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The New England Journal of Medicine Dec 2017Recent advances have enabled noninvasive mapping of cardiac arrhythmias with electrocardiographic imaging and noninvasive delivery of precise ablative radiation with...
BACKGROUND
Recent advances have enabled noninvasive mapping of cardiac arrhythmias with electrocardiographic imaging and noninvasive delivery of precise ablative radiation with stereotactic body radiation therapy (SBRT). We combined these techniques to perform catheter-free, electrophysiology-guided, noninvasive cardiac radioablation for ventricular tachycardia.
METHODS
We targeted arrhythmogenic scar regions by combining anatomical imaging with noninvasive electrocardiographic imaging during ventricular tachycardia that was induced by means of an implantable cardioverter-defibrillator (ICD). SBRT simulation, planning, and treatments were performed with the use of standard techniques. Patients were treated with a single fraction of 25 Gy while awake. Efficacy was assessed by counting episodes of ventricular tachycardia, as recorded by ICDs. Safety was assessed by means of serial cardiac and thoracic imaging.
RESULTS
From April through November 2015, five patients with high-risk, refractory ventricular tachycardia underwent treatment. The mean noninvasive ablation time was 14 minutes (range, 11 to 18). During the 3 months before treatment, the patients had a combined history of 6577 episodes of ventricular tachycardia. During a 6-week postablation "blanking period" (when arrhythmias may occur owing to postablation inflammation), there were 680 episodes of ventricular tachycardia. After the 6-week blanking period, there were 4 episodes of ventricular tachycardia over the next 46 patient-months, for a reduction from baseline of 99.9%. A reduction in episodes of ventricular tachycardia occurred in all five patients. The mean left ventricular ejection fraction did not decrease with treatment. At 3 months, adjacent lung showed opacities consistent with mild inflammatory changes, which had resolved by 1 year.
CONCLUSIONS
In five patients with refractory ventricular tachycardia, noninvasive treatment with electrophysiology-guided cardiac radioablation markedly reduced the burden of ventricular tachycardia. (Funded by Barnes-Jewish Hospital Foundation and others.).
Topics: Aged; Aged, 80 and over; Catheter Ablation; Cicatrix; Defibrillators, Implantable; Electrocardiography; Electrophysiologic Techniques, Cardiac; Fatal Outcome; Female; Heart Ventricles; Humans; Male; Middle Aged; Myocardium; Radiosurgery; Stroke; Stroke Volume; Tachycardia, Ventricular; Tomography, X-Ray Computed
PubMed: 29236642
DOI: 10.1056/NEJMoa1613773 -
Cardiac Electrophysiology Clinics Dec 2019Mapping and ablation of ventricular arrhythmias in patients with nonischemic cardiomyopathies remain a major challenge. The electroanatomic abnormalities are frequently... (Review)
Review
Mapping and ablation of ventricular arrhythmias in patients with nonischemic cardiomyopathies remain a major challenge. The electroanatomic abnormalities are frequently inaccessible to conventional endocardial ablations. Diagnostic diligence with a thorough understanding of the potential mechanisms/substrate, coupled with detailed electroanatomic mapping, is essential. Careful procedural planning, advanced imaging, and unipolar recordings help to formulate ablation strategy, facilitate work flow, and improve outcomes. Inaccessibility of arrhythmogenic substrate and disease progression are important causes of ablation failure. Early intervention may help to improve outcome and minimize complications. Several novel adjunctive ablation techniques are capable of serving as alternative options in refractory cases.
Topics: Adult; Aged; Arrhythmias, Cardiac; Cardiomyopathies; Catheter Ablation; Electrocardiography; Electrophysiologic Techniques, Cardiac; Female; Heart Ventricles; Humans; Male; Middle Aged
PubMed: 31706471
DOI: 10.1016/j.ccep.2019.08.005 -
Cardiac Electrophysiology Clinics Mar 2023Most idiopathic ventricular arrhythmias (VAs) originate from the outflow tract (OT) region and can be targeted with ablation either from the endocardial aspect of the... (Review)
Review
Most idiopathic ventricular arrhythmias (VAs) originate from the outflow tract (OT) region and can be targeted with ablation either from the endocardial aspect of the right and left ventricular outflow tracts or from the aortic sinuses of Valsalva. It is important to exclude scar in patients with OT VAs. In some patients, the site of origin may be intramural. Ablation of intramural OT VAs can be challenging to map and ablate due to deep intramural sites of origin. The coronary venous branches may permit mapping and ablation of intramural OT VAs.
Topics: Humans; Tachycardia, Ventricular; Electrocardiography; Treatment Outcome; Catheter Ablation; Arrhythmias, Cardiac; Heart Ventricles
PubMed: 36774136
DOI: 10.1016/j.ccep.2022.04.006 -
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 -
Cardiac Electrophysiology Clinics Jun 2021Catheter ablation is the most effective treatment option for idiopathic ventricular arrhythmias. Intracardiac echocardiography (ICE) has been increasingly used during... (Review)
Review
Catheter ablation is the most effective treatment option for idiopathic ventricular arrhythmias. Intracardiac echocardiography (ICE) has been increasingly used during ablation procedures, allowing real-time visualization of cardiac anatomy, and improving our understanding of the relationships between different cardiac structures. In this article we review the adjuvant role of ICE to guide mapping and ablation of ventricular arrhythmias in the structurally normal heart.
Topics: Arrhythmias, Cardiac; Catheter Ablation; Echocardiography; Heart Ventricles; Humans; Surgery, Computer-Assisted
PubMed: 33990271
DOI: 10.1016/j.ccep.2021.03.010 -
JACC. Clinical Electrophysiology Sep 2023
Topics: Humans; Tachycardia, Ventricular; Heart Conduction System; Heart Ventricles; Catheter Ablation
PubMed: 37498240
DOI: 10.1016/j.jacep.2023.05.021 -
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 -
JACC. Clinical Electrophysiology Sep 2023Three cases of ventricular tachycardia ablation with pulsed-field ablation technology performed at 2 separate centers are reported, highlighting the advantages and... (Review)
Review
Three cases of ventricular tachycardia ablation with pulsed-field ablation technology performed at 2 separate centers are reported, highlighting the advantages and disadvantages of this tool inside the ventricle: its dependence on proximity rather than contact makes it useful in sites with poor stability, while the speed of application and large scope of action provided by commercially available catheters could help with ablating large diseased areas of endocardium in a fast and hemodynamically well-tolerated fashion. However, lesion depth could be insufficient for guaranteeing efficacy in preventing ventricular tachycardias originating at an epicardial site, even in the right ventricle.
Topics: Humans; Heart Ventricles; Electrocardiography; Tachycardia, Ventricular; Catheter Ablation; Endocardium
PubMed: 37227358
DOI: 10.1016/j.jacep.2023.03.024 -
Cardiac Electrophysiology Clinics Mar 2023Endocardial catheter ablation of ventricular arrhythmias (VAs) originating from the left ventricular summit (LVS) at remote structures adjacent to the LVS may be an... (Review)
Review
Endocardial catheter ablation of ventricular arrhythmias (VAs) originating from the left ventricular summit (LVS) at remote structures adjacent to the LVS may be an alternative (anatomic approach) but may not be so successful. This type of catheter ablation is successful most commonly in the left ventricular outflow tract followed by the aortic cusps and rarely in the right ventricular outflow tract. A right bundle branch block QRS morphology and anatomic distance between the earliest ventricular activation site in the coronary venous system and endocardial ablation site (<13 mm) could be predictors of a successful endocardial catheter ablation of LVS VAs.
Topics: Humans; Treatment Outcome; Electrocardiography; Heart Ventricles; Arrhythmias, Cardiac; Bundle-Branch Block; Catheter Ablation; Tachycardia, Ventricular
PubMed: 36774132
DOI: 10.1016/j.ccep.2022.04.005 -
Cardiac Electrophysiology Clinics Mar 2023The left ventricular summit is a site of origin for idiopathic ventricular arrhythmias. With advancements in mapping and ablation techniques, sites previously considered... (Review)
Review
The left ventricular summit is a site of origin for idiopathic ventricular arrhythmias. With advancements in mapping and ablation techniques, sites previously considered inaccessible can now be approached. Anatomical knowledge of the 3-dimensional landmarks of this space is important, as critical structures reside within its boundaries and are potentially liable to collateral injury during ablation. This article reviews reported complications from ablation of ventricular arrhythmias arising from the left ventricular summit and its vicinity and discusses the pros and cons of different ablation technique and the role of an individualized anatomical approach to reduce procedural related complications and improve outcomes.
Topics: Humans; Electrocardiography; Treatment Outcome; Catheter Ablation; Heart Ventricles; Arrhythmias, Cardiac; Tachycardia, Ventricular
PubMed: 36774142
DOI: 10.1016/j.ccep.2022.07.004