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Frontiers in Cardiovascular Medicine 2021Noninvasive cardiac imaging is crucial for the characterization of patients who are candidates for cardiac ablations, for both procedure planning and long-term... (Review)
Review
Noninvasive cardiac imaging is crucial for the characterization of patients who are candidates for cardiac ablations, for both procedure planning and long-term management. Multimodality cardiac imaging can provide not only anatomical parameters but even more importantly functional information that may allow a better risk stratification of cardiac patients. Moreover, fusion of anatomical and functional data derived from noninvasive cardiac imaging with the results of endocavitary mapping may possibly allow a better identification of the ablation substrate and also avoid peri-procedural complications. As a result, imaging-guided electrophysiological procedures are associated with an improved outcome than traditional ablation procedures, with a consistently lower recurrence rate.
PubMed: 33996938
DOI: 10.3389/fcvm.2021.640087 -
Europace : European Pacing,... Apr 2023Data on ventricular pulsed-field ablation (PFA) are sparse in the setting of chronic myocardial infarction (MI). The objective of this study was to compare the...
AIMS
Data on ventricular pulsed-field ablation (PFA) are sparse in the setting of chronic myocardial infarction (MI). The objective of this study was to compare the biophysical and histopathologic characteristics of PFA in healthy and MI swine ventricular myocardium.
METHODS AND RESULTS
Myocardial infarction swine (n = 8) underwent coronary balloon occlusion and survived for 30 days. We then performed endocardial unipolar, biphasic PFA of the MI border zone and a dense scar with electroanatomic mapping and using an irrigated contact force (CF)-sensing catheter with the CENTAURI System (Galaxy Medical). Lesion and biophysical characteristics were compared with three controls: MI swine undergoing thermal ablation, MI swine undergoing no ablation, and healthy swine undergoing similar PFA applications that included linear lesion sets. Tissues were systematically assessed by gross pathology utilizing 2,3,5-triphenyl-2H-tetrazolium chloride staining and histologically with haematoxylin and eosin and trichrome. Pulsed-field ablation in healthy myocardium generated well-demarcated ellipsoid lesions (7.2 ± 2.1 mm depth) with contraction band necrosis and myocytolysis. Pulsed-field ablation in MI demonstrated slightly smaller lesions (depth 5.3 ± 1.9 mm, P = 0.0002), and lesions infiltrated into the irregular scar border, resulting in contraction band necrosis and myocytolysis of surviving myocytes and extending to the epicardial border of the scar. Coagulative necrosis was present in 75% of thermal ablation controls but only in 16% of PFA lesions. Linear PFA resulted in contiguous linear lesions with no gaps in gross pathology. Neither CF nor local R-wave amplitude reduction correlated with lesion size.
CONCLUSION
Pulsed-field ablation of a heterogeneous chronic MI scar effectively ablates surviving myocytes within and beyond the scar, demonstrating promise for the clinical ablation of scar-mediated ventricular arrhythmias.
Topics: Swine; Animals; Cicatrix; Myocardium; Heart Ventricles; Heart; Myocardial Infarction; Arrhythmias, Cardiac; Catheter Ablation; Tachycardia, Ventricular
PubMed: 36793229
DOI: 10.1093/europace/euac252 -
JACC. Clinical Electrophysiology Apr 2022This study sought to explore whether prolonged duration (PD) radiofrequency ablation (RFA) from adjacent endocardial locations can improve catheter ablation (CA)...
OBJECTIVES
This study sought to explore whether prolonged duration (PD) radiofrequency ablation (RFA) from adjacent endocardial locations can improve catheter ablation (CA) outcomes of left ventricular summit (LVS) ventricular arrhythmias (Vas).
BACKGROUND
CA of VAs originating from the LVS region can be challenging.
METHODS
Patients undergoing CA of LVS VAs from January 1, 2015, to December 31, 2019, were included. Standard RFA approach involved incremental power titration (20-45 W) over 60-120 seconds with irrigated tip catheter to achieve 10%-12% impedance drop. Prolonged duration RFA involved similar power titration; however, lesion application was extended beyond 120 seconds (maximum 5 minutes). Lesions were confined to lowest aspect of aortic cusps and/or subvalvular LV outflow tract region (≤0.5 cm from the valve). Procedural success was defined as suppression of VA ≥30 minutes postablation and clinical success as no arrhythmia symptoms on follow-up and >80% reduction of VA burden on postprocedure monitor.
RESULTS
This study included 102 patients (60±14 years old, 62% male): standard RFA in 80 and PD RFA in 38. Procedural success was achieved in 54 patients with standard and 32 patients with PD RFA (68% vs 84%; P = 0.05). Short-term clinical success was achieved in 48 patients (60%) with standard and 30 patients (79%) with PD RFA (P = 0.04). Two pericardial effusions occurred (1 in each group) and no steam pops were noted. Patients in whom standard RFA was successful were more likely to have R/S ratio >1 or absence of qS in lead I (odds ratio: 3.35; 95% CI: 1.20-9.35; P = 0.03).
CONCLUSIONS
Prolonged duration RFA from adjacent endocardial locations is a safe and effective technique for successfully targeting challenging LVS VAs that fail standard RFA.
Topics: Aged; Arrhythmias, Cardiac; Catheter Ablation; Endocardium; Female; Heart Ventricles; Humans; Male; Middle Aged; Treatment Outcome
PubMed: 35450601
DOI: 10.1016/j.jacep.2021.12.010 -
ESC Heart Failure Apr 2022End-stage heart failure necessitating evaluation for heart transplantation is increasingly recognized in arrhythmogenic right ventricular cardiomyopathy (ARVC). These...
AIMS
End-stage heart failure necessitating evaluation for heart transplantation is increasingly recognized in arrhythmogenic right ventricular cardiomyopathy (ARVC). These patients present unique challenges in pre-transplant and peri-transplant management given their predominantly right ventricular (RV) failure and propensity for ventricular arrhythmias. We sought to utilize a tertiary ARVC referral and heart transplant centre experience to describe management of a series of patients with ARVC undergoing heart transplantation at our centre.
METHODS AND RESULTS
We queried the Johns Hopkins ARVC Registry for all patients who underwent heart transplantation and further studied the subset undergoing transplantation at the Johns Hopkins Hospital. Patient demographics, clinical characteristics, and pre-transplant clinical course were obtained from the registry and electronic medical records. Of the 532 patients in the ARVC Registry, 63 (12%) underwent heart transplantation. Nine (six male) of these patients both had known ARVC prior to transplant and were transplanted at Johns Hopkins Hospital between 2006 and 2020 at a mean age of 42 ± 14 years old. Pathogenic ARVC genetic variants were identified in six (67%) patients, all of whom had variants in the plakophilin-2 (PKP2) gene. RV failure was universal with median right atrial to pulmonary capillary wedge pressure (RA/PCWP) ratio of 1.4 [interquartile range (IQR) 1.2-1.5] and median right ventricular stroke work index (RVSWI) of 0 g·m/m /beat (IQR 0-0.3). Six had a history of catheter ablation for ventricular arrhythmia with five of the six having at least three ablations. Transplant evaluation was initiated an average of 344 ± 407 days after first developing heart failure symptoms. The most common bridge to transplant support included inotropes (n = 3) and extracorporeal membrane oxygenation (ECMO) (n = 2). Contraindication to inotropes or mechanical support was common due to ventricular arrhythmia and RV predominant cardiomyopathy.
CONCLUSIONS
Heart transplantation is a curative treatment for ARVC, but due to frequent ventricular arrhythmias and RV predominant pathology, patients require unique considerations in regard to timing of evaluation, haemodynamic support options, and wait listing qualification.
Topics: Adult; Arrhythmogenic Right Ventricular Dysplasia; Cardiomyopathies; Catheter Ablation; Heart Failure; Heart Transplantation; Humans; Male; Middle Aged
PubMed: 34953065
DOI: 10.1002/ehf2.13757 -
Europace : European Pacing,... Dec 2023Recurrences of ventricular tachycardia (VT) after initial catheter ablation is a significant clinical problem. In this study, we report the efficacy and risks of repeat...
AIMS
Recurrences of ventricular tachycardia (VT) after initial catheter ablation is a significant clinical problem. In this study, we report the efficacy and risks of repeat VT ablation in patients with structural heart disease (SHD) in a tertiary single centre over a 7-year period.
METHODS AND RESULTS
Two hundred ten consecutive patients referred for repeat VT ablation after previous ablation in our institution were included in the analysis (53% ischaemic cardiomyopathy, 91% males, median age 65 years, mean left ventricular ejection fraction 35%). After performing repeat ablation, the clinical VTs were acutely eliminated in 82% of the patients, but 46% of the cohort presented with VT recurrence during the 25-month follow-up. Repeat ablation led to a 73% reduction of shock burden in the first year and 61% reduction until the end of follow-up. Similarly, VT burden was reduced 55% in the first year and 36% until the end of the study. Fifty-two patients (25%) reached the combined endpoint of ventricular assist device implantation, heart transplantation, or death. Advanced New York Heart Association functional class, anteroseptal substrate, and periprocedural complication after repeat ablation were associated with worse prognosis independently of the type of cardiomyopathy.
CONCLUSION
While complete freedom from VT after repeat ablation in SHD was difficult to achieve, ablation led to a significant reduction in VT and shock burden. Besides advanced heart failure characteristics, anteroseptal substrate and periprocedural complications predicted a worse outcome.
Topics: Male; Humans; Aged; Female; Stroke Volume; Ventricular Function, Left; Heart Diseases; Tachycardia, Ventricular; Cardiomyopathies; Catheter Ablation; Treatment Outcome; Recurrence
PubMed: 38127308
DOI: 10.1093/europace/euad367 -
Archivos de Cardiologia de Mexico 2022A young female patient with normal ejection fraction. History of premature ventricular complex (PVC) radiofrequency ablation located in left ventricular outflow tract....
A young female patient with normal ejection fraction. History of premature ventricular complex (PVC) radiofrequency ablation located in left ventricular outflow tract. Two years later frequent PVC is observed in a different location (> 47000 in 24 h Holter). Anti-arrhythmic drugs were used unsuccessfully. PVCs were located in left ventricular summit. Radiofrequency ablation through coronary sinus and anterior interventricular vein was performed. During follow up no recurrence was observed. A young female patient with normal ejection fraction. History of premature ventricular complex (PVC) radiofrequency ablation located in left ventricular outflow tract. Two years later frequent PVC is observed in a different location (> 47000 in 24 h Holter). Anti-arrhythmic drugs were used unsuccessfully. PVCs were located in left ventricular summit. Radiofrequency ablation through coronary sinus and anterior interventricular vein was performed. During follow up no recurrence was observed.
Topics: Catheter Ablation; Female; Heart Ventricles; Humans; Radiofrequency Ablation; Treatment Outcome; Ventricular Premature Complexes
PubMed: 34987237
DOI: 10.24875/ACM.20000356 -
HeartRhythm Case Reports Apr 2023
PubMed: 37101677
DOI: 10.1016/j.hrcr.2022.12.012 -
Journal of Clinical Medicine Apr 2023Frequent premature ventricular complexes (PVCs) can cause PVC-induced cardiomyopathy. The value of PVC ablation in patients with preserved left ventricular function in...
BACKGROUND
Frequent premature ventricular complexes (PVCs) can cause PVC-induced cardiomyopathy. The value of PVC ablation in patients with preserved left ventricular function in the low-normal range (ejection fraction: 50-55%) is not established. Strain analysis has been used to estimate changes in left ventricular function beyond assessment of the ejection fraction (EF). Longitudinal strain has been proposed as a method to detect changes over time in the setting of frequent asymptomatic premature ventricular complexes and preserved left ventricular (LV) function. A decrease in strain may be evidence of PVC-induced cardiomyopathy.
OBJECTIVE
In this study, we assessed the role of PVC ablation in patients with low-normal EF and the effect on EF and myocardial strain before and after PVC ablation.
METHODS
A total of 70 consecutive patients with either low-normal EF (0.5-<0.55, = 35) or high-normal EF (≥0.55; = 35), using available imaging and Holter data, were referred for ablation due to frequent PVCs. EF and longitudinal strain were assessed pre- and post-ablation.
RESULTS
There was a significant increase in EF (53.2 ± 0.4% to 58.3 ± 0.5%, < 0.001) and improvement in longitudinal strain (-15.2 ± 3.3 to -16.6 ± 3, 0.007) post-ablation in patients with low-normal EF and successful ablation. There was no change in EF or longitudinal strain in patients with high-normal EF and a successful ablation pre- vs. post-ablation.
CONCLUSIONS
Patients with frequent PVCs and low-normal LV EF compared to patients with frequent PVCs and high-normal LV EF have evidence of PVC-induced cardiomyopathy and may benefit from ablation despite a preserved left ventricular EF.
PubMed: 37109352
DOI: 10.3390/jcm12083017 -
Lakartidningen Jun 2024Ventricular tachycardia (VT) in patients with structural heart disease is potentially life threatening, and most patients have an indication for an implantable... (Review)
Review
Ventricular tachycardia (VT) in patients with structural heart disease is potentially life threatening, and most patients have an indication for an implantable cardioverter-defibrillator (ICD). Catheter ablation is an effective therapeutic strategy to reduce the risk of VT recurrence and subsequent ICD therapies. However, VT ablation is a technically complex procedure with significant risks and should be performed in experienced centers with appropriate resources. While several reports on outcome and procedural risks have been published, there is currently no data from Sweden. In addition to this literature review, we have analyzed VT ablation outcome data from our center. In 2021 and 2022, 68 VT ablations were performed in 60 patients with structural heart disease. After a median follow-up of 20 months, 18 percent had recurrent VT and there were 2 major adverse events (stroke and complete atrioventricular block). Seven patients died from non-arrhythmia related causes during follow-up. A large proportion (68 percent) were subacute procedures which are associated with a higher periprocedural risk. Referral for VT ablation earlier in the course of disease progression may likely further improve outcomes.
Topics: Humans; Catheter Ablation; Tachycardia, Ventricular; Defibrillators, Implantable; Treatment Outcome; Recurrence; Male; Female; Aged; Sweden; Middle Aged; Postoperative Complications
PubMed: 38832571
DOI: No ID Found -
European Heart Journal Mar 2022Mapping data of human ventricular fibrillation (VF) are limited. We performed detailed mapping of the activities underlying the onset of VF and targeted ablation in...
AIMS
Mapping data of human ventricular fibrillation (VF) are limited. We performed detailed mapping of the activities underlying the onset of VF and targeted ablation in patients with structural cardiac abnormalities.
METHODS AND RESULTS
We evaluated 54 patients (50 ± 16 years) with VF in the setting of ischaemic (n = 15), hypertrophic (n = 8) or dilated cardiomyopathy (n = 12), or Brugada syndrome (n = 19). Ventricular fibrillation was mapped using body-surface mapping to identify driver (reentrant and focal) areas and invasive Purkinje mapping. Purkinje drivers were defined as Purkinje activities faster than the local ventricular rate. Structural substrate was delineated by electrogram criteria and by imaging. Catheter ablation was performed in 41 patients with recurrent VF. Sixty-one episodes of spontaneous (n = 10) or induced (n = 51) VF were mapped. Ventricular fibrillation was organized for the initial 5.0 ± 3.4 s, exhibiting large wavefronts with similar cycle lengths (CLs) across both ventricles (197 ± 23 vs. 196 ± 22 ms, P = 0.9). Most drivers (81%) originated from areas associated with the structural substrate. The Purkinje system was implicated as a trigger or driver in 43% of patients with cardiomyopathy. The transition to disorganized VF was associated with the acceleration of initial reentrant activities (CL shortening from 187 ± 17 to 175 ± 20 ms, P < 0.001), then spatial dissemination of drivers. Purkinje and substrate ablation resulted in the reduction of VF recurrences from a pre-procedural median of seven episodes [interquartile range (IQR) 4-16] to 0 episode (IQR 0-2) (P < 0.001) at 56 ± 30 months.
CONCLUSIONS
The onset of human VF is sustained by activities originating from Purkinje and structural substrate, before spreading throughout the ventricles to establish disorganized VF. Targeted ablation results in effective reduction of VF burden.
KEY QUESTION
The initial phase of human ventricular fibrillation (VF) is critical as it involves the primary activities leading to sustained VF and arrhythmic sudden death. The origin of such activities is unknown.
KEY FINDING
Body-surface mapping shows that most drivers (≈80%) during the initial VF phase originate from electrophysiologically defined structural substrates. Repetitive Purkinje activities can be elicited by programmed stimulation and are implicated as drivers in 37% of cardiomyopathy patients.
TAKE-HOME MESSAGE
The onset of human VF is mostly associated with activities from the Purkinje network and structural substrate, before spreading throughout the ventricles to establish sustained VF. Targeted ablation reduces or eliminates VF recurrence.
Topics: Body Surface Potential Mapping; Brugada Syndrome; Catheter Ablation; Electrocardiography; Heart Ventricles; Humans; Ventricular Fibrillation
PubMed: 35134898
DOI: 10.1093/eurheartj/ehab893