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Heart Rhythm Apr 2021There are limited data on ventricular arrhythmias (VAs) associated with left ventricular noncompaction (LVNC) cardiomyopathy.
BACKGROUND
There are limited data on ventricular arrhythmias (VAs) associated with left ventricular noncompaction (LVNC) cardiomyopathy.
OBJECTIVES
This study aims to analyze the clinical and electrocardiographic characteristics of VAs in a group of patients with LVNC.
METHODS
Forty-two nonrelated patients with LVNC and VAs were included that were evaluated at the Inherited Cardiac Disease Unit of the University Hospital Virgen Arrixaca (Murcia-Spain) (ERN Guard-Heart Centre, European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart).
RESULTS
Thirteen patients (30.9%) had isolated LVNC, 27 (64.3%) had LVNC associated with dilated cardiomyopathy, and 2 (4.8%) had LVNC associated with hypertrophic cardiomyopathy. Among isolated LVNC individuals, 9 (69.2%) had premature ventricular complexes (PVCs)/nonsustained ventricular tachycardias (VTs), and 4 (30.8%) VTs (1 VT degenerating in ventricular fibrillation). In the dilated cardiomyopathy group, 11 (40.7%) patients had PVCs, 14 (51.9%) VTs, and 2 (7.4%) ventricular fibrillation. In the hypertrophic cardiomyopathy group, one patient had PVCs and the other VTs. Endocardial mapping and ablation were performed in 19 patients (45.2%): 7 ventricular outflow tracts (4 right ventricular outflow tract, 1 left coronary cusp, and 2 right coronary cusp), 2 in the left ventricular summit, 5 related to Purkinje potentials at the mid inferoseptal area, and 5 associated with endocardial scar localized in the basal anterolateral and inferolateral segments. Epicardial ablation was performed in 3 cases.
CONCLUSION
The substrate of VAs in LVNC cardiomyopathy is heterogeneous, with origin in ventricular outflow tracts, Purkinje system related, and resembling scar patterns in nonischemic cardiomyopathy.
Topics: Adult; Body Surface Potential Mapping; Catheter Ablation; Female; Follow-Up Studies; Heart Conduction System; Heart Ventricles; Humans; Male; Middle Aged; Retrospective Studies; Tachycardia, Ventricular; Ventricular Fibrillation; Ventricular Premature Complexes
PubMed: 33346135
DOI: 10.1016/j.hrthm.2020.12.014 -
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 -
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 -
Cardiology 2020Recurrent ventricular tachycardia (VT) after percutaneous ablation is associated with a high morbidity and mortality. We assessed the feasibility of open chest...
INTRODUCTION
Recurrent ventricular tachycardia (VT) after percutaneous ablation is associated with a high morbidity and mortality. We assessed the feasibility of open chest extracorporeal circulation (ECC)-supported 3D multielectrode mapping and targeted VT substrate ablation in patients with previously failed percutaneous endocardial and epicardial VT ablations.
METHODS
In patients with previously failed percutaneous endocardial and epicardial VT ablations and a high risk of hemodynamic collapse during the procedure, open chest ECC-supported mapping and ablation were performed in a hybrid EP lab setting. Electro-anatomic maps (3D) were acquired during sinus rhythm and VT using a multielectrode mapping catheter (HD grid; Abbott or Pentaray, Biosense Webster). Irrigated radiofrequency ablations of all inducible VT were performed with a contact force ablation catheter.
RESULTS
Hybrid VT ablation was performed in 5 patients with structural heart disease (i.e., 3 with previous old myocardial infarction and 2 with nonischemic cardiomy-opathy) and recurrent VT. Acute procedural success was achieved in all patients. Four patients were successfully weaned off the ECC. In 1 patient with a severely reduced LVEF (16%), damage to the venous graft occurred after sternotomy and that patient died after 1 month. Four patients (80%) remained VT free after a median follow-up of 6 (IQR 4-10) months.
CONCLUSION
In high-risk patients with previously failed percutaneous endocardial and epicardial VT ablations, open chest ECC-supported multielectrode epicardial mapping revealed a VT substrate in all of the patients, and targeted epicardial ablation abolished VT substrate in these patients.
Topics: Aged; Arrhythmogenic Right Ventricular Dysplasia; Body Surface Potential Mapping; Cardiomyopathy, Dilated; Catheter Ablation; Endocardium; Epicardial Mapping; Humans; Male; Middle Aged; Myocardial Ischemia; Recurrence; Tachycardia, Ventricular; Treatment Failure
PubMed: 31707389
DOI: 10.1159/000503251 -
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 -
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 -
Herzschrittmachertherapie &... Jun 2022Catheter ablation of ventricular tachycardias (VTs) is one of the most complex tasks in interventional electrophysiology. It is complicated by the fact that VT can recur... (Review)
Review
BACKGROUND
Catheter ablation of ventricular tachycardias (VTs) is one of the most complex tasks in interventional electrophysiology. It is complicated by the fact that VT can recur during treatment which can affect the hemodynamic stability of the patient. In addition, navigation with the ablation or mapping catheter through the valvular apparatus and the trabecularization of the ventricle can be challenging.
MATERIALS AND METHODS
In most cases, a three-dimensional mapping system is used to facilitate orientation and the search for the site where the tachycardia originates. Access to the right ventricle is usually via the tricuspid valve, but in exceptional cases it may also be necessary to use the epicardial venous system. The structures most commonly responsible for an arrhythmia from the right ventricle are the right ventricular outflow tract, the moderator band and the tricuspid valve annulus. The right ventricle is adjacent to vulnerable neighboring structures in many places: In the right ventricular outflow tract, the sinus valsalva, the pulmonary artery and the left ventricular endocardial transition between the aortic and mitral valves must be considered. When ablating along the tricuspid valve annulus, the proximity to the septum and thus to the specific conduction system is particularly important.
CONCLUSION
Knowledge of the surrounding structures helps, on the one hand, to draw the right conclusions about the point of origin in the surface ECG, and, on the other hand, to carry out the ablation successfully and safely.
Topics: Catheter Ablation; Electrocardiography; Heart Ventricles; Humans; Tachycardia, Ventricular; Ventricular Premature Complexes
PubMed: 35552488
DOI: 10.1007/s00399-022-00857-9 -
Current Cardiology Reports Sep 2023In this review, we summarize the procedural approach and outcomes of venous ethanol infusion in the treatment of ventricular arrhythmias with intramural site of origin. (Review)
Review
PURPOSE OF REVIEW
In this review, we summarize the procedural approach and outcomes of venous ethanol infusion in the treatment of ventricular arrhythmias with intramural site of origin.
RECENT FINDINGS
Coronary venous ethanol infusion has emerged as a novel, safe, and effective adjunctive strategy to radiofrequency ablation of drug refractory ventricular arrhythmias with an intramural origin. Radiofrequency catheter ablation is the first-line treatment for drug refractory ventricular arrythmias. Its success is highly dependent on the ability to reach targeted myocardium. Radiofrequency failures are common in patients with ventricular arrhythmias arising from deep intramural substrates, and those whose origin is in close proximity to vital structures such as coronary arteries or the phrenic nerve. Coronary venous ethanol infusion has emerged as a novel technique that circumvents these limitations.
Topics: Humans; Tachycardia, Ventricular; Ethanol; Electrocardiography; Arrhythmias, Cardiac; Coronary Vessels; Catheter Ablation; Treatment Outcome; Heart Ventricles
PubMed: 37450261
DOI: 10.1007/s11886-023-01914-6 -
Journal of Cardiovascular... Sep 2023Variants of cardiomyopathy genes in patients with nonischemic cardiomyopathy (NICM) generate various phenotypes of cardiac scar and delayed enhancement cardiac magnetic...
INTRODUCTION
Variants of cardiomyopathy genes in patients with nonischemic cardiomyopathy (NICM) generate various phenotypes of cardiac scar and delayed enhancement cardiac magnetic resonance (DE-CMR) imaging which may impact ventricular tachycardia (VT) management.
METHODS
The objective was to compare the findings of cardiomyopathy genetic testing on DE-CMR imaging and long-term outcomes among patients with NICM undergoing VT ablation procedures. Image phenotyping and genotyping were performed in a consecutive series of patients referred for VT ablation and correlated to survival free of VT. Scar depth index (SDI) (% of scar at 0-3 mm, 3-5 mm and >5 mm projected on the closest endocardial surface) was determined.
RESULTS
Forty-three patients were included (11 women, 55 ± 14 years, ejection fraction (EF) 45 ± 16%) and were followed for 3.4 ± 2.9 years. Pathogenic variants (PV) were identified in 16 patients (37%) in the following genes: LMNA (n = 5), TTN (n = 5), DSP (n = 2), AMLS1 (n = 1), MYBPC3 (n = 1), PLN (n = 1), and SCN5A (n = 1). A ring-like septal scar (RLSS) pattern was more often seen in patients with pathogenic variants (66% vs 15%, p = .001). RLSS was associated with deeper seated scars (SDI >5 mm 30.6 ± 22.6% vs 12.4 ± 16.2%, p = .005), and increased VT recurrence (HR 5.7 95% CI[1.8-18.4], p = .003). After adjustment for age, sex, EF, and total scar burden, the presence of a PV remained independently associated with worse outcomes (HR 4.7 95% CI[1.22-18.0], p = .02).
CONCLUSIONS
Preprocedural genotyping and scar phenotyping is beneficial to identify patients with a favorable procedural outcome. Some PVs are associated with an intramural, deeper seated scar phenotype and have an increase of VT recurrence after ablation.
Topics: Humans; Female; Cicatrix; Genotype; Cardiomyopathies; Tachycardia, Ventricular; Heart Ventricles; Catheter Ablation
PubMed: 37579221
DOI: 10.1111/jce.16039