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Kowey PR, Olleik FM. Class IC Drugs in Cardiomyopathy: Keeping an Open Mind. JACC Clin Electrophysiol 2024; 10:854-856. [PMID: 38811068 DOI: 10.1016/j.jacep.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 05/31/2024]
Affiliation(s)
- Peter R Kowey
- Lankenau Heart Institute, Wynnewood, Pennsylvania, USA; Jefferson Medical College, Philadelphia, Pennsylvania, USA.
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Stanciulescu LA, Vatasescu R. Ventricular Tachycardia Catheter Ablation: Retrospective Analysis and Prospective Outlooks-A Comprehensive Review. Biomedicines 2024; 12:266. [PMID: 38397868 PMCID: PMC10886924 DOI: 10.3390/biomedicines12020266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 01/16/2024] [Accepted: 01/23/2024] [Indexed: 02/25/2024] Open
Abstract
Ventricular tachycardia is a potentially life-threatening arrhythmia associated with an overall high morbi-mortality, particularly in patients with structural heart disease. Despite their pivotal role in preventing sudden cardiac death, implantable cardioverter-defibrillators, although a guideline-based class I recommendation, are unable to prevent arrhythmic episodes and significantly alter the quality of life by delivering recurrent therapies. From open-heart surgical ablation to the currently widely used percutaneous approach, catheter ablation is a safe and effective procedure able to target the responsible re-entry myocardial circuit from both the endocardium and the epicardium. There are four main mapping strategies, activation, entrainment, pace, and substrate mapping, each of them with their own advantages and limitations. The contemporary guideline-based recommendations for VT ablation primarily apply to patients experiencing antiarrhythmic drug ineffectiveness or those intolerant to the pharmacological treatment. Although highly effective in most cases of scar-related VTs, the traditional approach may sometimes be insufficient, especially in patients with nonischemic cardiomyopathies, where circuits may be unmappable using the classic techniques. Alternative methods have been proposed, such as stereotactic arrhythmia radioablation or radiotherapy ablation, surgical ablation, needle ablation, transarterial coronary ethanol ablation, and retrograde coronary venous ethanol ablation, with promising results. Further studies are needed in order to prove the overall efficacy of these methods in comparison to standard radiofrequency delivery. Nevertheless, as the field of cardiac electrophysiology continues to evolve, it is important to acknowledge the role of artificial intelligence in both the pre-procedural planning and the intervention itself.
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Affiliation(s)
- Laura Adina Stanciulescu
- Cardio-Thoracic Department, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Cardiology Department, Clinical Emergency Hospital, 014461 Bucharest, Romania
| | - Radu Vatasescu
- Cardio-Thoracic Department, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Cardiology Department, Clinical Emergency Hospital, 014461 Bucharest, Romania
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Freedman BL, Maher TR, Tracey M, Santangeli P, d'Avila A. Procedural Adaptations to Avoid Haemodynamic Instability During Catheter Ablation of Scar-related Ventricular Tachycardia. Arrhythm Electrophysiol Rev 2023; 12:e20. [PMID: 37465104 PMCID: PMC10350657 DOI: 10.15420/aer.2022.24] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 12/08/2022] [Indexed: 07/20/2023] Open
Abstract
Classically, catheter ablation for scar-related ventricular tachycardia (VT) relied upon activation and entrainment mapping of induced VT. Advances in post-MI therapies have led to VTs that are faster and haemodynamically less stable, because of more heterogeneous myocardial fibrosis patterns. The PAINESD score is one means of identifying patients at highest risk for haemodynamic decompensation during attempted VT induction, who may, therefore, benefit from alternative ablation strategies. One strategy is to use temporary mechanical circulatory support, although this warrants formal assessment of cost-effectiveness. A second strategy is to minimise or avoid VT induction altogether by employing a family of 'substrate'-based approaches aimed at identifying VT isthmuses during sinus or paced rhythm. Substrate mapping techniques are diverse, and focus on the timing, morphology and amplitude of local ventricular electrograms - sometimes aided by advanced non-invasive cardiac imaging modalities. In this review, the evolution of VT ablation over time is discussed, with an emphasis on procedural adaptations to the challenge of haemodynamic instability.
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Affiliation(s)
- Benjamin L Freedman
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, US
| | - Timothy R Maher
- Harvard-Thorndike Electrophysiology Institute and Arrhythmia Service, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, US
| | | | - Pasquale Santangeli
- Cardiovascular Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, US
| | - Andre d'Avila
- Harvard-Thorndike Electrophysiology Institute and Arrhythmia Service, Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, US
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Bhaskaran A, Fitzgerald J, Jackson N, Gizurarson S, Nanthakumar K, Porta-Sánchez A. Decrement Evoked Potential Mapping to Guide Ventricular Tachycardia Ablation: Elucidating the Functional Substrate. Arrhythm Electrophysiol Rev 2020; 9:211-218. [PMID: 33437489 PMCID: PMC7788395 DOI: 10.15420/aer.2020.25] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Empirical approaches to targeting the ventricular tachycardia (VT) substrate include mapping of late potentials, local abnormal electrogram, pace-mapping and homogenisation of the abnormal signals. These approaches do not try to differentiate between the passive or active role of local signals as the critical components of the VT circuit. By not considering the functional components, these approaches often view the substrate as a fixed anatomical barrier. Strategies to improve the success of VT ablation need to include the identification of critical functional substrate. Decrement-evoked potential (DeEP) mapping has been developed to elucidate this using an extra-stimulus added to a pacing drive train. With knowledge translation in mind, the authors detail the evolution of the DeEP concept by way of a study of simultaneous panoramic endocardial mapping in VT ablation; an in silico modelling study to demonstrate the factors influencing DeEPs; a multicentre VT ablation validation study; a practical approach to DeEP mapping; the potential utility of DeEPs to identify arrhythmogenic atrial substrate; and, finally, other functional mapping strategies.
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Affiliation(s)
| | | | | | | | | | - Andreu Porta-Sánchez
- Hospital Universitario Quirónsalud Madrid, Molecular Cardiology Laboratory, Centro Nacional de Investigaciones Cardiovasculares, Spain
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5
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Ventricular Tachycardia Ablation. JACC Clin Electrophysiol 2019; 5:1363-1383. [DOI: 10.1016/j.jacep.2019.09.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 09/23/2019] [Accepted: 09/26/2019] [Indexed: 11/23/2022]
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6
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Affiliation(s)
- Kalyanam Shivkumar
- From the University of California, Los Angeles (UCLA), Cardiac Arrhythmia Center and Electrophysiology Programs, David Geffen School of Medicine at UCLA, Los Angeles
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Kumar S, Tedrow UB, Stevenson WG. Adjunctive Interventional Techniques When Percutaneous Catheter Ablation for Drug Refractory Ventricular Arrhythmias Fail: A Contemporary Review. Circ Arrhythm Electrophysiol 2019; 10:e003676. [PMID: 28213504 DOI: 10.1161/circep.116.003676] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Saurabh Kumar
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.K., U.B.T., W.G.S.); and Department of Cardiology, Westmead Hospital, University of Sydney, NSW, Australia (S.K.)
| | - Usha B Tedrow
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.K., U.B.T., W.G.S.); and Department of Cardiology, Westmead Hospital, University of Sydney, NSW, Australia (S.K.)
| | - William G Stevenson
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (S.K., U.B.T., W.G.S.); and Department of Cardiology, Westmead Hospital, University of Sydney, NSW, Australia (S.K.).
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8
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Bradfield JS. Intraoperative ventricular tachycardia substrate mapping: What is old is new again. J Cardiovasc Electrophysiol 2018; 30:193-194. [PMID: 30556273 DOI: 10.1111/jce.13815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA
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Abstract
Sustained ventricular tachycardias are common in the setting of structural heart disease, either due to prior myocardial infarction or a variety of non-ischemic etiologies, including idiopathic dilated cardiomyopathy, hypertrophic cardiomyopathy, and arrhythmogenic right ventricular cardiomyopathy. Over the past two decades, percutaneous catheter ablation has evolved dramatically and has become an effective tool for the control of ventricular arrhythmias. Single and multicenter observational studies as well as several prospective randomized trials have begun to investigate long-term outcomes after catheter ablation procedures. These studies encompass a wide range of mapping and ablation techniques, including conventional activation mapping/entrainment criteria, substrate modification guided by pacemapping, late potential and abnormal electrogram ablation, scar de-channeling, and core isolation. While large-scale, multicenter prospective randomized clinical trials are somewhat limited, the published data demonstrate favorable outcomes with respect to a reduction in overall ventricular tachycardia (VT) burden, reduction of implantable cardioverter defibrillator (ICD) shocks, and discontinuation of anti-arrhythmic medications across varying disease subtypes and convincingly support the use of catheter ablation as the standard of care for many patients with VT in the setting of structural heart disease.
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Liang JJ, Betensky BP, Muser D, Zado ES, Anter E, Desai ND, Callans DJ, Deo R, Frankel DS, Hutchinson MD, Lin D, Riley MP, Schaller RD, Supple GE, Santangeli P, Acker MA, Bavaria JE, Szeto WY, Vallabhajosyula P, Marchlinski FE, Dixit S. Long-term outcome of surgical cryoablation for refractory ventricular tachycardia in patients with non-ischemic cardiomyopathy. Europace 2017; 20:e30-e41. [DOI: 10.1093/europace/eux029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 01/25/2017] [Indexed: 12/24/2022] Open
Affiliation(s)
- Jackson J Liang
- Department of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9, Philadelphia, PA 19104, USA
| | - Brian P Betensky
- Department of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9, Philadelphia, PA 19104, USA
| | - Daniele Muser
- Department of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9, Philadelphia, PA 19104, USA
| | - Erica S Zado
- Department of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9, Philadelphia, PA 19104, USA
| | - Elad Anter
- Harvard-Thorndike Electrophysiology Institute, Division of Cardiovascular Disease, Beth Israel Deaconess Medical Center, Harvard Medical School, 85 Pilgrim Road, Baker 4, Boston, MA 02215, USA
| | - Nimesh D Desai
- Division of Cardiac Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - David J Callans
- Department of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9, Philadelphia, PA 19104, USA
| | - Rajat Deo
- Department of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9, Philadelphia, PA 19104, USA
| | - David S Frankel
- Department of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9, Philadelphia, PA 19104, USA
| | - Mathew D Hutchinson
- Department of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9, Philadelphia, PA 19104, USA
| | - David Lin
- Department of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9, Philadelphia, PA 19104, USA
| | - Michael P Riley
- Department of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9, Philadelphia, PA 19104, USA
| | - Robert D Schaller
- Department of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9, Philadelphia, PA 19104, USA
| | - Gregory E Supple
- Department of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9, Philadelphia, PA 19104, USA
| | - Pasquale Santangeli
- Department of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9, Philadelphia, PA 19104, USA
| | - Michael A Acker
- Division of Cardiac Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Joseph E Bavaria
- Division of Cardiac Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Wilson Y Szeto
- Division of Cardiac Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Prashanth Vallabhajosyula
- Division of Cardiac Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Francis E Marchlinski
- Department of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9, Philadelphia, PA 19104, USA
| | - Sanjay Dixit
- Department of Cardiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, Founders 9, Philadelphia, PA 19104, USA
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11
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Anter E, Hutchinson MD, Deo R, Haqqani HM, Callans DJ, Gerstenfeld EP, Garcia FC, Bala R, Lin D, Riley MP, Litt HI, Woo JY, Acker MA, Szeto WY, Zado ES, Marchlinski FE, Dixit S. Surgical Ablation of Refractory Ventricular Tachycardia in Patients With Nonischemic Cardiomyopathy. Circ Arrhythm Electrophysiol 2011; 4:494-500. [DOI: 10.1161/circep.111.962555] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Elad Anter
- From the Cardiovascular Division, Department of Medicine (E.A., M.D.H., R.D., H.M.H., D.J.C., E.P.G., F.C.G., R.B.. D.L., M.P.R., E.S.Z., F.E.M., S.D.), Department of Cardiovascular Surgery, Department of Surgery (J.Y.W., M.A.A., W.Y.Z.), and Department of Radiology (H.I.L.), Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Mathew D. Hutchinson
- From the Cardiovascular Division, Department of Medicine (E.A., M.D.H., R.D., H.M.H., D.J.C., E.P.G., F.C.G., R.B.. D.L., M.P.R., E.S.Z., F.E.M., S.D.), Department of Cardiovascular Surgery, Department of Surgery (J.Y.W., M.A.A., W.Y.Z.), and Department of Radiology (H.I.L.), Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Rajat Deo
- From the Cardiovascular Division, Department of Medicine (E.A., M.D.H., R.D., H.M.H., D.J.C., E.P.G., F.C.G., R.B.. D.L., M.P.R., E.S.Z., F.E.M., S.D.), Department of Cardiovascular Surgery, Department of Surgery (J.Y.W., M.A.A., W.Y.Z.), and Department of Radiology (H.I.L.), Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Haris M. Haqqani
- From the Cardiovascular Division, Department of Medicine (E.A., M.D.H., R.D., H.M.H., D.J.C., E.P.G., F.C.G., R.B.. D.L., M.P.R., E.S.Z., F.E.M., S.D.), Department of Cardiovascular Surgery, Department of Surgery (J.Y.W., M.A.A., W.Y.Z.), and Department of Radiology (H.I.L.), Hospital of the University of Pennsylvania, Philadelphia, PA
| | - David J. Callans
- From the Cardiovascular Division, Department of Medicine (E.A., M.D.H., R.D., H.M.H., D.J.C., E.P.G., F.C.G., R.B.. D.L., M.P.R., E.S.Z., F.E.M., S.D.), Department of Cardiovascular Surgery, Department of Surgery (J.Y.W., M.A.A., W.Y.Z.), and Department of Radiology (H.I.L.), Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Edward P. Gerstenfeld
- From the Cardiovascular Division, Department of Medicine (E.A., M.D.H., R.D., H.M.H., D.J.C., E.P.G., F.C.G., R.B.. D.L., M.P.R., E.S.Z., F.E.M., S.D.), Department of Cardiovascular Surgery, Department of Surgery (J.Y.W., M.A.A., W.Y.Z.), and Department of Radiology (H.I.L.), Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Fermin C. Garcia
- From the Cardiovascular Division, Department of Medicine (E.A., M.D.H., R.D., H.M.H., D.J.C., E.P.G., F.C.G., R.B.. D.L., M.P.R., E.S.Z., F.E.M., S.D.), Department of Cardiovascular Surgery, Department of Surgery (J.Y.W., M.A.A., W.Y.Z.), and Department of Radiology (H.I.L.), Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Rupa Bala
- From the Cardiovascular Division, Department of Medicine (E.A., M.D.H., R.D., H.M.H., D.J.C., E.P.G., F.C.G., R.B.. D.L., M.P.R., E.S.Z., F.E.M., S.D.), Department of Cardiovascular Surgery, Department of Surgery (J.Y.W., M.A.A., W.Y.Z.), and Department of Radiology (H.I.L.), Hospital of the University of Pennsylvania, Philadelphia, PA
| | - David Lin
- From the Cardiovascular Division, Department of Medicine (E.A., M.D.H., R.D., H.M.H., D.J.C., E.P.G., F.C.G., R.B.. D.L., M.P.R., E.S.Z., F.E.M., S.D.), Department of Cardiovascular Surgery, Department of Surgery (J.Y.W., M.A.A., W.Y.Z.), and Department of Radiology (H.I.L.), Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Michael P. Riley
- From the Cardiovascular Division, Department of Medicine (E.A., M.D.H., R.D., H.M.H., D.J.C., E.P.G., F.C.G., R.B.. D.L., M.P.R., E.S.Z., F.E.M., S.D.), Department of Cardiovascular Surgery, Department of Surgery (J.Y.W., M.A.A., W.Y.Z.), and Department of Radiology (H.I.L.), Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Harold I. Litt
- From the Cardiovascular Division, Department of Medicine (E.A., M.D.H., R.D., H.M.H., D.J.C., E.P.G., F.C.G., R.B.. D.L., M.P.R., E.S.Z., F.E.M., S.D.), Department of Cardiovascular Surgery, Department of Surgery (J.Y.W., M.A.A., W.Y.Z.), and Department of Radiology (H.I.L.), Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Joseph Y. Woo
- From the Cardiovascular Division, Department of Medicine (E.A., M.D.H., R.D., H.M.H., D.J.C., E.P.G., F.C.G., R.B.. D.L., M.P.R., E.S.Z., F.E.M., S.D.), Department of Cardiovascular Surgery, Department of Surgery (J.Y.W., M.A.A., W.Y.Z.), and Department of Radiology (H.I.L.), Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Michael A. Acker
- From the Cardiovascular Division, Department of Medicine (E.A., M.D.H., R.D., H.M.H., D.J.C., E.P.G., F.C.G., R.B.. D.L., M.P.R., E.S.Z., F.E.M., S.D.), Department of Cardiovascular Surgery, Department of Surgery (J.Y.W., M.A.A., W.Y.Z.), and Department of Radiology (H.I.L.), Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Wilson Y. Szeto
- From the Cardiovascular Division, Department of Medicine (E.A., M.D.H., R.D., H.M.H., D.J.C., E.P.G., F.C.G., R.B.. D.L., M.P.R., E.S.Z., F.E.M., S.D.), Department of Cardiovascular Surgery, Department of Surgery (J.Y.W., M.A.A., W.Y.Z.), and Department of Radiology (H.I.L.), Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Erica S. Zado
- From the Cardiovascular Division, Department of Medicine (E.A., M.D.H., R.D., H.M.H., D.J.C., E.P.G., F.C.G., R.B.. D.L., M.P.R., E.S.Z., F.E.M., S.D.), Department of Cardiovascular Surgery, Department of Surgery (J.Y.W., M.A.A., W.Y.Z.), and Department of Radiology (H.I.L.), Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Francis E. Marchlinski
- From the Cardiovascular Division, Department of Medicine (E.A., M.D.H., R.D., H.M.H., D.J.C., E.P.G., F.C.G., R.B.. D.L., M.P.R., E.S.Z., F.E.M., S.D.), Department of Cardiovascular Surgery, Department of Surgery (J.Y.W., M.A.A., W.Y.Z.), and Department of Radiology (H.I.L.), Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Sanjay Dixit
- From the Cardiovascular Division, Department of Medicine (E.A., M.D.H., R.D., H.M.H., D.J.C., E.P.G., F.C.G., R.B.. D.L., M.P.R., E.S.Z., F.E.M., S.D.), Department of Cardiovascular Surgery, Department of Surgery (J.Y.W., M.A.A., W.Y.Z.), and Department of Radiology (H.I.L.), Hospital of the University of Pennsylvania, Philadelphia, PA
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KHAIRY PAUL, DUBUC MARC. Transcatheter Cryoablation Part I: Preclinical Experience. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 31:112-20. [DOI: 10.1111/j.1540-8159.2007.00934.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bella PD, Riva S. Hybrid therapies for ventricular arrhythmias. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 29 Suppl 2:S40-7. [PMID: 17169132 DOI: 10.1111/j.1540-8159.2006.00491.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In recent years several trials demonstrated the efficacy of implantable cardioverter-defibrillation (ICD) therapy in reducing cardiac and total mortality in patients affected by rapid ventricular tachycardia (VT) and/or ventricular fibrillation. Nevertheless, ICD do not prevent arrhythmia recurrences, thus being a palliative and not a curative treatment modality. The tolerance to ICD therapy varies greatly, and within individuals, this leading to a nonuniform acceptance of this form of therapy. The very frequent occurrence of VT, defined as an arrhythmic storm, may be a life threatening condition. The majority of ICD patients is under antiarrhythmic drug therapy, to reduce episodes of VT or to make antitachycardia pacing more effective by slowing the tachycardia rate. Drug therapy, however, may cause additional problems, and does not represent the optimal solution. The prevention of VT and/or ventricular fibrillation episodes and excessive ICD therapy, remains a worthwhile goal. Radiofrequency catheter ablation (RFCA) is a curative approach, and can be expected to reduce the frequency of recurrent VT episodes in the majority of patients. The combination of these treatment modalities (ICD and RFCA) is often described as hybrid therapy, implying that the two treatments act providing some form of synergism. In experienced centers, RFCA is now performed, regardless of whether the VT rate is rapid and/or is hemodynamically unstable. Newer mapping and ablation techniques are now available, enhancing the acute success rate of the procedure. In this review the most recent application of VT catheter ablation and the use of advanced mapping and ablation techniques will be discussed.
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Affiliation(s)
- Paolo Della Bella
- Arrhythmia Department, Institute of Cardiology, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy.
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14
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Bourke JP, Loaiza A, Parry G, Hilton C, Furniss S, Dark J, Forty J. Role of orthotopic heart transplantation in the management of patients with recurrent ventricular tachyarrhythmias following myocardial infarction. HEART (BRITISH CARDIAC SOCIETY) 1998; 80:473-8. [PMID: 9930047 PMCID: PMC1728857 DOI: 10.1136/hrt.80.5.473] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To report the outcome of an intention to treat by heart transplantation strategy in two groups of patients after infarction, one with both left ventricular failure (LVF) and ventricular tachyarrhythmias (VTA) (group A) and the other with progressive LVF following antiarrhythmic surgery for VTA (group B). PATIENTS AND METHODS Group A comprised 17 consecutive patients for whom transplantation was considered the best primary non-pharmacological treatment; group B comprised five consecutive patients assessed and planned for transplantation after antiarrhythmic surgery. RESULTS In group A, eight patients underwent transplantation and all survived the first 30 day period. At median follow up of 55 months (range 11 to 109) seven of this subgroup were still alive. Five patients died of recurrent VTA before transplantation, despite circulatory support. In the face of uncontrollable VTA, four of these underwent "high risk" antiarrhythmic surgery while awaiting transplantation: three died of LVF within 30 days and one was saved by heart transplantation two days after arrhythmia surgery. Mortality for the transplantation strategy in group A patients was 47% by intention to treat analysis. Quality of life in the eight actually transplanted, however, was good and only one died during median follow up of 56 months. The five patients in group B were accepted for transplantation for progressive LVF at a median of 21 months (range 12 to 28) after antiarrhythmic surgery. One died of LVF before transplantation, 22 months after initial surgery; another died of high output LVF three days after transplantation. Thus mortality of the intended strategy was 40%. The three transplanted patients are alive and well at 8-86 months. CONCLUSIONS Although the short and medium term outcome in category A or B patients who undergo transplantation is good, the overall success of the transplantation strategy in category A patients is limited by lack of donors in the short time frame in which they are required.
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Affiliation(s)
- J P Bourke
- University Department of Cardiology, Freeman Hospital, Newcastle upon Tyne, UK.
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15
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Josephson ME, Zimetbaum P, Huang D, Sauberman R, Monahan KM, Callans DS. Pathophysiologic substrate for sustained ventricular tachycardia in coronary artery disease. JAPANESE CIRCULATION JOURNAL 1997; 61:459-66. [PMID: 9225190 DOI: 10.1253/jcj.61.459] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Sustained ventricular tachycardia (VT) in the presence of coronary artery disease (CAD) is almost always associated with prior infarction. Its mechanism is reentrant excitation and it can be initiated > 95% of the time. Disrupted and delayed endocardial activation and prolonged, fragmented electrograms recorded during sinus rhythm distinguish patients with VT from those with normal ventricles and those of prior infarction without VT. The extent of abnormalities of activation and number of abnormal, fragmented and late electrograms are greatest in patients with sustained VT. These abnormalities are associated with scar tissue separating the viable myocytes. Fragmented electrograms are due to discontinuous activation due to nonuniform anisotropy caused by the scar tissue. Patients with CAD demonstrate depressed excitability and prolonged relative refractory periods (ie, an upward shift in the strength-interval curve) at sites of infarction but effective refractory periods measured at 10 mA comparable to normals and dispersion of refractory periods. However the associated abnormalities of conduction and activation produce an abnormal dispersion of recovery. Intraoperative mapping of patients with CAD has shown that most of the abnormalities of endocardial activation and conduction are in the subendocardial layers and subendocardial resection of these areas cures VT and abolishes delayed, fragmented electrograms and split potentials and normalizes the electrograms recorded from the subjacent tissue. This supports the hypothesis that abnormalities of conduction are the critical pathophysiologic substrate of VT in CAD.
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Affiliation(s)
- M E Josephson
- Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
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16
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Hargrove WC, Addonizio VP, Miller JM. Surgical therapy of ventricular tachyarrhythmias in patients with coronary artery disease. J Cardiovasc Electrophysiol 1996; 7:469-80. [PMID: 8722593 DOI: 10.1111/j.1540-8167.1996.tb00553.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- W C Hargrove
- Medical College of Pennsylvania Hospital, Philadelphia, USA
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17
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Ferguson TB, Smith JM, Cox JL, Cain ME, Lindsay BD. Direct operation versus ICD therapy for ischemic ventricular tachycardia. Ann Thorac Surg 1994; 58:1291-6. [PMID: 7944809 DOI: 10.1016/0003-4975(94)90532-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Now that the implantable cardioverter defibrillator is available as a therapeutic option for the management of ventricular tachycardia (VT), some argue that there no longer should be a role for direct surgical intervention for this malignant arrhythmia. Rebuttal of this argument is difficult for the following reasons: (1) there are many patients who are candidates for implantable cardioverter defibrillator therapy but not for direct VT operation, and thus direct comparisons of the two therapies is difficult; (2) implantable cardioverter defibrillator therapy by definition is palliative, but a VT operation is curative in most instances; (3) in many electrophysiologic triage algorithms, implantation of a cardioverter defibrillator and VT operation are employed as alternative, not competitive, therapies, again making direct comparisons difficult; and (4) probably most importantly, there are misconceptions in the literature regarding the risks and benefits of direct VT surgical procedures as they are currently performed. In this brief review, we examine the currently available data on both sides of this argument.
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Affiliation(s)
- T B Ferguson
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110
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18
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Abstract
The future of arrhythmia surgery is discussed in light of the 25 years of historical developments that have led to the present explosion in antiarrhythmic therapies and technologies. The role of the arrhythmia surgeon in these developments is outlined, along with a number of exciting near-term and far-term developments that will continue to revolutionize therapeutic interventions for arrhythmia problems.
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Affiliation(s)
- T B Ferguson
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri
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19
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Results of nonguided subtotal endocardiectomy associated with left ventricular reconstruction in patients with ischemic ventricular arrhythmias. J Thorac Cardiovasc Surg 1994. [DOI: 10.1016/s0022-5223(94)70051-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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20
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Trouton TG, Powell AC, Garan H, Ruskin JN. Risk identification for sudden cardiac death--implications for implantable cardioverter-defibrillator use. Prog Cardiovasc Dis 1993; 36:195-208. [PMID: 8234773 DOI: 10.1016/0033-0620(93)90013-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- T G Trouton
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Boston 02114
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21
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22
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23
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Noble RJ. A case of sudden death. Questions of management. Chest 1991; 99:1511-4. [PMID: 2036838 DOI: 10.1378/chest.99.6.1511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
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24
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Schoenfeld MH. Sustained ventricular tachyarrhythmias after infarction: when should the worrying begin? J Am Coll Cardiol 1991; 17:327-9. [PMID: 1991888 DOI: 10.1016/s0735-1097(10)80094-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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25
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Gunnar RM, Bourdillon PD, Dixon DW, Fuster V, Karp RB, Kennedy JW, Klocke FJ, Passamani ER, Pitt B, Rapaport E. ACC/AHA guidelines for the early management of patients with acute myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (subcommittee to develop guidelines for the early management of patients with acute myocardial infarction). Circulation 1990; 82:664-707. [PMID: 2197021 DOI: 10.1161/01.cir.82.2.664] [Citation(s) in RCA: 139] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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26
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Gunnar RM, Passamani ER, Bourdillon PD, Pitt B, Dixon DW, Rapaport E, Fuster V, Reeves TJ, Karp RB, Russell RO. Guidelines for the early management of patients with acute myocardial infarction. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee to Develop Guidelines for the Early Management of Patients with Acute Myocardial Infarction). J Am Coll Cardiol 1990; 16:249-92. [PMID: 2197309 DOI: 10.1016/0735-1097(90)90575-a] [Citation(s) in RCA: 273] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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27
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Bourke JP, Hilton CJ, McComb JM, Cowan JC, Tansuphaswadikul S, Kertes PJ, Campbell RW. Surgery for control of recurrent life-threatening ventricular tachyarrhythmias within 2 months of myocardial infarction. J Am Coll Cardiol 1990; 16:42-8. [PMID: 2358600 DOI: 10.1016/0735-1097(90)90453-v] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Twenty-seven patients (mean age 57 +/- 7 years) underwent surgery for control of recurrent drug-refractory ventricular tachyarrhythmias (uniform ventricular tachycardia alone in 9 patients, ventricular tachycardia and ventricular fibrillation in 15 and ventricular fibrillation alone in 3) within 2 months of acute myocardial infarction. The mean number of major arrhythmic episodes per patient was 15 (range 2 to 200) and of drug failures 4 +/- 2. Left ventricular function was severely impaired in the majority (ejection fraction 29%; range 14% to 47%) and 18 patients (66%) had a left ventricular aneurysm. Endocardial resection guided by a combination of endocardial activation mapping during tachycardia and fragmentation mapping during sinus rhythm was performed in all patients. All electrically abnormal left ventricular endocardium was excised. Eight patients (29.6%) died within 30 days of surgery. Death was not related to age, time of surgery after infarction, ventricular function, bypass time or type of arrhythmia. Patients requiring emergency surgery had a higher early postoperative mortality rate than did those undergoing planned surgery (43% versus 15%). During a follow-up period of 32 +/- 20 months, there have been no arrhythmic deaths and only three patients (16%) have required antiarrhythmic drug therapy. When required in the early weeks after infarction, surgery for ventricular arrhythmias offers a high cure rate at a risk related to the patient's preoperative arrhythmia frequency, which in turn relates to the risk of arrhythmic death.
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Affiliation(s)
- J P Bourke
- Regional Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne, England
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28
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Guidelines for clinical intracardiac electrophysiologic studies. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee to Assess Clinical Intracardiac Electrophysiologic Studies). J Am Coll Cardiol 1989; 14:1827-42. [PMID: 2584574 DOI: 10.1016/0735-1097(89)90040-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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29
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Guidelines for Clinical Intracardiac Electrophysiologic Studies. A report of the American College of Cardiology/American Heart Association Task Force on Assessment of Diagnostic and Therapeutic Cardiovascular Procedures. Circulation 1989; 80:1925-39. [PMID: 2688977 DOI: 10.1161/01.cir.80.6.1925] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
-
- Office of Scientific Affairs, American Heart Association, 7320 Greenville Avenue, Dallas, TX 75231, USA
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30
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Zee-Cheng CS, Kouchoukos NT, Connors JP, Ruffy R. Treatment of life-threatening ventricular arrhythmias with nonguided surgery supported by electrophysiologic testing and drug therapy. J Am Coll Cardiol 1989; 13:153-62. [PMID: 2909563 DOI: 10.1016/0735-1097(89)90564-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Forty-six patients who had coronary artery disease, left ventricular aneurysm and life-threatening ventricular tachyarrhythmia underwent surgical treatment to eliminate or facilitate control of the arrhythmia. Surgery was performed without the assistance of intraoperative mapping techniques. Forty-three patients underwent preoperative or postoperative electrophysiologic testing, or both, and antiarrhythmic therapy was added, when indicated, postoperatively. The patients had a mean age of 63 years, a mean preoperative left ventricular ejection fraction of 27 +/- 9% and a mean preoperative left ventricular end-diastolic pressure of 23 +/- 9 mm Hg. Twenty-one patients (46%) underwent surgical treatment within 2 months of their last myocardial infarction. The overall operative mortality rate was 6.5% (three patients). Eighteen of the 43 operative survivors were discharged from the hospital on no antiarrhythmic therapy, whereas 25 received additional antiarrhythmic treatment. During a mean follow-up period of 36 months (range 2 to 88), there were 13 deaths; eight patients died suddenly, three died of congestive heart failure, one of myocardial reinfarction and one from a noncardiac cause. The overall cumulative cardiac mortality rate at 1, 2 and 3 years was 16, 22 and 35%, respectively, whereas the sudden cardiac death rate was 5, 12 and 20%, respectively. This experience suggests that high risk patients who undergo nonguided surgery for life-threatening ventricular arrhythmia and left ventricular aneurysm have a relatively low surgical mortality and a better long-term survival than previously reported. However, if utilized, such an approach must be systematically supported by perioperative electrophysiologic testing to determine the need for supplemental antiarrhythmic therapy.
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Affiliation(s)
- C S Zee-Cheng
- Division of Cardiology, Jewish Hospital, Washington University Medical Center, St. Louis, Missouri 63110
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31
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Cox JL, Rosenbloom M. Surgical treatment of ventricular arrhythmias. Ann Thorac Surg 1988; 46:598-600. [PMID: 3056299 DOI: 10.1016/s0003-4975(10)64713-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- J L Cox
- Department of Surgery, Barnes Hospital, Washington University School of Medicine, St. Louis, MO
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32
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Kleiman RB, Miller JM, Buxton AE, Josephson ME, Marchlinski FE. Prognosis following sustained ventricular tachycardia occurring early after myocardial infarction. Am J Cardiol 1988; 62:528-33. [PMID: 3414543 DOI: 10.1016/0002-9149(88)90649-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Eighty-seven patients with sustained ventricular tachycardia (VT) between 3 and 90 days after acute myocardial infarction (AMI) were evaluated to define factors associated with a high risk of arrhythmia recurrence or death. Most patients had poor left ventricular function (mean ejection fraction 29 +/- 12%), multivessel coronary artery disease (71%) and inducible sustained VT with programmed stimulation (87%). During a mean follow-up of 26 months, 36 patients (41%) died and 21 patients had arrhythmia recurrence (with 19 sudden deaths). Factors independently associated with mortality included: (1) treatment before 1981 (p less than 0.01); (2) anterior AMI (p less than 0.05); (3) short time from AMI to first episode of VT (p less than 0.06); and (4) multivessel coronary artery disease (p less than 0.07). Factors independently associated with arrhythmia recurrence were: (1) medical treatment (as opposed to surgical) (p less than 0.01); (2) greater than or equal to 3 episodes of spontaneous VT (p = 0.01); (3) multivessel coronary disease (p less than 0.05); and (4) anterior AMI (p less than 0.07). Medically and surgically treated patients did not differ significantly in overall survival (49 vs 61%, respectively), although short-term (6 month) surgical survival improved from 31% during the first half of the study to 96% in the latter half (p less than 0.01). For patients with sustained VT early after AMI the risk of death and arrhythmia recurrence can be assessed based on clinical and angiographic characteristics; in addition, surgical treatment is associated with a lower incidence of arrhythmia recurrence than medical treatment.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R B Kleiman
- Clinical Electrophysiology Laboratory, Hospital of the University of Pennsylvania, Philadelphia 19104
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33
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Brandt B, Martins JB, Kienzle MG. Predictors of failure after endocardial resection for sustained ventricular tachycardia. J Thorac Cardiovasc Surg 1988. [DOI: 10.1016/s0022-5223(19)35769-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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34
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Sager PT, Batsford WP. Ventricular Arrhythmias: Medical Therapy, Device Treatment, and Indications for Electrophysiologic Study. Cardiol Clin 1988. [DOI: 10.1016/s0733-8651(18)30500-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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35
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Hauer RN, de Zwart MT, de Bakker JM, Hitchcock JF, Penn OC, Nijsen-Karelse M, Robles de Medina EO. Endocardial catheter mapping: wire skeleton technique for representation of computed arrhythmogenic sites compared with intraoperative mapping. Circulation 1986; 74:1346-54. [PMID: 3779920 DOI: 10.1161/01.cir.74.6.1346] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Guiding surgical therapy of ventricular tachycardia by preoperative endocardial catheter mapping necessitates improvement of the accuracy of localization of the arrhythmogenic site. We therefore used a new mathematical cineradiographic method during catheter mapping to compute the position of left ventricular arrhythmogenic sites relative to three anatomic reference points: the centers of aortic and mitral valve ostia and the left ventricular apex. To enable the surgeon to identify the position of the computed sites, a wire skeleton (one for each patient) representing a single or multiple arrhythmogenic site(s) relative to the anatomic reference points was constructed. This wire skeleton was inserted into the left ventricular cavity during surgery. Side branches of the device indicated preoperatively localized arrhythmogenic sites. Results in eight consecutive patients were compared with those of intraoperative simultaneous mapping of 64 endocardial sites. Sixteen morphologically distinct monomorphic ventricular tachycardias were mapped by catheter and 15 by intraoperative mapping. In 12 ventricular tachycardias an identical morphology was recorded during both techniques. The distance between arrhythmogenic sites localized with both methods was 1 cm or less in 11 of these 12 ventricular tachycardias and 2 cm in one ventricular tachycardia. These results indicate that endocardial catheter mapping combined with wire skeleton representation of computed positions of arrhythmogenic sites is reliable for guiding surgical therapy of ventricular tachycardia and since some of the ventricular tachycardias were inducible only during either preoperative or intraoperative mapping, both techniques have an additive value. In addition, the wire skeleton proved convenient during surgery by identifying the arrhythmogenic sites.
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36
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Kron IL, Lerman B, DiMarco JP. Surgical management of sustained ventricular arrhythmias presenting within eight weeks of acute myocardial infarction. Ann Thorac Surg 1986; 42:13-6. [PMID: 3729611 DOI: 10.1016/s0003-4975(10)61826-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
When it occurs after a recent (less than eight weeks) myocardial infarction, sustained ventricular tachycardia (VT) or fibrillation (VF) has resulted in a high one-year mortality despite antiarrhythmic drug therapy. We have operated on 29 patients with this syndrome either on an emergency basis because they had medically refractory VT or VF (19 patients) or electively if they had persistent congestive heart failure or angina and VT or VF (10 patients). Ages ranged from 36 to 82 years (mean, 60 years), and the mean left ventricular ejection fraction was 31 +/- 13%. Each patient had failed a trial of one or more (average, four) antiarrhythmic drugs and because of VT, required electrical cardioversion on an average of five occasions. Intraoperative mapping was complicated by multiple VT morphologies (9 patients), the rapid degeneration of VT to VF (5 patients), and the inability to induce VT reliably (5 patients). Subendocardial excision was performed at the site of the earliest electrical activity, or if no single site could be identified, a wide subendocardial excision of all visible scar was performed. There were 4 perioperative deaths (14%). All operative survivors underwent postoperative electrophysiological studies. Twenty of them required no further antiarrhythmic therapy, but 5 patients required drug therapy because of either spontaneous (2 patients) or electrically induced (3 patients) VT. During follow-up (average, 16 months) of these 25 patients, there have been 3 late deaths, 2 of them sudden. Two of the 3 late deaths were those of patients taking antiarrhythmic drugs. Our results demonstrate the effectiveness of early operative intervention when sustained ventricular arrhythmias complicate recovery after myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)
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37
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Miller JM, Josephson ME. Malignant ventricular arrhythmias early after myocardial infarction: brighter prospects. J Am Coll Cardiol 1985; 6:769-71. [PMID: 4031291 DOI: 10.1016/s0735-1097(85)80480-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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38
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DiMarco JP, Lerman BB, Kron IL, Sellers TD. Sustained ventricular tachyarrhythmias within 2 months of acute myocardial infarction: results of medical and surgical therapy in patients resuscitated from the initial episode. J Am Coll Cardiol 1985; 6:759-68. [PMID: 4031290 DOI: 10.1016/s0735-1097(85)80479-4] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Sustained ventricular tachycardia or fibrillation that develops during the early recovery period after acute myocardial infarction is a common clinical problem whose management remains controversial. Fifty-three patients who survived an initial episode of sustained ventricular tachycardia or fibrillation occurring between 3 and 60 days (mean +/- SD 21 +/- 16) after myocardial infarction were evaluated. Most of these patients had had a large (peak creatine kinase = 1,729 +/- 882 IU) complicated infarction. Forty-two (79%) of the 53 patients had had repetitive sustained ventricular arrhythmias and the condition of 19 of these could not be stabilized with drug therapy. Twenty-eight patients received medical therapy only. Twenty-four survived and were discharged from the hospital. Twenty-five patients underwent infarctectomy or aneurysmectomy either on an emergency basis (16 patients) or electively because of coexistent heart failure or angina (9 patients). Intraoperative mapping was attempted in these patients but was completely successful in only 13 (52%). Operative mortality was 16% with all deaths occurring in patients who were in shock before surgery. Five of 21 surgically treated survivors required long-term antiarrhythmic therapy. Twenty-one of 24 patients medically treated remain alive and well after 15 +/- 10 months of follow-up. Nineteen of 21 surgically treated patients remain alive and well after 17.9 +/- 11 months. One of these patients required reoperation for severe mitral regurgitation. These results confirm the poor medical prognosis of sustained ventricular tachyarrhythmias that present during the first 2 months after myocardial infarction but demonstrate that an acceptable rate of survival can be achieved with a combined medical and surgical approach to therapy.
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