmias, making catheter ablation for arrhythmias beyond the right ventricular OT a feasible option for cure-indeed ablation is now a class I indication in recent guidelines. The surface 12-lead ECG is routinely used to localize the anatomic site of origin before catheter ablation. However, the intimate and complex anatomy of the OT limits predictive value ECG criteria alone for localization for these arrhythmias. Multiple ECG algorithms have been developed to assist preprocedural localization, and hence predict safety and efficacy for catheter ablation of OT ventricular arrhythmias. This review will summarize all of the published 12-lead ECG algorithms used to guide localization of OT ventricular arrhythmias.
Topics: Action Potentials; Adolescent; Adult; Aged; Algorithms; Arrhythmias, Cardiac; Diagnosis, Differential; Electrocardiography; Female; Heart Rate; Heart Ventricles; Humans; Male; Middle Aged; Predictive Value of Tests; Prognosis; Signal Processing, Computer-Assisted; Ventricular Function, Left; Ventricular Function, Right; Young Adult
PubMed: 31159581
DOI: 10.1161/CIRCEP.119.007392