1
|
Bisceglia C, Limite LR, Baratto F, D'Angelo G, Cireddu M, Della Bella P. Road-Map to Epicardial Approach for Catheter Ablation of Ventricular Tachycardia in Structural Heart Disease: Results From a 10-Year Tertiary-Center Experience. Circ Arrhythm Electrophysiol 2024; 17:e012181. [PMID: 38836351 DOI: 10.1161/circep.123.012181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 05/14/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Epicardial approach in ventricular tachycardia (VT) ablation is still regarded as a second-step strategy, due to the risk of complications. We evaluated the frequency that epicardial ablation targets were identified and ablation performed following pericardial access compared with unnecessary pericardial access for different VT causes and potential markers of epicardial VT. METHODS All VT ablation procedures including epicardial approach over a 10-year period were included. First-line epicardial approach was indicated in arrhythmogenic right ventricular cardiomyopathy (ARVC) and postmyocarditis VT; in patients with idiopathic dilated cardiomyopathy (IDCM) and postmyocardial infarction, indications resulted from available imaging techniques or 12-lead VT morphology. The epicardial approach was considered useful if epicardial ablation was performed after epicardial mapping. Feasibility, complications, and long-term outcome were reported. RESULTS Four hundred and eighty-eight subjects with a median age of 60 years (interquartile range, 47-65) and of left ventricle ejection fraction 41% (interquartile range, 30-55) underwent 626 epicardial VT ablations. Percutaneous access had a success rate of 92.2% and a complication rate of 3.6%. Overall, epicardial approach was, respectively, indicated to 11.8% of postmyocardial infarction patients, 49.5% in IDCM, 94% in myocarditis, and 90.7% in ARVC. Epicardial ablation at the first ablation attempt was performed in 9.3% of postmyocardial infarction patients, 28.8% in IDCM, 86.5% in myocarditis, and 81.3% in patients with ARVC. In first-line epicardial group, ARVC and myocarditis showed the highest odds for epicardial ablation (OR, 4.057 [95% CI, 1.299-8.937]; P=0.007; OR, 3.971 [95% CI, 1.376-11.465]; P=0.005, respectively). IDCM independently predicted unnecessary epicardial approach (OR, 2.7 [95% CI, 1.7-4.3]; P<0.001). After a follow-up of 41 months (interquartile range, 19-64), patients with IDCM experienced higher rate of recurrences and mortality compared with other causes. CONCLUSIONS Epicardial approach is integral part of ablation armamentarium regardless of the VT cause, with high feasibility and low complication rate in experienced centers. Our data support its use at first ablation attempt in VTs related to ARVC and myocarditis.
Collapse
Affiliation(s)
- Caterina Bisceglia
- Arrhythmia Unit and EP laboratories, San Raffaele Hospital, Milan, Italy
| | - Luca R Limite
- Arrhythmia Unit and EP laboratories, San Raffaele Hospital, Milan, Italy
| | - Francesca Baratto
- Arrhythmia Unit and EP laboratories, San Raffaele Hospital, Milan, Italy
| | - Giuseppe D'Angelo
- Arrhythmia Unit and EP laboratories, San Raffaele Hospital, Milan, Italy
| | - Manuela Cireddu
- Arrhythmia Unit and EP laboratories, San Raffaele Hospital, Milan, Italy
| | - Paolo Della Bella
- Arrhythmia Unit and EP laboratories, San Raffaele Hospital, Milan, Italy
| |
Collapse
|
2
|
Hayase J, Fishbein G, Rerkpichaisuth V, Chung WH, Ajijola O, Shivkumar K, Bradfield JS. Linear epicardial cryoablation effects in a porcine model: Lesion characteristics and vascular risk. J Cardiovasc Electrophysiol 2023; 34:1878-1884. [PMID: 37473428 DOI: 10.1111/jce.16014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 03/19/2023] [Accepted: 07/11/2023] [Indexed: 07/22/2023]
Abstract
INTRODUCTION Cryoablation in open-chest surgical interventions for ventricular arrhythmias has been reported with reasonable procedural outcomes. However, the characteristics of cryoablation lesions on the ventricular myocardium are not well defined. The purpose of the present study was to determine the tissue and vascular effects of a linear epicardial cryoablation probe in a porcine animal model. METHODS Five adult Yorkshire swine underwent median sternotomy and application of linear cryoablation lesions using a malleable aluminum linear cryoablation probe of varying duration (2, 3, 4, and 5 min), including one lesion placed intentionally over the left anterior descending coronary (LAD) artery. Histological analysis was performed. RESULTS Maximum lesion depth was approximately 1.0 cm with 3 min freezes, with no significant increase in depth achieved with longer lesions. No transmural lesions were achieved. No large vessel epicardial coronary artery injuries were seen to the LAD; however, surprisingly, remote isolated interventricular septal injury was seen in all animals, suggestive of possible compromise of smaller coronary arterial vessels. CONCLUSION Single application freezes with an aluminum linear cryoablation probe can create homogeneous ablative lesions over the ventricular myocardium with a maximum depth of approximately 1.0 cm. No large vessel injury occurred with direct lesion application of the LAD; however, small coronary vessels may be at risk.
Collapse
Affiliation(s)
- Justin Hayase
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Gregory Fishbein
- UCLA Department of Pathology, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Vilasinee Rerkpichaisuth
- UCLA Department of Pathology, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
- Department of Pathology, Faculty of Medicine Siriraj Hospital, Mahidol University, Kanchanaburi, Thailand
| | - Wei-Hsin Chung
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
- Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Olujimi Ajijola
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| |
Collapse
|
3
|
Kunkel M, Rothstein P, Sauer P, Zipse MM, Sandhu A, Tumolo AZ, Borne RT, Aleong RG, Cleveland JC, Fullerton D, Pal JD, Davies AS, Lane C, Nguyen DT, Sauer WH, Tzou WS. Open surgical ablation of ventricular tachycardia: Utility and feasibility of contemporary mapping and ablation tools. Heart Rhythm O2 2021; 2:271-279. [PMID: 34337578 PMCID: PMC8322924 DOI: 10.1016/j.hroo.2021.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Ventricular tachycardia (VT) catheter ablation success may be limited when transcutaneous epicardial access is contraindicated. Surgical ablation (SurgAbl) is an option, but ablation guidance is limited without simultaneously acquired electrophysiological data. Objective We describe our SurgAbl experience utilizing contemporary electroanatomic mapping (EAM) among patients with refractory VT storm. Methods Consecutive patients with recurrent VT despite antiarrhythmic drugs (AADs) and prior ablation, for whom percutaneous epicardial access was contraindicated, underwent open SurgAbl using intraoperative EAM guidance. Results Eight patients were included, among whom mean age was 63 ± 5 years, all were male, mean left ventricular ejection fraction was 39% ± 12%, and 2 (25%) had ischemic cardiomyopathy. Reasons for surgical epicardial access included dense adhesions owing to prior cardiac surgery, hemopericardium, or pericarditis (n = 6); or planned left ventricular assist device (LVAD) implantation at time of SurgAbl (n = 2). Cryoablation guided by real-time EAM was performed in all. Goals of clinical VT noninducibility or core isolation were achieved in 100%. VT burden was significantly reduced, from median 15 to 0 events in the month pre- and post-SurgAbl (P = .01). One patient underwent orthotopic heart transplantation for recurrent VT storm 2 weeks post-SurgAbl. Over mean follow-up of 3.4 ± 1.7 years, VT storm–free survival was achieved in 6 (75%); all continued AADs, although at lower dose. Conclusion Surgical mapping and ablation of refractory VT with use of contemporary EAM is feasible and effective, particularly among patients with contraindication to percutaneous epicardial access or with another indication for cardiac surgery.
Collapse
Affiliation(s)
- Megan Kunkel
- University of Colorado School of Medicine, Division of Cardiology, Section of Cardiac Electrophysiologist, Aurora, Colorado
| | - Peter Rothstein
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas
| | - Peter Sauer
- Brigham and Women's Hospital, Cardiac Arrhythmia Service, Boston, Massachusetts
| | - Matthew M. Zipse
- University of Colorado School of Medicine, Division of Cardiology, Section of Cardiac Electrophysiologist, Aurora, Colorado
| | - Amneet Sandhu
- University of Colorado School of Medicine, Division of Cardiology, Section of Cardiac Electrophysiologist, Aurora, Colorado
- VA Eastern Colorado Health Care System, Aurora, Colorado
| | - Alexis Z. Tumolo
- University of Colorado School of Medicine, Division of Cardiology, Section of Cardiac Electrophysiologist, Aurora, Colorado
| | - Ryan T. Borne
- University of Colorado School of Medicine, Division of Cardiology, Section of Cardiac Electrophysiologist, Aurora, Colorado
| | - Ryan G. Aleong
- University of Colorado School of Medicine, Division of Cardiology, Section of Cardiac Electrophysiologist, Aurora, Colorado
| | - Joseph C. Cleveland
- University of Colorado School of Medicine, Division of Cardiology, Section of Cardiac Electrophysiologist, Aurora, Colorado
| | - David Fullerton
- University of Colorado School of Medicine, Division of Cardiology, Section of Cardiac Electrophysiologist, Aurora, Colorado
| | - Jay D. Pal
- University of Colorado School of Medicine, Division of Cardiology, Section of Cardiac Electrophysiologist, Aurora, Colorado
| | | | | | - Duy T. Nguyen
- Stanford University, Section of Electrophysiology, Division of Cardiology, Palo Alto, California
| | - William H. Sauer
- Brigham and Women's Hospital, Cardiac Arrhythmia Service, Boston, Massachusetts
| | - Wendy S. Tzou
- University of Colorado School of Medicine, Division of Cardiology, Section of Cardiac Electrophysiologist, Aurora, Colorado
- Address reprint requests and correspondence: Dr Wendy S. Tzou, University of Colorado School of Medicine Anschutz Medical Campus, Division of Cardiology, Cardiac Electrophysiology Section, 12401 E 17th Ave, MS B-136, Aurora, CO 80045.
| |
Collapse
|