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Circulation Nov 2022Ablation of ventricular tachycardia (VT) in the setting of structural heart disease often requires extensive substrate elimination that is not always achievable by...
BACKGROUND
Ablation of ventricular tachycardia (VT) in the setting of structural heart disease often requires extensive substrate elimination that is not always achievable by endocardial radiofrequency ablation. Epicardial ablation is not always feasible. Case reports suggest that venous ethanol ablation (VEA) through a multiballoon, multivein approach can lead to effective substrate ablation, but large data sets are lacking.
METHODS
VEA was performed in 44 consecutive patients with ablation-refractory VT (ischemic, n=21; sarcoid, n=3; Chagas, n=2; idiopathic, n=18). Targeted veins were selected by mapping coronary veins on the epicardial aspect of endocardial scar (identified by bipolar voltage <1.5 mV), using venography and signal recording with a 2F octapolar catheter or by guidewire unipolar signals. Epicardial mapping was performed in 15 patients. Vein segments in the epicardial aspect of VT substrates were treated with double-balloon VEA by blocking flow with 1 balloon while injecting ethanol through the lumen of the second balloon, forcing (and restricting) ethanol between balloons. Multiple balloon deployments and multiple veins were used as needed. In 22 patients, late gadolinium enhancement cardiac magnetic resonance imaged the VEA scar and its evolution.
RESULTS
Median ethanol delivered was 8.75 (interquartile range, 4.5-13) mL. Injected veins included interventricular vein (6), diagonal (5), septal (12), lateral (16), posterolateral (7), and middle cardiac vein (8), covering the entire range of left ventricular locations. Multiple veins were targeted in 14 patients. Ablated areas were visualized intraprocedurally as increased echogenicity on intracardiac echocardiography and incorporated into 3-dimensional maps. After VEA, vein and epicardial ablation maps showed elimination of abnormal electrograms of the VT substrate. Intracardiac echocardiography demonstrated increased intramural echogenicity at the targeted region of the 3-dimensional maps. At 1 year of follow-up, median of 314 (interquartile range, 198-453) days of follow-up, VT recurrence occurred in 7 patients, for a success of 84.1%.
CONCLUSIONS
Multiballoon, multivein intramural ablation by VEA can provide effective substrate ablation in patients with ablation-refractory VT in the setting of structural heart disease over a broad range of left ventricular locations.
Topics: Humans; Coronary Vessels; Cicatrix; Ethanol; Contrast Media; Gadolinium; Tachycardia, Ventricular; Catheter Ablation
PubMed: 36321460
DOI: 10.1161/CIRCULATIONAHA.122.060882 -
JACC. Clinical Electrophysiology Jun 2023Despite extensive conventional endoepicardial ablation, significant intramural arrhythmogenic substrate may remain out of reach of unipolar radiofrequency ablation... (Review)
Review
Despite extensive conventional endoepicardial ablation, significant intramural arrhythmogenic substrate may remain out of reach of unipolar radiofrequency ablation (RFA). The authors present clinical findings and procedural workflow for bipolar radiofrequency ablation (B-RFA) with 1 catheter placed against the endocardium and the other in the pericardial sac to ablate refractory ventricular arrhythmias. No serious adverse events occurred during B-RFA procedures, and the short-term and midterm clinical results were satisfactory. Optimal catheter choice and ablation parameters settings for B-RFA remain to be determined.
Topics: Humans; Tachycardia, Ventricular; Treatment Outcome; Catheter Ablation; Arrhythmias, Cardiac; Pericardium
PubMed: 37227350
DOI: 10.1016/j.jacep.2023.02.026 -
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 -
Clinical Research in Cardiology :... May 2022Catheter ablation of ventricular arrhythmias (VA) has proven to be an effective therapeutic option for secondary arrhythmia prophylaxis. We sought to assess the...
AIMS
Catheter ablation of ventricular arrhythmias (VA) has proven to be an effective therapeutic option for secondary arrhythmia prophylaxis. We sought to assess the procedural efficacy, safety and in-hospital mortality of a large patient cohort with and without structural heart disease undergoing VA ablation.
METHODS
A total of 1417 patients (804 patients with structural heart disease) undergoing 1792 endo- and epicardial procedures were analyzed. Multivariable risk factor analysis for occurrence of major complications and intrahospital mortality was obtained and a score to allow preprocedural risk assessment for patients undergoing VA ablation procedures was established.
RESULTS
Major complication occurred in 4.4% of all procedures and significantly more often in patients with structural heart disease than in structurally normal hearts (6.0 vs. 1.8%). The frequency of these periprocedural complications was significantly different between procedures with sole right ventricular and a combination of RV and LV access (0.5 vs. 3.1%). The most common complication was cardiac tamponade in 46 cases (3.0%). Intrahospital death was observed in 32 patients (1.8%). Logistic regression model revealed presence of ischemic heart disease, epicardial ablation, presence of oral anticoagulation or dual antiplatelet therapy as independent risk factors for the occurrence of complications or intrahospital death, while a history of previous heart surgery was an independent predictor with a decreased risk. Based on this analysis a risk score incorporating 5 standard variables was established to predict the occurrence of complications and intrahospital mortality.
CONCLUSIONS
Safety of VA catheter ablation mainly relies on patient baseline characteristics and the type of access into the ventricles or epicardial space.
Topics: Arrhythmias, Cardiac; Cardiac Tamponade; Catheter Ablation; Humans; Risk Factors; Tachycardia, Ventricular; Treatment Outcome
PubMed: 34318341
DOI: 10.1007/s00392-021-01902-2 -
Reviews in Cardiovascular Medicine Jan 2022Catheter ablation is a well-established treatment option for patients with ventricular arrhythmias. Recent advances in various imaging modalities, including... (Review)
Review
Catheter ablation is a well-established treatment option for patients with ventricular arrhythmias. Recent advances in various imaging modalities, including three-dimensional electroanatomic mapping systems, magnetic resonance imaging, transesophageal and intracardiac echocardiography (ICE) have been adopted in catheter ablation of ventricular arrhythmias improving procedural outcome and safety. ICE is an imaging tool which provides real-time visualization of anatomical structures of the heart, facilitating catheter manipulation and navigation during ablation procedures. In this review we aim to highlight the benefits of ICE use in catheter ablation of ventricular arrhythmias and to describe practical techniques for visualization of cardiac structures with ICE during ventricular tachycardia ablations.
Topics: Arrhythmias, Cardiac; Catheter Ablation; Echocardiography; Heart; Humans
PubMed: 35092217
DOI: 10.31083/j.rcm2301025 -
Journal of Cardiology Sep 2022About 30% of patients with hypertrophic cardiomyopathy have a significant left ventricular pressure gradient at rest, and 60%-70% of these patients are diagnosed with... (Review)
Review
About 30% of patients with hypertrophic cardiomyopathy have a significant left ventricular pressure gradient at rest, and 60%-70% of these patients are diagnosed with hypertrophic obstructive cardiomyopathy (HOCM) because an induced pressure gradient is also present. Percutaneous transluminal septal myocardial ablation (PTSMA) is a procedure in which ethanol is used to ablate the portion of the septal myocardium that is involved in the pathogenesis of the left ventricular outflow tract pressure gradient (LVOT PG). In 1995, Sigwart et al. reported three cases of PTSMA in The Lancet. The introduction of PTSMA into clinical practice has enabled the reduction of LVOT PG and improvement of heart failure symptoms in elderly and high-risk patients with symptomatic, drug-refractory HOCM. In 1998, Faber et al. published a report in Circulation on selective septal myocardial ablation using myocardial contrast echocardiography (MCE). MCE-guided PTSMA is now recognized as the standard method of PTSMA in many countries and regions, including Europe, North America, and Asia, and is estimated to be performed on about 300 to 400 patients per year in Japan based on reports from the Japanese Circulation Society's Clinical Practice Survey. The current problems with this technique are: 1) the outcome is greatly influenced by operators' and institutional experience, and 2) it is difficult to determine in advance whether the patient is a PTSMA responder or not. Recently, advancements in imaging modalities, including cardiac computed tomography and magnetic resonance imaging, have facilitated clarification of the mechanisms of LVOT obstruction. Therefore, more appropriate decisions regarding PTSMA and surgical myectomy (SM) are now made. Better treatment selection will undoubtedly improve the prognosis of patients with drug-refractory HOCM complicated by heart failure, and further elucidation of the pathogenesis of LVOT obstruction and technical advances in PTSMA and SM are eagerly awaited.
Topics: Aged; Cardiac Surgical Procedures; Cardiomyopathy, Hypertrophic; Catheter Ablation; Echocardiography; Heart Failure; Heart Septum; Humans; Treatment Outcome
PubMed: 34924238
DOI: 10.1016/j.jjcc.2021.11.023 -
JACC. Clinical Electrophysiology Mar 2023
Topics: Humans; Cicatrix; Tachycardia, Ventricular; Electrocardiography; Catheter Ablation
PubMed: 36990594
DOI: 10.1016/j.jacep.2023.02.005 -
Europace : European Pacing,... Nov 2021We studied the extent/area of electrical pulmonary vein isolation (PVI) after either pulsed field ablation (PFA) using a pentaspline catheter or thermal ablation... (Clinical Trial)
Clinical Trial
AIMS
We studied the extent/area of electrical pulmonary vein isolation (PVI) after either pulsed field ablation (PFA) using a pentaspline catheter or thermal ablation technologies.
METHODS AND RESULTS
In a clinical trial (NCT03714178), paroxysmal atrial fibrillation (PAF) patients underwent PVI with a multi-electrode pentaspline PFA catheter using a biphasic waveform, and after 75 days, detailed voltage maps were created during protocol-specified remapping studies. Comparative voltage mapping data were retrospectively collected from consecutive PAF patients who (i) underwent PVI using thermal energy, (ii) underwent reablation for recurrence, and (iii) had durably isolated PVs. The left and right PV antral isolation areas and non-ablated posterior wall were quantified. There were 20 patients with durable PVI in the PFA cohort, and 39 in the thermal ablation cohort [29 radiofrequency ablation (RFA), 6 cryoballoon, and 4 visually guided laser balloon]. Pulsed field ablation patients were younger with shorter follow-up. Left atrial diameter and ventricular systolic function were preserved in both cohorts. There was no significant difference between the PFA and thermal ablation cohorts in either the left- and right-sided PV isolation areas, or the non-ablated posterior wall area. The right superior PV isolation area was smaller with PFA than RFA, but this disappeared after propensity score matching. Notch-like normal voltage areas were seen at the posterior aspect of the carina in the balloon sub-cohort, but not the PFA or RFA cohorts.
CONCLUSION
Catheter-based PVI with the pentaspline PFA catheter creates chronic PV antral isolation areas as encompassing as thermal energy ablation.
Topics: Atrial Fibrillation; Catheter Ablation; Cryosurgery; Humans; Laser Therapy; Pulmonary Veins; Radiofrequency Ablation; Recurrence; Retrospective Studies; Treatment Outcome
PubMed: 34151947
DOI: 10.1093/europace/euab150 -
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 -
Circulation. Arrhythmia and... May 2020There is paucity of data regarding radiofrequency ablation for ventricular tachycardia (VT) in patients with cardiogenic shock and concomitant VT refractory to... (Comparative Study)
Comparative Study
BACKGROUND
There is paucity of data regarding radiofrequency ablation for ventricular tachycardia (VT) in patients with cardiogenic shock and concomitant VT refractory to antiarrhythmic drugs on mechanical support.
METHODS
Patients undergoing VT ablation at our center were enrolled in a prospectively maintained registry and screened for the current study (2010-2017).
RESULTS
All 21 consecutive patients with cardiogenic shock and concomitant refractory ventricular arrhythmia undergoing bailout ablation due to inability to wean off mechanical support were included. Median age was 61 years, 86% were men, median left ventricular ejection fraction was 20%, 81% had ischemic cardiomyopathy, and PAINESD score was 18±5. The type of mechanical support in place before the procedure was intra-aortic balloon pump in 14 patients (67%), Impella CP in 2, extracorporeal membrane oxygenation in 2, extracorporeal membrane oxygenation and intra-aortic balloon pump in 2, and extracorporeal membrane oxygenation and Impella CP in 1. Endocardial voltage maps showed myocardial scar in 19 patients (90%). The clinical VTs were inducible in 13 patients (62%), whereas 6 patients had premature ventricular contraction-induced ventricular fibrillation/VT (29%), and VT could not be induced in 2 patients (9%). Activation mapping was possible in all 13 with inducible clinical VTs. Substrate modification was performed in 15 patients with scar (79%). After ablation and scar modification, the arrhythmia was noninducible in 19 patients (91%). Seventeen (81%) were eventually weaned off mechanical support successfully, but 6 (29%) died during the index admission from persistent cardiogenic shock. Patients who had ventricular arrhythmia and cardiogenic shock on presentation had a trend toward lower in-hospital mortality compared with those who presented with cardiogenic shock and later developed ventricular arrhythmia.
CONCLUSIONS
Bailout ablation for refractory ventricular arrhythmia in cardiogenic shock allowed successful weaning from mechanical support in a large proportion of patients. Mortality remains high, but the majority of patients were discharged home and survived beyond 1 year.
Topics: Aged; Anti-Arrhythmia Agents; Assisted Circulation; Catheter Ablation; Drug Resistance; Extracorporeal Membrane Oxygenation; Female; Heart Rate; Hospital Mortality; Humans; Male; Middle Aged; Recovery of Function; Recurrence; Registries; Retrospective Studies; Risk Factors; Shock, Cardiogenic; Stroke Volume; Tachycardia, Ventricular; Time Factors; Treatment Outcome; Ventricular Fibrillation; Ventricular Function, Left
PubMed: 32281407
DOI: 10.1161/CIRCEP.119.007669