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Cells Oct 2021Ischemic heart disease is the most common cause of lethal ventricular arrhythmias and sudden cardiac death (SCD). In patients who are at high risk after myocardial... (Review)
Review
Ischemic heart disease is the most common cause of lethal ventricular arrhythmias and sudden cardiac death (SCD). In patients who are at high risk after myocardial infarction, implantable cardioverter defibrillators are the most effective treatment to reduce incidence of SCD and ablation therapy can be effective for ventricular arrhythmias with identifiable culprit lesions. Yet, these approaches are not always successful and come with a considerable cost, while pharmacological management is often poor and ineffective, and occasionally proarrhythmic. Advances in mechanistic insights of arrhythmias and technological innovation have led to improved interventional approaches that are being evaluated clinically, yet pharmacological advancement has remained behind. We review the mechanistic basis for current management and provide a perspective for gaining new insights that centre on the complex tissue architecture of the arrhythmogenic infarct and border zone with surviving cardiac myocytes as the source of triggers and central players in re-entry circuits. Identification of the arrhythmia critical sites and characterisation of the molecular signature unique to these sites can open avenues for targeted therapy and reduce off-target effects that have hampered systemic pharmacotherapy. Such advances are in line with precision medicine and a patient-tailored therapy.
Topics: Animals; Arrhythmias, Cardiac; Cardiomyopathies; Heart Ventricles; Humans; Myocardial Ischemia; Risk Assessment; Vascular Remodeling
PubMed: 34685609
DOI: 10.3390/cells10102629 -
Europace : European Pacing,... Dec 2021Ventricular arrhythmias (VAs) from the basal inferoseptal (BIS) area are rare and can pose unique challenges during catheter ablation (CA) due to the anatomic...
AIMS
Ventricular arrhythmias (VAs) from the basal inferoseptal (BIS) area are rare and can pose unique challenges during catheter ablation (CA) due to the anatomic complexity. The study sought to describe the electrocardiographic and clinical characteristics of VAs originating from the BIS area.
METHODS AND RESULTS
Patients with VAs and successful ablation at the BIS area from 2016 to 2020 were included. The 12-lead electrocardiogram (ECG), intracardiac findings, and outcomes were analysed. Of 482 patients with VAs referred for CA, 17 (3.5%) had successful ablation at BIS area. There were 12 males, mean age was 66.7 ± 9 years, 82% had ejection fraction <50%. Mean baseline premature ventricular complex burden was 28.6 ± 9%. All patients had a leftward superior axis. Left bundle branch block (LBBB) with early transition in V2 was noted in eight patients and right bundle branch block (RBBB) in nine patients. Detailed mapping of the right ventricle (RV) was performed in 15 patients (88%), coronary sinus (CS)/middle cardiac vein (MCV) in 13 (76%), right atrium (RA) adjacent to the inferoseptal process (ISP) of left ventricle (LV) in 5 (29%), ISP-LV in 13 (76%), and epicardium in 2 (12%). Successful ablation site was in LV in 10 (59%), RV in 2 (12%), CS/MCV in 1 (6%), RA in 1 (6%), and epicardium in 2 (12%). Fifteen patients (88%) required mapping in at least two chambers (range 2-5) and seven patients (41%) required ablation in at least two chambers (range 2-3).
CONCLUSIONS
Ventricular arrhythmias originating in the BIS are uncommon. The most common ECG patterns were leftward superior axis, LBBB with transition in V2 or RBBB. The VA foci can be endocardial or epicardial and meticulous mapping/ablation from multiple chambers is often required to eliminate these foci successfully.
Topics: Aged; Bundle-Branch Block; Catheter Ablation; Electrocardiography; Heart Ventricles; Humans; Male; Middle Aged; Tachycardia, Ventricular; Treatment Outcome; Ventricular Premature Complexes
PubMed: 34472607
DOI: 10.1093/europace/euab189 -
Journal of Nuclear Cardiology :... Feb 2021
Topics: Arrhythmias, Cardiac; Catheter Ablation; Heart Ventricles; Humans
PubMed: 30719658
DOI: 10.1007/s12350-019-01632-z -
Journal of Electrocardiology 2023A recent study using an epicardial-only electrocardiographic imaging (ECGI), suggests that the agreement of ECGI activation mapping and that of the contact mapping for...
BACKGROUND AND AIM
A recent study using an epicardial-only electrocardiographic imaging (ECGI), suggests that the agreement of ECGI activation mapping and that of the contact mapping for ventricular arrhythmias (VA) is poor. The aim of this study was to assess the diagnostic value of two endo-epicardial ECGI systems using different cardiac sources and the agreement between them.
METHODS
We performed 69 ECGI procedures in 52 patients referred for ablation of VA at our center. One system based on the extracellular potentials was used in 26 patients, the other based on the equivalent double layer model in 9, and both in 17 patients. The first uses up to 224 leads and the second just the 12‑lead ECG. The localization of the VA was done using a segmental model of the ventricles. A perfect match (PM) was defined as a predicted location within the same anatomic segment, whereas a near match (NM) as a predicted location within the same segment or a contiguous one.
RESULTS
44 patients underwent ablation, corresponding to 58 ECGI procedures (37 with the first and 21 with the second system). The percentage of PMs and NMs was not significantly different between the two systems, respectively 76% and 95%, p = 0.077, and 97% and 100%, p = 1.000. In 14 patients that underwent ablation and had the ECGI performed with both systems, raw agreement for PMs was 79%, p = 0.250 for disagreement.
CONCLUSIONS
ECGI systems were useful to identify the origin of the VAs, and the results were reproducible regardless the cardiac source.
Topics: Humans; Electrocardiography; Arrhythmias, Cardiac; Heart; Diagnostic Imaging; Heart Ventricles; Catheter Ablation; Tachycardia, Ventricular
PubMed: 37390586
DOI: 10.1016/j.jelectrocard.2023.06.003 -
Journal of Interventional Cardiac... Aug 2021Aortic cusps might be the source of supraventricular or ventricular arrhythmias. For many years, aortic cusp ablation has been widely used to treat premature ventricular...
PURPOSE
Aortic cusps might be the source of supraventricular or ventricular arrhythmias. For many years, aortic cusp ablation has been widely used to treat premature ventricular contractions (PVCs) and ventricular tachycardia (VT). However, the data on the outcomes of this procedure in children are limited. The study aimed to convey or describe our own aortic cusp ablation experiences in children and, thus, contribute to the literature.
METHODS
The focus was pediatric cases of ventricular arrhythmia in which the origin of the PVCs was ablated above the Valsalva. The sample comprised patients who underwent aortic cusp ablation between 2013 and 2018. The demographic characteristics, noninvasive test results, procedure details, and follow-up results for the patients were noted.
RESULTS
The 3D EnSite Precision cardiac mapping system and limited fluoroscopy were used. A total of 26 procedures were performed on 22 patients. The mean age was 14.4 ± 3.0 (9-19) years, and the mean weight was 57.3 ± 17.5 (27-99) kg. The mean follow-up period after the first presentation was 38.6 ± 22.9 (3-72) months. There were significant differences in the values of the transition index, V2S/V3R, IIR/IIIR, aVRS/aVLS ratio, and QRS polarity in I at various locations. The most common ablation site was the left coronary cusp (LCC). Radio frequency (RF) ablation, cryoablation, and irrigated RF ablation were found to be effective energy sources in 15, 4, and 3 patients, respectively. Patients who underwent ablation at the LCC-right coronary cusp (RCC) commissure were more likely to present with only VT and to experience worsening symptoms. Twelve patients had previously undergone ablation of the right ventricular outflow tract (RVOT). Ablation in the RVOT had been previously performed in all the patients who eventually underwent ablation at the RCC and the LCC-RCC commissure.
CONCLUSION
Aortic cusp ablation can be safely performed in children. The careful evaluation of previous noninvasive tests provides important data for determining the location. There might be significant differences in the signs and requirements on the basis of the locations during mapping and ablation.
Topics: Adolescent; Catheter Ablation; Child; Cryosurgery; Electrocardiography; Heart Ventricles; Humans; Tachycardia, Ventricular; Ventricular Premature Complexes
PubMed: 32594368
DOI: 10.1007/s10840-020-00803-0 -
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 -
Heart Rhythm Jun 2023Ventricular fibrillation (VF) can be initiated by ventricular premature depolarizations (VPDs) in the absence of obvious structural abnormalities.
BACKGROUND
Ventricular fibrillation (VF) can be initiated by ventricular premature depolarizations (VPDs) in the absence of obvious structural abnormalities.
OBJECTIVE
The purpose of this study was to determine the prevalence of 12-lead electrocardiographic (ECG) sinus rhythm reduced QRS amplitude, QRS fractionation (QRSf), and early repolarization (ER) pattern, and the outcome of catheter ablation and VPD anatomic distribution in patients with VPDs initiating VF.
METHODS
We compared a cohort with no apparent structural heart disease and VPDs initiating VF (group 1; n = 42) to a reference cohort (group 2; n = 61) of patients with no structural heart disease and symptomatic unifocal VPDs.
RESULTS
A reduced QRS amplitude (<0.55 mV) in aVF (59% vs 10%; P <.001), QRSf in ≥2 contiguous leads (50% vs 16%; P <.001), and ER pattern (21.4% vs 1.6%; P = .01) were more common in group 1 than in group 2. At least 1 abnormal ECG finding was present in 34 group 1 patients (81%) vs 17 group 2 patients (28%) (P <.001). VPD origin included right ventricular and left ventricular distal Purkinje system and moderator band/papillary muscles in 83% of group 1 patients vs 18% of group 2 patients (P <.001). VF was eliminated with a single ablation procedure in 77% of group 1 patients with at least 2 years of follow-up.
CONCLUSION
A reduced QRS amplitude (<0.55 mV) in aVF, QRSf in ≥2 contiguous leads, and/or an ER pattern are frequently observed in patients with VPDs initiating VF. VPDs initiating VF typically originate from the distal Purkinje system and papillary muscles and can be successfully eliminated with catheter ablation.
Topics: Humans; Ventricular Fibrillation; Ventricular Premature Complexes; Electrocardiography; Heart Ventricles; Papillary Muscles; Catheter Ablation
PubMed: 36958413
DOI: 10.1016/j.hrthm.2023.03.019 -
Cardiac Electrophysiology Clinics Dec 2022The Purkinje system has been found to mediate several monomorphic ventricular tachycardias (VTs). These include fascicular VTs and bundle branch reentrant (BBR) VTs.... (Review)
Review
The Purkinje system has been found to mediate several monomorphic ventricular tachycardias (VTs). These include fascicular VTs and bundle branch reentrant (BBR) VTs. Previous studies have revealed that VTs involving the His-Purkinje system are composed of multiple discrete subtypes that are best differentiated by their mechanism, drug effect, VT morphology, and successful ablation site. Recognition of the heterogeneity of these VTs and their unique characteristics should facilitate the appropriate diagnosis and therapy and help guide catheter ablation therapy. In this article, we focus on the latest updates of the mechanisms underlying left ventricle fascicular VTs and BBR-VTs as well as the latest catheter ablation techniques.
Topics: Humans; Tachycardia, Ventricular; Catheter Ablation; Heart Ventricles; Ablation Techniques; Catheters
PubMed: 36396182
DOI: 10.1016/j.ccep.2022.06.003 -
JACC. Clinical Electrophysiology Jun 2021This study sought to determine intramural scar characteristics associated with successful premature ventricular complex (PVC) ablations.
OBJECTIVES
This study sought to determine intramural scar characteristics associated with successful premature ventricular complex (PVC) ablations.
BACKGROUND
Ablating ventricular arrhythmias (VAs) originating from intramural scarring can be challenging. Imaging of intramural scar location may help to determine whether the scar is within reach of the ablation catheter.
METHODS
Mapping and ablation of premature ventricular complexes (PVCs) was performed in a consecutive series of patients with intramural scarring and frequent PVCs. Data from delayed enhanced cardiac magnetic resonance were assessed and the proximity of the endocardium containing the breakout site to the intramural scar was correlated with outcomes.
RESULTS
Fifty-six patients were included, and intramural VAs were successfully targeted in 42 patients (75%) and ablation failed in 14 patients (25%). Scarring was more superficial to the endocardium in patients with successful ablations compared with patients with failed procedures (0.35 mm [interquartile range (IQR): 0.22 to 1.20 mm] vs. 2.45 mm [IQR: 1.60 to 3.13 mm]; p < 0.001). In 18 (32%) patients, ablation at the breakout site resulted in a significant change of the PVC-QRS morphology that could successfully be ablated in 9 of 12 patients from another anatomical aspect of the wall harboring the intramural scar. The scar was larger in size (1.79 cm [IQR: 1.25 to 2.85 cm] vs. 1.00 cm [IQR: 0.59 to 1.68 cm]; p < 0.005) compared with patients who did not have a change in the PVC-QRS morphology with ablation.
CONCLUSIONS
VAs in patients with intramural scaring can be successfully ablated especially if the intramural scar is within close proximity to the anatomic area containing the breakout site. Changes in the QRS-PVC morphology often precede successful ablation at another breakout site and indicate larger intramural scars.
Topics: Catheter Ablation; Cicatrix; Endocardium; Humans; Tachycardia, Ventricular; Ventricular Premature Complexes
PubMed: 33358663
DOI: 10.1016/j.jacep.2020.11.004 -
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