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Journal of Interventional Cardiac... Jan 2023Ventricular tachycardia (VT) ablation of mid- or epicardial substrate is difficult and requires a creative approach in patients with a history of coronary bypass that...
BACKGROUND
Ventricular tachycardia (VT) ablation of mid- or epicardial substrate is difficult and requires a creative approach in patients with a history of coronary bypass that precludes percutaneous epicardial catheter manipulation. The coronary venous system (CVS) provides limited access to the epicardial surface of the heart. The objective of this study is to assess the feasibility, safety, and efficacy of epicardial mapping and ablation of VT substrates from the CVS in patients with history of coronary bypass.
METHODS
Patients undergoing VT ablation at our institution were retrospectively reviewed. Those who had basal to mid ventricular substrate based on computed tomography imaging and history of coronary bypass were included. Endocardial and CVS mapping and ablation was performed in standard fashion using 3D electroanatomic mapping. The primary endpoint was defined as VT circuit elimination, termination, non-inducibility, or perturbation of the circuit.
RESULTS
Of 192 consecutive VT ablations from 2017 to 2020, 35 (18%) had a history of coronary bypass and basal to the mid-ventricular substrate by imaging. There were no significant characteristic differences between the endocardial only (n = 19) vs endocardial + CVS (n = 16) groups. In 14 (88%) of patients undergoing CVS mapping, the VT circuit was identified to be within access from the epicardial surface. Ablation was attempted in 8 (57%) of these patients, and the primary endpoint was reached in 88% of those undergoing CVS ablation. There were no complications related to CVS ablation.
CONCLUSION
Mapping and ablation of mid- or epicardial VT circuits from the CVS branches are feasible and safe and may be helpful in the treatment of VT in patients who are otherwise not candidates for percutaneous epicardial ablation.
Topics: Humans; Epicardial Mapping; Retrospective Studies; Tachycardia, Ventricular; Heart Ventricles; Endocardium; Catheter Ablation; Treatment Outcome; Pericardium
PubMed: 35581463
DOI: 10.1007/s10840-022-01250-9 -
Journal of Cardiovascular... Jul 2022In radiofrequency ablation procedures for cardiac arrhythmia, the efficacy of creating repeated lesions at the same location ("insurance lesions") remains poorly...
INTRODUCTION
In radiofrequency ablation procedures for cardiac arrhythmia, the efficacy of creating repeated lesions at the same location ("insurance lesions") remains poorly studied. We assessed the effect of type of tissue, power, and time on the resulting lesion geometry during such multiple ablation procedures.
METHODS
A custom ex vivo ablation model was used to assess lesion formation. An ablation catheter was oriented perpendicular to the tissue and used to create lesions that varied by type of tissue (atrial or ventricular free wall), power (30 or 50 W), and time (30, 40, or 50 s for standard ablations and 5, 10, or 15 s for high-power, short-duration [HPSD] ablations). Lesion dimensions were recorded and then analyzed. Radiofrequency ablations were performed on 57 atrial tissue samples (28 HPSD, 29 standard) and 28 ventricular tissue samples (all standard).
RESULTS
With ablation parameters held constant, performing multiple ablations significantly increased lesion depth in ventricular tissue when ablations were performed at 30 W for 50 s. No other set of ablation parameters was shown to affect the width or depth of the resulting lesions in either tissue type.
CONCLUSION
Multiple ablations created with the same power and time, delivered within 30 s of each other at the same exact location, offer no meaningful benefit in lesion depth or width over single ablations, with the exception of ventricular ablation at 30 W for 50 s. Given the risks associated with excessive ablation, our results suggest that this practice should be re-evaluated by clinical electrophysiologists.
Topics: Catheter Ablation; Heart Atria; Heart Ventricles; Humans; Insurance; Radiofrequency Ablation
PubMed: 35437855
DOI: 10.1111/jce.15497 -
Journal of Nuclear Cardiology :... Feb 2021
Topics: Arrhythmias, Cardiac; Catheter Ablation; Heart Ventricles; Humans
PubMed: 30719658
DOI: 10.1007/s12350-019-01632-z -
Heart Rhythm Sep 2020Managing arrhythmias from the left ventricular summit and interventricular septum is a major challenge for the clinical electrophysiologist requiring intimate knowledge... (Review)
Review
Managing arrhythmias from the left ventricular summit and interventricular septum is a major challenge for the clinical electrophysiologist requiring intimate knowledge of cardiac anatomy, advanced training and expertise. Novel mapping and ablation strategies are needed to treat arrhythmias originating from these regions given the current suboptimal long-term success rates with standard techniques. Herein, we describe innovative approaches to improve acute and long-term clinical outcomes such as mapping and ablation using the septal coronary venous system and the septal coronary arteries, alcohol ablation, coil embolization, and ablation of all early sites among others.
Topics: Catheter Ablation; Electrophysiologic Techniques, Cardiac; Heart Ventricles; Humans; Tachycardia, Ventricular; Tomography, X-Ray Computed; Ventricular Septum
PubMed: 32333973
DOI: 10.1016/j.hrthm.2020.04.026 -
Cardiac Electrophysiology Clinics Dec 2022Idiopathic ventricular arrhythmias (VAs) most commonly originate from the ventricular outflow tracts. Because the anatomy of this region is complex and some of those VA... (Review)
Review
Idiopathic ventricular arrhythmias (VAs) most commonly originate from the ventricular outflow tracts. Because the anatomy of this region is complex and some of those VA origins are intramural and epicardial, it may sometimes be difficult to locate the site of the VA origin. Meticulous mapping in multiple different locations such as the right and left ventricular outflow tracts, endocardial and epicardial sites, and above and below the aortic and pulmonic valves may be required to achieve successful catheter ablation of those VAs. Special ablation techniques may be considered to improve the outcome of catheter ablation of intramural and epicardial VAs.
Topics: Humans; Catheter Ablation; Heart Ventricles; Arrhythmias, Cardiac; Endocardium; Aorta
PubMed: 36396181
DOI: 10.1016/j.ccep.2022.07.008 -
Expert Review of Medical Devices Feb 2020: Brugada syndrome (BrS) is an inherited disease characterized by an increased risk of sudden cardiac death (SCD). Therapeutic options in symptomatic patients are... (Review)
Review
: Brugada syndrome (BrS) is an inherited disease characterized by an increased risk of sudden cardiac death (SCD). Therapeutic options in symptomatic patients are limited to implantable cardioverter defibrillator (ICD) and quinidine, but catheter ablation of the right ventricular outflow tract (RVOT) offers a potential cure. Different ablation strategies have been used to treat patients with symptomatic Brugada syndrome. Epicardial radiofrequency substrate ablation of the RVOT/right ventricle (RV) has emerged as a promising tool for the management of the disease.: The historical management of BrS, endocardial and epicardial ablation techniques, the use of sodium channel blockers (SCB) and complications are summarized here.: Ventricular fibrillation (VF)-triggering premature ventricular contractions (PVCs) in patients with BrS are unpredictable, spontaneous ones are rarely present to be mapped, making this approach impractical. Furthermore, endocardial mapping for BrS substrates does not seem effective due to the epicardial pathological substrate localization. The size variation of the BrS substrate areas during SCB infusion suggests a dynamic process as arrhythmogenic basis and SCB infusion should guide BrS epicardial ablation of all abnormal potentials areas. If BrS epicardial ablation can truly provide long-term prevention of ventricular arrhythmias it may potentially become an alternative to ICD therapy.
Topics: Ablation Techniques; Brugada Syndrome; Epicardial Mapping; Heart Ventricles; Humans; Pericardium; Thoracoscopy
PubMed: 31986921
DOI: 10.1080/17434440.2020.1719831 -
JACC. Clinical Electrophysiology Jul 2022
Topics: Electrophysiologic Techniques, Cardiac; Heart Ventricles; Humans
PubMed: 35863810
DOI: 10.1016/j.jacep.2022.05.002 -
Toxicologic Pathology Apr 2019Cardiac electrophysiology utilizes nonimplantable, catheter-based devices for diagnosis and treatment of arrhythmias as well as electroanatomical mapping of cardiac... (Review)
Review
Cardiac electrophysiology utilizes nonimplantable, catheter-based devices for diagnosis and treatment of arrhythmias as well as electroanatomical mapping of cardiac chambers. Gross pathology and histopathological assessments in preclinical studies play critical roles in determining the safety and efficacy of cardiac ablation systems used to treat tachyarrhythmias. The pathologist must assess ablation sites, adjacent structures and organs, and downstream organs to characterize the effects of the ablation treatment and determine whether adverse local reactions, collateral injury, or downstream thromboembolism are present. Histopathological assessment serves as an adjunct to electroanatomical data in determining efficacy in preclinical studies. Histopathology is the standard in definitively demonstrating transmurality of ablation lesions, which is necessary for complete conduction block, as well as showing the linear or circumferential distribution of a contiguous, transmural ablation lesion necessary for electroanatomical isolation of entire target structures such as pulmonary veins and the cavotricuspid isthmus, which are involved in propagating certain arrhythmias. This article will detail gross and histological methods for the pathology assessment of preclinical studies evaluating the safety and/or efficacy of cardiac ablation catheter systems as well as discuss correlation of pathology data with other supporting evidence for safety and efficacy such as acute, electroanatomical data.
Topics: Animals; Cardiac Catheters; Catheter Ablation; Cryosurgery; Equipment Safety; Heart Atria; Heart Conduction System; Heart Ventricles; Tachycardia
PubMed: 30727858
DOI: 10.1177/0192623319826063 -
Heart Rhythm Feb 2017Left ventricular noncompaction (LVNC) is a primary cardiomyopathy that can present with recurrent ventricular arrhythmias (VAs). Data on the benefit of catheter ablation...
BACKGROUND
Left ventricular noncompaction (LVNC) is a primary cardiomyopathy that can present with recurrent ventricular arrhythmias (VAs). Data on the benefit of catheter ablation of VAs in LVNC are lacking.
OBJECTIVE
The purpose of this study was to describe the electrophysiologic features and outcomes of catheter ablation of VAs in LVNC.
METHODS
The cohort consisted of 9 patients (age 42 ± 15 years) with diagnosis of LVNC based on established criteria and VA (ventricular tachycardia [VT] in 3 and frequent premature ventricular contractions (PVCs) in 6) despite treatment with a mean of 2 ± 1 antiarrhythmic drugs. Ablation sites were identified using a combination of entrainment, activation, late/fractionated potential ablation, and pace-mapping.
RESULTS
A total of 8 patients (89%) had left ventricular (LV) systolic dysfunction (mean ejection fraction 40% ± 13%). Patients who presented with VT had evidence of abnormal electroanatomic substrate involving the mid- to apical segments of the LV, which matched the noncompacted myocardial segments identified by preprocedural magnetic resonance imaging or echocardiography. In patients presenting with frequent PVCs, the site of origin was identified at the papillary muscles (50%) and/or basal septal regions (67%). After median follow-up of 4 years (range 1-11) and a mean of 1.8 ± 1.1 procedures, VAs recurred in 1 patient (11%). Significant improvement in LV function occurred in 4 of 8 cases (50%). No patients died or underwent heart transplantation.
CONCLUSION
The VA substrate in patients with LVNC and VT typically involves the mid-apical LV segments, whereas focal PVCs often arise from LV basal-septal regions and/or papillary muscles. Catheter ablation is safe and effective in achieving good VA control over long-term follow-up in most patients.
Topics: Adult; Anti-Arrhythmia Agents; Catheter Ablation; Echocardiography; Electrophysiologic Techniques, Cardiac; Female; Follow-Up Studies; Heart Defects, Congenital; Heart Ventricles; Humans; Magnetic Resonance Imaging, Cine; Male; Middle Aged; Outcome and Process Assessment, Health Care; Preoperative Care; Tachycardia, Ventricular; United States; Ventricular Premature Complexes
PubMed: 27890738
DOI: 10.1016/j.hrthm.2016.11.014 -
JACC. Clinical Electrophysiology Oct 2020This study sought to establish a mapping and ablation strategy to target intramural ventricular arrhythmias (VAs) by identifying the precise arrhythmia site of origin...
OBJECTIVES
This study sought to establish a mapping and ablation strategy to target intramural ventricular arrhythmias (VAs) by identifying the precise arrhythmia site of origin (SOO).
BACKGROUND
Radiofrequency ablation of intramural VAs is challenging because the arrhythmia origin is difficult to localize.
METHODS
In 83 consecutive patients with intramural VAs, a stepwise mapping approach was performed: ablation targeted directly the SOO when possible followed by the closest adjacent anatomical structure when necessary. If the SOO could not be identified, the earliest endocardial breakout sites were ablated. Safety and procedural outcomes between patients in whom the SOO could and could not be identified were compared.
RESULTS
The SOO was identified in 19 of 83 (23%) patients, and radiofrequency ablation was effective in eliminating VAs in all 19 (100%) patients by ablation at the SOO alone (n = 3), at the SOO and an anatomically adjacent area (n = 7), or at an anatomically adjacent area alone (n = 9). Breakout site mapping and ablation in the remaining 64 patients in whom the SOO was not identified was effective in 43 of 64 patients, which was significantly less than in patients in whom the SOO was identified (67% vs. 100%; p < 0.05).
CONCLUSIONS
Identification of the SOO was associated with a successful ablation procedure by either targeting the SOO directly or targeting an adjacent anatomical structure. Ablation at the breakout sites of intramural VAs has a lower efficacy than when the SOO can be directly targeted.
Topics: Arrhythmias, Cardiac; Catheter Ablation; Endocardium; Heart Ventricles; Humans; Tachycardia, Ventricular
PubMed: 33121661
DOI: 10.1016/j.jacep.2020.05.021