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JACC. Clinical Electrophysiology Dec 2022
Topics: Humans; Papillary Muscles; Heart Ventricles; Mitral Valve Insufficiency
PubMed: 36543497
DOI: 10.1016/j.jacep.2022.08.030 -
JACC. Clinical Electrophysiology Jan 2023The characteristics of patients with post-myocardial infarction (PMI) ventricular tachycardia (VT) who require right ventricular (RV) ablation are underreported.
BACKGROUND
The characteristics of patients with post-myocardial infarction (PMI) ventricular tachycardia (VT) who require right ventricular (RV) ablation are underreported.
OBJECTIVES
The aims of this study were to examine the characteristics and outcomes of patients undergoing PMI VT ablation who have target sites in the right ventricle and to compare patient and VT characteristics between patients with free wall vs septal RV target sites.
METHODS
Consecutive patients undergoing ablation for PMI VT with target sites located within the right ventricle were included. Patients were stratified on the basis of the presence of free wall vs septal RV target sites.
RESULTS
Among 277 consecutive patient undergoing PMI VT ablation, 30 (11%) had RV target sites (mean age 68.71 ± 9.5 years, 29 men [97%], mean left ventricular ejection fraction [LVEF] 28.7% ± 16.7%). Twenty patients had only septal VTs, and 10 patients had only free wall VTs. Fifty-seven VTs with RV targets (1.9 ± 1.4 per patient, mean cycle length 338 ± 90 ms, 53 left bundle branch, 36 superior axis) were induced. Patients with RV free wall VTs had greater rates of RV dysfunction (80% vs 30%; P = 0.023) but had greater LVEFs (38.3% ± 21.06% vs 23.9% ± 11.93%; P = 0.02). Over a mean follow-up period of 3.4 ± 3.2 years, patients with RV septal target sites had worse survival free of VT, transplantation, or left ventricular assist device placement after ablation (log-rank P < 0.05).
CONCLUSIONS
The arrhythmogenic substrate in PMI patients often involves the right ventricle, including the septum and free wall. The presence of RV dysfunction and greater LVEF were associated with the presence of RV free wall target sites. Patients with only RV septal target sites had worse postablation outcomes.
Topics: Male; Humans; Middle Aged; Aged; Heart Ventricles; Stroke Volume; Ventricular Function, Left; Tachycardia, Ventricular; Myocardial Infarction; Catheter Ablation
PubMed: 36697197
DOI: 10.1016/j.jacep.2022.08.034 -
Acute and Long-Term Scar Characterization of Venous Ethanol Ablation in the Left Ventricular Summit.JACC. Clinical Electrophysiology Jan 2023Venous ethanol ablation (VEA) can be effective for ventricular arrhythmias from the left ventricular summit (LVS); however, there are concerns about excessive ablation...
BACKGROUND
Venous ethanol ablation (VEA) can be effective for ventricular arrhythmias from the left ventricular summit (LVS); however, there are concerns about excessive ablation by VEA.
OBJECTIVES
The purpose of this study was to delineate and quantify the location, extent, and evolution of ablated tissue after VEA as an intramural ablation technique in the LVS.
METHODS
VEA was performed in 59 patients with LVS ventricular arrhythmias. Targeted intramural veins were selected by electrograms from a 2F octapolar catheter or by guide-wire unipolar signals. Median ethanol delivered was 4 mL (IQR: 4-7 mL). Ablated areas were estimated intraprocedurally as increased echogenicity on intracardiac echocardiography (ICE) and incorporated into 3-dimensional maps. In 44 patients, late gadolinium enhancement cardiac magnetic resonance (CMR) imaged VEA scar and its evolution.
RESULTS
ICE-demonstrated increased intramural echogenicity (median volume of 2 mL; IQR: 1.7-4.3) at the targeted region of the 3-dimensional maps. Post-ethanol CMR showed intramural scar of 2.5 mL (IQR: 2.1-3.5 mL). Early (within 48 hours after VEA) CMR showed microvascular obstruction (MVO) in 30 of 31 patients. Follow-up CMR after a median of 51 (IQR: 41-170) days showed evolution of MVO to scar. ICE echogenicity and CMR scar volumes correlated with each other and with ethanol volume. Ventricular function and interventricular septum remained intact.
CONCLUSIONS
VEA leads to intramural ablation that can be tracked intraprocedurally by ICE and creates regions of MVO that are chronically replaced by myocardial scar. VEA scar volume does not compromise septal integrity or ventricular function.
Topics: Humans; Cicatrix; Contrast Media; Tachycardia, Ventricular; Catheter Ablation; Gadolinium; Arrhythmias, Cardiac; Ventricular Septum
PubMed: 37166222
DOI: 10.1016/j.jacep.2022.08.035 -
Europace : European Pacing,... Dec 2023High-power ablation is effective for ventricular arrhythmia ablation; however, it increases the risk of steam pops. The aim of this study was to define the safety and...
AIMS
High-power ablation is effective for ventricular arrhythmia ablation; however, it increases the risk of steam pops. The aim of this study was to define the safety and efficacy of QMODE ablation in the ventricle and the risk of steam pop.
METHODS AND RESULTS
Consecutive patients undergoing ventricular ablation using QDOT were included in a prospective single-centre registry. Procedural data, complications, and follow-up were systematically analysed and compared with a historical ventricular tachycardia (VT) and premature ventricular complexes (PVC) cohort ablated using STSF. QMODE (≤50 W) ablation was performed in 107 patients [age 62 ± 13 years; 76% male; VT (n = 41); PVC (n = 66)]. A total of 2456 applications were analysed [power: 45.9 ± 5.0 W with minimal power titration (90% > 95% max power); duration 26 ± 8 s; impedance drop 9.4 ± 4.7 Ω; ablation index: 569 ± 163; mean-max temperature 44.3 ± 2.6°C]. Ventricular tachycardia ablation was associated with shorter radiofrequency (RF) time and a trend towards shorter procedure times using QDOT (QDOT vs. STSF: 20.1 ± 14.7 vs. 31 ± 17 min; P = 0.002, 151 ± 59 vs. 172 ± 48 min; P = 0.06). Complications, VT recurrence, and mortality rates were comparable (QDOT vs. STSF: 2% vs. 2%; P = 0.9, 24% vs. 27%; P = 0.82, and 2% vs. 4%; P = 0.67). Five audible steam pops (0.02%) occurred. Premature ventricular complex ablation was associated with comparable RF and procedure times (QDOT vs. STSF: 4.8 ± 4.6 vs. 3.9 ± 3.1 min; P = 0.25 and 96.1 ± 31.9 vs. 94.6 ± 24.7 min; P = 0.75). Complication and PVC recurrence were also comparable (QDOT vs. STSF: 0% vs. 3%; P = 0.17 and 19% vs. 22%; P = 0.71).
CONCLUSION
Ventricular ablation using QMODE ≤ 50 W is safe and effective for both VT and PVC ablation and is associated with a low risk for steam pop.
Topics: Humans; Male; Middle Aged; Aged; Female; Prospective Studies; Steam; Temperature; Arrhythmias, Cardiac; Radiofrequency Ablation; Tachycardia, Ventricular
PubMed: 38193796
DOI: 10.1093/europace/euad372 -
Journal of Clinical Medicine Dec 2023Thanks to advancements in percutaneous cardiac interventions, an expanding patient population now qualifies for treatment through percutaneous endovascular procedures.... (Review)
Review
Thanks to advancements in percutaneous cardiac interventions, an expanding patient population now qualifies for treatment through percutaneous endovascular procedures. High-risk interventions far exceed coronary interventions and include transcatheter aortic valve replacement, endovascular management of acute pulmonary embolism and ventricular tachycardia ablation. Given the frequent impairment of ventricular function in these patients, frequently deteriorating during percutaneous interventions, it is hypothesized that mechanical ventricular support may improve periprocedural survival and subsequently patient outcome. In this narrative review, we aimed to provide the relevant evidence found for the clinical use of percutaneous mechanical circulatory support (pMCS). We searched the Pubmed database for articles related to pMCS and to pMCS and invasive cath lab procedures. The articles and their references were evaluated for relevance. We provide an overview of the clinically relevant evidence for intra-aortic balloon pump, Impella, TandemHeart and ECMO and their role as pMCS in high-risk percutaneous coronary intervention, transcatheter valvular procedures, ablations and high-risk pulmonary embolism. We found that the right choice of periprocedural pMCS could provide a solution for the hemodynamic challenges during these procedures. However, to enhance the understanding of the safety and effectiveness of pMCS devices in an often high-risk population, more randomized research is needed.
PubMed: 38137824
DOI: 10.3390/jcm12247755 -
Europace : European Pacing,... May 2023Ablation of outflow tract ventricular arrhythmias may be limited by a deep intramural location of the arrhythmogenic source. This study evaluates the acute and long-term...
AIMS
Ablation of outflow tract ventricular arrhythmias may be limited by a deep intramural location of the arrhythmogenic source. This study evaluates the acute and long-term outcomes of patients undergoing ablation of intramural outflow tract premature ventricular complexes (PVCs).
METHODS AND RESULTS
This multicenter series included patients with structurally normal heart or nonischemic cardiomyopathy and intramural outflow tract PVCs defined by: (a) ≥ 2 of the following criteria: (1) earliest endocardial or epicardial activation < 20ms pre-QRS; (2) Similar activation in different chambers; (3) no/transient PVC suppression with ablation at earliest endocardial/epicardial site; or (b) earliest ventricular activation recorded in a septal coronary vein. Ninety-two patients were included, with a mean PVC burden of 21.5±10.9%. Twenty-six patients had had previous ablations. All PVCs had inferior axis, with LBBB pattern in 68%. In 29 patients (32%) direct mapping of the intramural septum was performed using an insulated wire or multielectrode catheter, and in 13 of these cases the earliest activation was recorded within a septal vein. Most patients required special ablation techniques (one or more), including sequential unipolar ablation in 73%, low-ionic irrigation in 26%, bipolar ablation in 15% and ethanol ablation in 1%. Acute PVC suppression was achieved in 75% of patients. Following the procedure, the PVC burden was reduced to 5.8±8.4%. The mean follow-up was 15±14 months and 16 patients underwent a repeat ablation.
CONCLUSION
Ablation of intramural PVCs is challenging; acute arrhythmia elimination is achieved in 3/4 patients, and non-conventional approaches are often necessary for success.
Topics: Humans; Tachycardia, Ventricular; Ventricular Premature Complexes; Heart Ventricles; Catheter Ablation; Endocardium; Treatment Outcome
PubMed: 37096979
DOI: 10.1093/europace/euad100 -
JACC. Clinical Electrophysiology Jun 2023A new functional mapping strategy based on targeting deceleration zones (DZs) has become one of the most commonly used strategies within the armamentarium of...
BACKGROUND
A new functional mapping strategy based on targeting deceleration zones (DZs) has become one of the most commonly used strategies within the armamentarium of substrate-based ablation methods for ventricular tachycardia (VT) in patients with structural heart disease. The classic conduction channels detected by voltage mapping can be accurately determined by cardiac magnetic resonance (CMR).
OBJECTIVES
The purpose of this study was to analyze the evolution of DZs during ablation and their correlation with CMR.
METHODS
Forty-two consecutive patients with scar-related VT undergoing ablation after CMR in Hospital Clinic (October 2018-December 2020) were included (median age 65.3 ± 11.8 years; 94.7% male; 73.7% ischemic heart disease). Baseline DZs and their evolution in isochronal late activation remaps were analyzed. A comparison between DZs and CMR conducting channels (CMR-CCs) was realized. Patients were prospectively followed for VT recurrence for 1 year.
RESULTS
Overall, 95 DZs were analyzed, 93.68% of which were correlated with CMR-CCs: 44.8% located in the middle segment and 55.2% located in the entrance/exit of the channel. Remapping was performed in 91.7% of patients (1 remap: 33.3%, 2 remaps: 55.6%, and 3 remaps: 2.8%). Regarding the evolution of DZs, 72.2% disappeared after the first ablation set, with 14.13% not ablated at the end of the procedure. A total of 32.5% of DZs in remaps correlated with a CMR-CCs already detected, and 17.5% were associated with an unmasked CMR-CCs. One-year VT recurrence was 22.9%.
CONCLUSIONS
DZs are highly correlated with CMR-CCs. In addition, remapping can lead to the identification of hidden substrate initially not identified by electroanatomic mapping but detected by CMR.
Topics: Humans; Male; Middle Aged; Aged; Female; Deceleration; Magnetic Resonance Imaging; Heart; Tachycardia, Ventricular; Magnetic Resonance Spectroscopy
PubMed: 37380313
DOI: 10.1016/j.jacep.2022.12.015 -
International Journal of Cardiology Jul 2024Radiofrequency ablation (RFA) has been a central therapeutic strategy for ventricular tachycardia (VT). However, concerns about its long-term effectiveness and... (Review)
Review
Radiofrequency ablation (RFA) has been a central therapeutic strategy for ventricular tachycardia (VT). However, concerns about its long-term effectiveness and complications have arisen. Pulsed field ablation (PFA), characterized by its nonthermal, highly tissue-selective ablation technique, has emerged as a promising alternative. This comprehensive review delves into the potential advantages and opportunities presented by PFA in the realm of VT, drawing insights from both animal experimentation and clinical case studies. PFA shows promise in generating superior lesions within scarred myocardial tissue, and its inherent repetition dependency holds the potential to enhance therapeutic outcomes. Clinical cases underscore the promise of PFA for VT ablation. Despite its promising applications, challenges such as catheter maneuverability and proarrhythmic effects require further investigation. Large-scale, long-term studies are essential to establish the suitability of PFA for VT treatment.
Topics: Tachycardia, Ventricular; Humans; Catheter Ablation; Animals; Treatment Outcome
PubMed: 38513736
DOI: 10.1016/j.ijcard.2024.131985 -
Cureus Nov 2021Background EnSite Precision technology (Abbott, Chicago, Illinois) is a novel mapping and navigation system facilitating the visualization and manipulation of...
Background EnSite Precision technology (Abbott, Chicago, Illinois) is a novel mapping and navigation system facilitating the visualization and manipulation of intracardiac catheters during arrhythmia ablation procedures. When using Sensor Enabled (SE) catheters (Abbott, Chicago, Illinois), the mapping system uses both electrical impedance and magnetic data to facilitate more accurate mapping and navigation. Whether this translates into better clinical outcomes is unknown. Methods This retrospective study will examine whether SE catheters improve the success rate or decrease the risks compared to Biosense Thermocool catheters (Biosense Webster Inc., Irvine, California) not employing sensor-enabled technology utilizing NavX EnSite Precision algorithms. Charts of 146 patients who underwent radiofrequency ablations for supraventricular and ventricular arrhythmias between 2016 and 2019 in the Beirut Cardiac Institute were reviewed and analyzed. It was concluded that SE catheters have the same success rate as electrical impedance catheters. Results A total of 70% of the ablations carried using the impedance-based catheter were successful compared to 74% using the SE catheter. However, the difference was statistically non-significant (p-value: 0.7). As for complications, the ventricular fibrillation rate was increased in the SE catheter group. Three procedures were complicated by pericardial effusion, three patients had reversible heart block, and one death was recorded, all reported while using the standard catheter (p-value: 0.01). Conclusion SE catheters have the same success rates compared to standard catheters using the EnSite Precision mapping system.
PubMed: 34926037
DOI: 10.7759/cureus.19550 -
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