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Yamada T, Litovsky S, Neal Kay G. Prevalence and electrocardiographic and electrophysiological characteristics of idiopathic ventricular arrhythmias originating from the septal left ventricular summit. J Cardiovasc Electrophysiol 2024; 35:1174-1184. [PMID: 38867544 DOI: 10.1111/jce.16270] [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: 01/14/2024] [Revised: 03/18/2024] [Accepted: 03/21/2024] [Indexed: 06/14/2024]
Abstract
INTRODUCTION The left ventricular summit (LVS) is the highest point on the epicardial surface of the left ventricle. A part of the LVS that is located between the left coronary arteries (lateral-LVS) is one of the major sites of idiopathic ventricular arrhythmia (VA) origins. Some idiopathic epicardial VAs can be ablated at endocardial sites adjacent to the epicardial area septal to the lateral-LVS (septal-LVS). This study examined the prevalence and electrocardiographic and electrophysiological characteristics of septal-LVS VAs. METHODS We studied consecutive patients with idiopathic VAs originating from the LVS (67 patients) and aortic root (93 patients). RESULTS Based on the ablation results, among 67 LVS VAs, 54 were classified as lateral and 13 as septal-LVS VAs. As compared with the lateral-LVS VAs, the septal-LVS VAs were characterized by a greater prevalence of left bundle branch block with left inferior-axis QRS pattern, later precordial transition, lower R-wave amplitude ratio in leads III to II, lower Q-wave amplitude ratio in leads aVL to aVR, and later local ventricular activation time relative to the QRS onset during VAs (V-QRS) in the great cardiac vein. The electrocardiographic and electrophysiological characteristics of the septal-LVS VAs were similar to those of the aortic root VAs. However, the V-QRS at the successful ablation site was significantly later during the septal-LVS VAs than aortic root VAs (p < .0001). The precordial transition was significantly later during the septal-LVS VAs than aortic root VAs (p < .05). CONCLUSIONS Septal-LVS VAs are considered a distinct subgroup of idiopathic VAs originating from the left ventricular outflow tract.
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Affiliation(s)
- Takumi Yamada
- Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota, USA
| | - Silvio Litovsky
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - George Neal Kay
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Naurushev A, Kodasbayev A. Natural increase in the efficiency of ablation of ventricular tachyarrhythmias using high-density mapping in patients with non-ischemic etiology. MINIM INVASIV THER 2024; 33:147-156. [PMID: 38240355 DOI: 10.1080/13645706.2024.2305141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 12/13/2023] [Indexed: 06/02/2024]
Abstract
OBJECTIVE This research is aimed at evaluating the efficacy and safety of ablation of ventricular tachyarrhythmias using high-density mapping in patients with non-ischemic etiology. MATERIAL AND METHODS This study analyzed 60 patients with ventricular tachyarrhythmias, using diagnostic tools like electrocardiography and MRI. Treatment involved epicardial ablation following the E. Sosa method, with efficacy evaluated through the SF-36 survey and MRI. Success rates were categorized, and post-treatment care included troponin monitoring and aspirin. Data was analyzed using Excel and Statistika 11.0. RESULTS Of the 60 patients, 30 underwent surgery at the City Cardiological Center in Almaty and 30 patients were operated on at the National Research Cardiac Surgery Center in Astana. Prior to surgery, all patients underwent a standard clinical diagnostic examination followed by ablation of ventricular tachyarrhythmias using high-density mapping. After six and 12 months from the beginning of the study, all patients underwent a follow-up examination, with an assessment of the effectiveness of the above treatment. After 12 months, follow-up examination of patients showed good results. Left ventricular ejection fraction in patients after 12 months increased from 47 ± 2.4 to 58 ± 4.5%. The end-diastolic diameter of the left ventricle decreased from 61.2 ± 2.31 to 50.1 ± 1.9 mm. CONCLUSION In summary, the study highlights the efficacy and safety of high-density mapping ablation in treating ventricular tachyarrhythmias, especially from the right ventricular outflow tract in patients with reduced left ventricular ejection fraction. The success rate of the procedure was 95%. This approach proves beneficial for patients unresponsive to antiarrhythmic therapy, enhancing both the quality of life and potentially reducing mortality in patients with ventricular arrhythmias.
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Affiliation(s)
- Azamat Naurushev
- Department of Cardiovascular Surgery, Asfendiyarov Kazakh National Medical University, Almaty, Republic of Kazakhstan
| | - Almat Kodasbayev
- Department of Cardiovascular Surgery, Asfendiyarov Kazakh National Medical University, Almaty, Republic of Kazakhstan
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Yamada T, Kay GN. Trends Favoring an Anatomical Approach to Radiofrequency Catheter Ablation of Idiopathic Ventricular Arrhythmias Originating From the Left Ventricular Summit. Circ Arrhythm Electrophysiol 2024; 17:e012548. [PMID: 38629301 DOI: 10.1161/circep.123.012548] [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: 10/12/2023] [Accepted: 03/26/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Epicardial radiofrequency catheter ablation (RFCA) of idiopathic ventricular arrhythmias (VAs) originating from the left ventricular summit (LVS) is challenging because of the anatomic barriers. On the other hand, RFCA at the endocardial sites near the earliest epicardial activation site of LVS-VAs (anatomic approach) has proven successful. The evolving trends in the approaches and outcomes of RFCA of LVS-VAs at a single center were evaluated. METHODS We studied 88 consecutive patients with idiopathic LVS-VAs at our institute from 2009 to 2019. These patients were divided into 3 periods: 2009 to 2012 (early), 2013 to 2015 (middle), and 2016 to 2019 (recent). The data were compared among the 3 periods. RESULTS The RFCA success rate did not significantly change from the early to middle period but significantly increased from the middle to recent period (P=0.0315). The transpericardial approach usage significantly decreased over the 3 periods. The anatomic approach usage significantly increased over the 3 periods. The use of the transpericardial approach did not affect the RFCA outcomes over the 3 periods. The success rate of the anatomic RFCA tended to increase from the early to middle period and significantly increased from the middle to recent period (P=0.0412). The number of endocardial locations where RFCA was successful increased over the 3 periods. CONCLUSIONS Over the 10-year period, the transpericardial approach became decreasingly performed, whereas the anatomic approach became increasingly performed with a satisfactory improvement in the RFCA outcomes of LVS-VAs. The anatomic RFCA became more successful by identifying more and various endocardial locations as target sites.
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Affiliation(s)
- Takumi Yamada
- Cardiovascular Division, University of Minnesota, Minneapolis (T.Y.)
| | - George Neal Kay
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL (G.N.K.)
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Chen N, Wang L, Jiao J, Ju W, Wang Z, Zou C, Yi F, Xiao F, Shen W, Li C, Shi L, Chen L, Ji Y, Wei Y, Gu K, Yang G, Chen H, Li M, Liu H, Chen M. RV1+RV3 Index to Differentiate Idiopathic Ventricular Arrhythmias Arising From Right Ventricular Outflow Tract and Aortic Sinus of Valsalva: A Multicenter Study. J Am Heart Assoc 2024; 13:e033779. [PMID: 38533964 PMCID: PMC11179762 DOI: 10.1161/jaha.123.033779] [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: 12/05/2023] [Accepted: 03/03/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND This study aimed to investigate the predictive value of parameters of every precordial lead and their combinations in differentiating between idiopathic ventricular arrhythmias (IVAs) from the right ventricular outflow tract and aortic sinus of Valsalva (ASV). METHODS AND RESULTS Between March 1, 2018, and December 1, 2021, consecutive patients receiving successful ablation of right ventricular outflow tract or ASV IVAs were enrolled. The amplitude and duration of the R wave and S wave were measured in every precordial lead during IVAs. These parameters were either summed, subtracted, multiplied, or divided to create different indexes. The index with the highest area under the curve to predict ASV IVAs was developed, compared with established indexes, and validated in an independent prospective multicenter cohort. A total of 150 patients (60 men; mean age, 45.3±16.4 years) were included in the derivation cohort. The RV1+RV3 index (summed R-wave amplitude in leads V1 and V3) had the highest area under the curve (0.942) among the established indexes. An RV1+RV3 index >1.3 mV could predict ASV IVAs with a sensitivity of 95% and a specificity of 83%. Its predictive performance was maintained in the validation cohort (N=109). In patients with V3 R/S transition, an RV1+RV3 index >1.3 mV could predict ASV IVAs, with an area under the curve of 0.892, 93% sensitivity, and 75% specificity. CONCLUSIONS The RV1+RV3 index is a simple and novel criterion that accurately differentiates between right ventricular outflow tract and ASV IVAs. Its performance outperformed established indexes, making it a valuable tool in clinical practice.
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Affiliation(s)
- Ning Chen
- The First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Lei Wang
- The First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Jincheng Jiao
- The First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Weizhu Ju
- The First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Zhe Wang
- The First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Cao Zou
- The First Affiliated Hospital of Soochow UniversitySoochowChina
| | - Fu Yi
- Xijing HospitalXi’anChina
| | - Fangyi Xiao
- The First Affiliated Hospital of Wenzhou Medical UniversityWenzhouChina
| | | | - Chengzong Li
- The Affiliated Hospital of Xuzhou Medical UniversityXuzhouChina
| | - Linsheng Shi
- The Second Affiliated Hospital of Nantong UniversityNantongChina
| | | | - Yuan Ji
- Changzhou No.2 People’s HospitalChangzhouChina
| | - Youquan Wei
- The First Affiliated Yijishan Hospital of Wannan Medical CollegeWuhuChina
| | - Kai Gu
- The First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Gang Yang
- The First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Hongwu Chen
- The First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Mingfang Li
- The First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Hailei Liu
- The First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
| | - Minglong Chen
- The First Affiliated Hospital of Nanjing Medical UniversityNanjingChina
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Ballı Ş, Kanlıoğlu P, Akgun G. Experience of left ventricular outflow tract arrhythmia ablation in paediatric patients using limited fluoroscopy and three-dimensional mapping technique. Cardiol Young 2023:1-6. [PMID: 38037860 DOI: 10.1017/s1047951123003955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
OBJECTIVE The left ventricular outflow tract is an important source of ventricular arrhythmias. Up to one-third of all idiopathic ventricular arrhythmias in patients with structurally normal hearts may arise from this region. We would like to share the results of our left ventricular outflow tract ablation using three-dimensional mapping and limited fluoroscopy. MATERIALS AND METHODS This is a single-centre retrospective cohort study. Forty-six consecutive patients who underwent left ventricular outflow tract ablation procedures between January 2015 and June 2023 were included in the study. The EnSite Precision System (Abbott, St. Paul, MN, USA) was used to facilitate mapping and to reduce or eliminate the need for fluoroscopy. RESULTS The study group comprised 29 males and 17 females, with a mean age of 13.4 ± 4.5 years. The most common location for arrhythmias was the left coronary cusp (n : 21). Other locations, in sequence, included the junction of the right and left coronary commissure (n : 10), right coronary cusp (n : 10), left ventricular outflow tract endocardium (n:4), aorto-mitral junction (n : 1), and great cardiac vein (n : 1). Nine of these patients had previously undergone unsuccessful right ventricular outflow tract ablation at another centre. Cryoablation was performed in three patients, irrigated radiofrequency ablation in three patients, and conventional radiofrequency ablation in the remaining patients. The acute success rate was 100%, and no recurrences were observed. The mean follow-up period was 49.6 ± 24.4 months. All patients were asymptomatic and were being followed without antiarrhythmic medication. CONCLUSION Although left ventricular outflow tract ablations pose a risk for coronary artery and heart valve complications, they can be performed successfully and safely with the guidance of three-dimensional mapping.
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Affiliation(s)
- Şevket Ballı
- Department of Pediatric Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training & Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Pınar Kanlıoğlu
- Department of Pediatric Cardiology, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training & Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Gokmen Akgun
- Department of Pediatric Cardiology, Kocaeli City Hospital, Kocaeli, Turkey
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Zhao L, Li R, Bai L, Zhang J, Lu J, Yang X, Liu D, Cui W. Lead I R-wave indexes: A novel electrocardiographic criterion for distinguishing the origin of idiopathic premature ventricular contractions from the three subregions of the aortic sinus cusps. J Electrocardiol 2023; 81:176-185. [PMID: 37741272 DOI: 10.1016/j.jelectrocard.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/15/2023] [Accepted: 09/11/2023] [Indexed: 09/25/2023]
Abstract
PURPOSE The current study was conducted to investigate the electrocardiographic (ECG) characteristics of idiopathic premature ventricular contractions (PVCs) originating from the aortic sinus cusp (ASC) and establish a novel ECG criterion to discriminate PVCs originating from the right coronary cusp (RCC), left coronary cusp (LCC), and the left and right coronary cusp junction (LRJ). METHODS A retrospective analysis was performed on a total of 133 patients with idiopathic PVCs who underwent successful mapping and ablation. The sites of origin (SOO) were confirmed using fluoroscopy and a three-dimensional mapping system during radiofrequency catheter ablation (RFCA). Among the patients, 69 had PVCs originating from the LCC, 39 from the RCC, and 25 from the LRJ. Characteristics of surface 12‑lead electrocardiograms (ECGs) recorded during PVCs were analyzed. Q-, R-, S, and R'-wave amplitudes were measured in lead I, and the lead I R-wave indexes (IRa, IRb, IRc, IRd, and IRe) were derived by employing multiplication, subtraction, sum, and division operations on these ECG measurements. Notably, IRb and IRe demonstrated usefulness as ECG indexes for discriminating PVCs originating from RCC, LCC, and LRJ in the ASC. RESULTS The R- and S-wave amplitudes in lead I exhibited statistically significant differences among the three groups (P < 0.001 and P < 0.001, respectively). In discriminating PVCs originating from the RCC from the other two groups, IRb showed the largest area under the curve (AUC) of 0.813, as assessed by receiver operating characteristic (ROC) analysis, with a cutoff value of ≤0.5 indicating PVCs of RCC origin. The sensitivity and specificity were 80.3% and 78.7%, respectively. For discriminating PVCs arising from the LCC from those in the LRJ group, IRe exhibited the largest AUC of 0.801, with an optimal cutoff value of 0. An IRe value >0 indicated PVCs originating from the LRJ, while an IRe value ≤0 indicated PVCs originating from the LCC. The sensitivity and specificity of the IRe index were 84.0% and 70.7%, respectively. CONCLUSION Lead I R-wave indexes provided simple and useful ECG criteria for discriminating PVCs originating from the LCC, RCC, and LRJ in the left ventricular outflow tract (LVOT).
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Affiliation(s)
- Lei Zhao
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Ruibin Li
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Long Bai
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jidong Zhang
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Jingchao Lu
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Xiaohong Yang
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Demin Liu
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Wei Cui
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei, China.
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Mori S, Bradfield JS. Ventricular Arrhythmias Ablated From the Noncoronary Aortic Sinus: Underrecognized Myocardium of the Right Ventricle. JACC Clin Electrophysiol 2023; 9:1292-1295. [PMID: 37354184 DOI: 10.1016/j.jacep.2023.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 04/21/2023] [Indexed: 06/26/2023]
Affiliation(s)
- Shumpei Mori
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California, USA.
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Hanson M, Futyma P, Bode W, Liang JJ, Tapia C, Adams C, Zarębski Ł, Wrzos A, Saenz L, Sadek M, Muser D, Baranchuk A, Marchlinski F, Santangeli P, Garcia F, Enriquez A. Catheter ablation of intramural outflow tract premature ventricular complexes: a multicentre study. Europace 2023; 25:euad100. [PMID: 37096979 PMCID: PMC10228610 DOI: 10.1093/europace/euad100] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 03/20/2023] [Indexed: 04/26/2023] Open
Abstract
AIMS Ablation of outflow tract ventricular arrhythmias may be limited by a deep intramural location of the arrhythmogenic source. This study evaluates the acute and long-term outcomes of patients undergoing ablation of intramural outflow tract premature ventricular complexes (PVCs). METHODS AND RESULTS This multicenter series included patients with structurally normal heart or nonischemic cardiomyopathy and intramural outflow tract PVCs defined by: (a) ≥ 2 of the following criteria: (1) earliest endocardial or epicardial activation < 20ms pre-QRS; (2) Similar activation in different chambers; (3) no/transient PVC suppression with ablation at earliest endocardial/epicardial site; or (b) earliest ventricular activation recorded in a septal coronary vein. Ninety-two patients were included, with a mean PVC burden of 21.5±10.9%. Twenty-six patients had had previous ablations. All PVCs had inferior axis, with LBBB pattern in 68%. In 29 patients (32%) direct mapping of the intramural septum was performed using an insulated wire or multielectrode catheter, and in 13 of these cases the earliest activation was recorded within a septal vein. Most patients required special ablation techniques (one or more), including sequential unipolar ablation in 73%, low-ionic irrigation in 26%, bipolar ablation in 15% and ethanol ablation in 1%. Acute PVC suppression was achieved in 75% of patients. Following the procedure, the PVC burden was reduced to 5.8±8.4%. The mean follow-up was 15±14 months and 16 patients underwent a repeat ablation. CONCLUSION Ablation of intramural PVCs is challenging; acute arrhythmia elimination is achieved in 3/4 patients, and non-conventional approaches are often necessary for success.
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Affiliation(s)
- Matthew Hanson
- Division of Cardiology, Queen’s University, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada
| | - Piotr Futyma
- University of Rzeszów and St. Joseph's Heart Rhythm Center, Rzeszów, Poland
| | - Weeranun Bode
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jackson J Liang
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Carlos Tapia
- Fundación Cardioinfantil, Instituto de Cardiología, Bogotá, Colombia
| | - Christian Adams
- Fundación Cardioinfantil, Instituto de Cardiología, Bogotá, Colombia
| | - Łukasz Zarębski
- University of Rzeszów and St. Joseph's Heart Rhythm Center, Rzeszów, Poland
| | - Aleksandra Wrzos
- University of Rzeszów and St. Joseph's Heart Rhythm Center, Rzeszów, Poland
| | - Luis Saenz
- Fundación Cardioinfantil, Instituto de Cardiología, Bogotá, Colombia
| | - Mouhannad Sadek
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Daniele Muser
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Adrian Baranchuk
- Division of Cardiology, Queen’s University, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada
| | - Francis Marchlinski
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pasquale Santangeli
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fermin Garcia
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andres Enriquez
- Division of Cardiology, Queen’s University, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada
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Kuniewicz M, Budnicka K, Dusza M, Jakob N, Cholewa N, Defonseka R, Gosnell M, Wadhwa T, Walocha J, Dobrzynski H, Hołda M. Gross anatomic relationship between the human left atrial appendage and the left ventricular summit region: implications for catheter ablation of ventricular arrhythmias originating from the left ventricular summit. J Interv Card Electrophysiol 2023; 66:301-310. [PMID: 35262858 DOI: 10.1007/s10840-022-01172-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 02/25/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE The left ventricular summit (LVS) is a source of difficult-to-treat arrhythmias because of anatomical limitations. The aim of this study was to perform detailed research of the left atrial appendage (LAA) anatomy of cadaveric hearts to analyze their complex anatomy and coverage of the LVS. METHODS AND RESULTS Eighty human formalin fixed hearts (mean age 44.4 ± 15.5, 27.5% females) were investigated. Each LAA size, type, and its relationship to the LVS were analyzed, as well as possible access sites for mapping/ablating electrode. Four types of LAA were observed over two LVS sites that are either accessible or not. The highest coverage over an inaccessible LVS area was observed in the Broccoli type, followed by the Windsock then the Chicken Wing and finally the Cactus types; over the accessible area of the LVS was observed in the Windsock, then in the Chicken Wing, then in the Cactus, and finally in the Broccoli types. The attainable coverage for electrode access is diminished from 25 to 65% because of the complex pectinate muscles and sharp angles. The highest density of the LAA floor made by pectinate muscles can be found in the Broccoli type (p < 0.005), while the Chicken Wing had the highest number of paper-thin-like pouches. CONCLUSIONS The LAA appears to be a promising entry for ablation-qualified patients with the LV summit originate arrhythmias. The complex internal structure of the LAA may complicate ablation procedures. More prominent appendages are promising in more extensive mapping areas over the LVS.
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Affiliation(s)
- M Kuniewicz
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland. .,Department of Electrocardiology, Institute of Cardiology, Jagiellonian University Medical College, Cracow, Poland.
| | - K Budnicka
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - M Dusza
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - N Jakob
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - N Cholewa
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - R Defonseka
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - M Gosnell
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - T Wadhwa
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - J Walocha
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland
| | - H Dobrzynski
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland.,Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK
| | - M Hołda
- Department of Anatomy, Jagiellonian University Medical College, Kopernika 12, 31-034, Cracow, Poland.,Division of Cardiovascular Sciences, The University of Manchester, Manchester, UK.,HEART-Heart Embryology and Anatomy Research Team, Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
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Yamada T. Predictors of Successful Endocardial Ablation of Epicardial Left Ventricular Summit Arrhythmias. Card Electrophysiol Clin 2023; 15:15-24. [PMID: 36774132 DOI: 10.1016/j.ccep.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Takumi Yamada
- Cardiovascular Division, University of Minnesota, 420 Delaware Street Southeast, MMC 508, Minneapolis, MN 55455, USA.
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11
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Shimojo M, Inden Y, Yanagisawa S, Suzuki N, Tsurumi N, Watanabe R, Nakagomi T, Okajima T, Suga K, Tsuji Y, Murohara T. A novel practical algorithm using machine learning to differentiate outflow tract ventricular arrhythmia origins. J Cardiovasc Electrophysiol 2023; 34:627-637. [PMID: 36651347 DOI: 10.1111/jce.15823] [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: 10/07/2022] [Revised: 01/04/2023] [Accepted: 01/10/2023] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Diagnosis of outflow tract ventricular arrhythmia (OTVA) localization by an electrocardiographic complex is key to successful catheter ablation for OTVA. However, diagnosing the origin of OTVA with a precordial transition in lead V3 (V3TZ) is challenging. This study aimed to create the best practical electrocardiogram algorithm to differentiate the left ventricular outflow tract (LVOT) from the right ventricular outflow tract (RVOT) of OTVA origin with V3TZ using machine learning. METHODS Of 498 consecutive patients undergoing catheter ablation for OTVA, we included 104 patients who underwent ablation for OTVA with V3TZ and identified the origin of LVOT (n = 62) and RVOT (n = 42) from the results. We analyzed the standard 12-lead electrocardiogram preoperatively and measured 128 elements in each case. The study population was randomly divided into training group (70%) and testing group (30%), and decision tree analysis was performed using the measured elements as features. The performance of the algorithm created in the training group was verified in the testing group. RESULTS Four measurements were identified as important features: the aVF/II R-wave ratio, the V2S/V3R index, the QRS amplitude in lead V3, and the R-wave deflection slope in lead V3. Among them, the aVF/II R-wave ratio and the V2S/V3R index had a particularly strong influence on the algorithm. The performance of this algorithm was extremely high, with an accuracy of 94.4%, precision of 91.5%, recall of 100%, and an F1-score of 0.96. CONCLUSIONS The novel algorithm created using machine learning is useful in diagnosing the origin of OTVA with V3TZ.
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Affiliation(s)
- Masafumi Shimojo
- Department of Cardiovascular Research and Innovation, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Satoshi Yanagisawa
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Noriyuki Suzuki
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Naoki Tsurumi
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Ryo Watanabe
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Toshifumi Nakagomi
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Takashi Okajima
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Kazumasa Suga
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Yukiomi Tsuji
- Department of Cardiovascular Research and Innovation, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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12
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Matto F, Venugopal D, Bhave PD, Rhodes TE, Mazur A. Utility of high resolution mapping to guide ablation of ventricular arrhythmias from the aortic sinuses of Valsalva. J Interv Card Electrophysiol 2023; 66:51-59. [PMID: 34363567 DOI: 10.1007/s10840-021-01040-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 07/14/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Left ventricular outflow tract (LVOT) arrhythmias are commonly targeted from the aortic sinuses of Valsalva (SOV). Both presystolic potentials during ventricular arrhythmia (VA) and late diastolic potentials during sinus rhythm have been recognized as markers of successful ablation sites. The study aimed to evaluate the utility of high resolution mapping (HRM) with small and closely spaced electrodes for guiding ablation of VA from the SOV. METHODS Seventeen patients with LVOT VA underwent HRM in the SOV with either PentaRay (13) or Orion (4) catheters. Ablation was guided by low amplitude high frequency potentials that were identified with HRM and tagged on the electroanatomic map. RESULTS High frequency low amplitude potentials during sinus rhythm (late) or VA (early) were demonstrated with HRM in all 17 consecutive patients; while these potentials were either absent or usually had a far-field appearance in the recordings obtained at the same sites with a 3.5-mm standard ablation catheter. On intracardiac echocardiogram, sites with these potentials corresponded to the bases of the sinuses adjacent to the LV ostium. Ablation was acutely successful in 16 out of 17 patients. Significant reduction in VA burden (≥ 90%) was noted in 15 patients. CONCLUSIONS High frequency low amplitude potentials during sinus rhythm (late) and VA (early) are consistently recorded using HRM in the SOV in patients with VA arising from the aortic sinuses of Valsalva. Standard ablation catheters have limited resolution for detecting these potentials. HRM may potentially improve outcomes of ablation of VA originating from the aortic SOV.
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Affiliation(s)
- Faisal Matto
- Division of Cardiovascular Medicine, University of Iowa Hospitals & Clinics, E-317C GH, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Dev Venugopal
- Division of Cardiology, University of Kentucky College of Medicine, Bowling Green, KY, USA
| | - Prashant D Bhave
- Division of Cardiology, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Troy E Rhodes
- Division of Cardiovascular Medicine, University of Iowa Hospitals & Clinics, E-317C GH, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Alexander Mazur
- Division of Cardiovascular Medicine, University of Iowa Hospitals & Clinics, E-317C GH, 200 Hawkins Drive, Iowa City, IA, 52242, USA.
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13
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Evaluation of five algorithms in predicting the sublocalisation of right ventricular outflow tract arrhythmia (RVOTA) when compared to 3D electroanatomical mapping origin. COR ET VASA 2022. [DOI: 10.33678/cor.2022.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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14
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Yamada T. Techniques for Catheter Ablation of Idiopathic Ventricular Arrhythmias Originating from the Outflow Tract and Left Ventricular Summit. Card Electrophysiol Clin 2022; 14:621-631. [PMID: 36396181 DOI: 10.1016/j.ccep.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Idiopathic ventricular arrhythmias (VAs) most commonly originate from the ventricular outflow tracts. Because the anatomy of this region is complex and some of those VA origins are intramural and epicardial, it may sometimes be difficult to locate the site of the VA origin. Meticulous mapping in multiple different locations such as the right and left ventricular outflow tracts, endocardial and epicardial sites, and above and below the aortic and pulmonic valves may be required to achieve successful catheter ablation of those VAs. Special ablation techniques may be considered to improve the outcome of catheter ablation of intramural and epicardial VAs.
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Affiliation(s)
- Takumi Yamada
- Cardiovascular Division, University of Minnesota, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA.
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15
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A Four-Stepwise Electrocardiographic Algorithm for Differentiation of Ventricular Arrhythmias Originated from Left Ventricular Outflow Tract. J Clin Med 2022; 11:jcm11216398. [PMID: 36362626 PMCID: PMC9653710 DOI: 10.3390/jcm11216398] [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: 09/26/2022] [Revised: 10/21/2022] [Accepted: 10/27/2022] [Indexed: 11/17/2022] Open
Abstract
Several electrocardiographic algorithms have been proposed to identify the site of origin for the ventricular arrhythmias (VAs) from the left ventricular outflow tract (LVOT) versus right ventricular outflow tract. However, the electrocardiographic criteria for distinguishing VAs originated from the different sites of LVOT is lacking. We aimed to develop a simple and efficient ECG algorithm to differentiate LVOT VAs originated from the aortic root, AMC and LV summit. We analyzed 12-lead ECG characteristics of 68 consecutive patients who underwent successful radiofrequency catheter ablation of symptomatic VAs from LVOT. Patients were divided into RCC (right coronary cusp) group (n = 8), the L-RCC (the junction between the LCC and RCC) group (n = 21), the LCC (left coronary cusp) group (n = 24), the aortomitral continuity (AMC) group (n = 9) and the LV summit group (n = 6) according to the final ablation sites. Measurements with the highest diagnostic performance were modeled into a 4-stepwise algorithm to discriminate LVOT VAs. The performance of this novel algorithm was prospectively tested in a validation cohort of 43 consecutive patients undergoing LVOT VAs ablation. Based on the accuracy of AUC, a 4-stepwise ECG algorithm was developed. First, the QS duration in aVL > 134 ms was used to distinguish VAs from AMC, LV summit and VAs from aortic root (80% sensitivity and 76% specificity). Second, the R duration in II > 155 ms was used to differentiate VAs from LV summit and VAs from AMC (67% sensitivity and 56% specificity). Third, the ratio of III/II < 0.9 was used to discriminate VAs from RCC and VAs from LCC, L-RCC (82% sensitivity and 63% specificity). Fourth, the QS duration of aVR > 130 ms was used to discern VAs from LCC and VAs from L-RCC (75% sensitivity and 62% specificity). In the prospective evaluation, our 4-stepwise ECG algorithm exhibited a good predictive value. We have developed a novel and simple 4-stepwise ECG algorithm with good predictive value to discriminate the AVs from different sites of LVOT.
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16
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Zeppenfeld K, Tfelt-Hansen J, de Riva M, Winkel BG, Behr ER, Blom NA, Charron P, Corrado D, Dagres N, de Chillou C, Eckardt L, Friede T, Haugaa KH, Hocini M, Lambiase PD, Marijon E, Merino JL, Peichl P, Priori SG, Reichlin T, Schulz-Menger J, Sticherling C, Tzeis S, Verstrael A, Volterrani M. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J 2022; 43:3997-4126. [PMID: 36017572 DOI: 10.1093/eurheartj/ehac262] [Citation(s) in RCA: 866] [Impact Index Per Article: 433.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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17
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Heeger CH, Popescu SS, Kirstein B, Hatahet S, Traub A, Phan HL, Feher M, D́Ambrosio G, Keelani A, Schlüter M, Vogler J, Eitel C, Kuck KH, Tilz RR. Very-high-power short-duration ablation for treatment of premature ventricular contractions - The FAST-AND-FURIOUS PVC study. IJC HEART & VASCULATURE 2022; 40:101042. [PMID: 35573650 PMCID: PMC9092262 DOI: 10.1016/j.ijcha.2022.101042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 04/05/2022] [Accepted: 04/24/2022] [Indexed: 11/21/2022]
Abstract
Objectives We sought to assess the efficacy, safety and short-term clinical outcome of very high-power short-duration (vHP-SD) radiofrequency (RF) catheter ablation for the treatment of idiopathic PVCs originating from the cardiac outflow tract (OT). Background Power-controlled RF ablation is a widely used technique for the treatment of premature ventricular contractions (PVCs). A novel ablation catheter offers three microelectrodes and six thermocouples at its tip and provides temperature-controlled vHP-SD (90 Watts/4 s,) with the opportunity to switch to moderate-power mode. Methods In this pilot study, twenty-four consecutive, prospectively enrolled patients underwent PVC ablation utilizing the vHP-SD ablation (study group) and were compared with 24 consecutive patients previously treated with power-controlled ablation (control group). Each group included 12 patients with PVCs originating from the right ventricular OT (RVOT) and 12 patients with PVCs originating from the left ventricular OT (LVOT). The acute endpoint was PVC elimination and was achieved in all patients. Results In 16/24 (67%) patients (study group) it was achieved by using vHP-SD only. The median RF delivery time was 52 (interquartile range [IQR] 16, 156) seconds (study group) and 350 (IQR 240, 442) seconds (control group, p < 0.0001). No difference was observed regarding procedure duration (p = 0.489) as well as 6-months follow-up (p = 0.712). One (4%, study group) and 2 (8%, control group) severe adverse events occured (p = 0.551). Conclusion In this study, vHP-SD PVC ablation was similarly effective and safe as compared to conventional power-controlled ablation. The RF time was significantly shorter.
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Affiliation(s)
- Christian-Hendrik Heeger
- Department of Rhythmology, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Lübeck, Germany
| | - Sorin S. Popescu
- Department of Rhythmology, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Germany
- Carol Davila, University of Medicine and Pharmacy, Bucharest, Romania
| | - Bettina Kirstein
- Department of Rhythmology, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Germany
| | - Sascha Hatahet
- Department of Rhythmology, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Germany
| | - Anna Traub
- Department of Rhythmology, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Germany
| | - Huong-Lan Phan
- Department of Rhythmology, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Germany
| | - Marcel Feher
- Department of Rhythmology, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Germany
| | - Gabriele D́Ambrosio
- Department of Rhythmology, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Germany
| | - Ahmad Keelani
- Department of Rhythmology, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Germany
| | | | - Julia Vogler
- Department of Rhythmology, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Germany
| | - Charlotte Eitel
- Department of Rhythmology, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Germany
| | - Karl-Heinz Kuck
- Department of Rhythmology, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Germany
- LANS Cardio, Stephansplatz 5, 20354 Hamburg, Germany
| | - Roland R. Tilz
- Department of Rhythmology, University Heart Center Lübeck, University Hospital Schleswig-Holstein, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Lübeck, Germany
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18
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Supple GE. Don't Forget the Sinuses: an important site for some infarct-related VT. J Cardiovasc Electrophysiol 2022; 33:1208-1210. [PMID: 35388564 DOI: 10.1111/jce.15485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/01/2022] [Indexed: 11/28/2022]
Abstract
The aortic sinuses of Valsalva are an important ablation site in non-ischemic substrates and in patients with idiopathic ventricular arrhythmias. Siontis and colleagues have demonstrated that these sites should also be considered for ablation in patients with infarct-related inferior axis VT. Low voltage in the aortic sinuses of Valsalva or in the sub-aortic region should prompt further evaluation of these regions for ablation. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Gregory E Supple
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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19
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Siontis KC, Njeim M, Dabbagh GS, Yokokawa M, Morady F, Bogun F. Ventricular Tachycardia Targeted in the Aortic Sinuses of Valsalva in Patients with Prior Myocardial Infarction. J Cardiovasc Electrophysiol 2022; 33:1199-1207. [PMID: 35388571 DOI: 10.1111/jce.15486] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 03/04/2022] [Accepted: 03/16/2022] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Ventricular tachycardia (VT) in structurally normal hearts or non-ischemic cardiomyopathy can originate from the aortic sinuses of Valsalva (SoV). It is unknown whether VT can originate from the SoVs in patients with prior myocardial infarction (MI). OBJECTIVE To evaluate the prevalence, arrhythmogenic substrate, and ablation outcomes of post-infarction VT originating from the SoVs. METHODS Among 217 consecutive patients with post-infarction VT undergoing ablation, we identified 13 (6%) patients who had ≥1 VT mapped in a SoV. Control groups of 13 patients with idiopathic SoV VT and 13 post-infarction patients without SoV VT were included. RESULTS In the study group, 17 VTs were mapped in a SoV (right n=5, left-right commissure n=6, left n=6). SoV VT target sites had low bipolar voltage during sinus rhythm [median 0.42 (IQR 0.16-0.53) mV] which was significantly lower than target sites in patients with idiopathic SoV VTs [median 1.02 (IQR 0.89-1.52) mV; p<0.001]. An area of endocardial low voltage was found below the aortic valve in all patients with post-infarction SoV VTs compared to 9 (69%) of the patients in the post-infarction control group without SoV VT (p=0.02). Morphology characteristics of post-infarction SoV VTs differed from idiopathic SoV VTs. None of the post-infarction SoV VTs were inducible after ablation and none recurred after a median follow-up of 14 months. CONCLUSION In patients with prior MI, VT can be targeted in an aortic SoV. The SoVs should be routinely investigated in post-infarction patients with inferior axis VT and an area of low-voltage below the aortic valve. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Mario Njeim
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Miki Yokokawa
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Fred Morady
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Frank Bogun
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Tanaka A, Nozoe M, Tsutsumi T, Kubota T. Ventricular premature complexes successfully ablated from the non-coronary cusp: a case report. Eur Heart J Case Rep 2022; 6:ytac129. [PMID: 35434512 PMCID: PMC9007433 DOI: 10.1093/ehjcr/ytac129] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 12/21/2021] [Accepted: 03/18/2022] [Indexed: 12/21/2022]
Abstract
Background Ventricular premature complexes (VPCs) occasionally originate from the aortic sinus of Valsalva. Because the anterior part of the left coronary cusp (LCC) and right coronary cusp (RCC) are connected through the ventricular musculature at their bases, VPCs are more common in the LCC and the RCC than in the non-coronary cusp (NCC). We herein report a case in which VPCs were successfully ablated from the NCC, which is considered rare. Case summary A 30-year-old woman was admitted to our hospital for the ablation of VPCs, which comprised 43% of the total heart beats. The clinical VPCs had an inferior axis and left bundle branch block morphology with a precordial transition between V4 and V5. Three-dimensional mapping of the target VPCs indicated that the earliest activation site was RCC. After radiofrequency (RF) energy application at the RCC, VPCs were temporally suppressed but recurred after 24 min. Remapping of the recurrent VPCs revealed that the earliest activation site shifted from the RCC to the His region. To avoid the risk of atrioventricular block, RF energy was applied from the NCC, which resulted in successful elimination of the VPCs without any complications. Discussion The present case suggests that RF energy application from the NCC may be a safe and effective option for the ablation of VPCs with the earliest activation at the RCC and His region.
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Affiliation(s)
- Atsushi Tanaka
- Division of Cardiology, Cardiovascular and Aortic Center, Saiseikai Fukuoka General Hospital, 1-3-46 Tenjin Chuo-ku, Fukuoka 810-0001, Japan
| | - Masatsugu Nozoe
- Division of Cardiology, Cardiovascular and Aortic Center, Saiseikai Fukuoka General Hospital, 1-3-46 Tenjin Chuo-ku, Fukuoka 810-0001, Japan
| | - Takaki Tsutsumi
- Division of Cardiology, Cardiovascular and Aortic Center, Saiseikai Fukuoka General Hospital, 1-3-46 Tenjin Chuo-ku, Fukuoka 810-0001, Japan
| | - Toru Kubota
- Division of Cardiology, Cardiovascular and Aortic Center, Saiseikai Fukuoka General Hospital, 1-3-46 Tenjin Chuo-ku, Fukuoka 810-0001, Japan
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Hanson MG, Enriquez A. Mind the valve: Ventricular tachycardia ablation post-valve interventions. J Cardiovasc Electrophysiol 2022; 33:605-607. [PMID: 35106890 DOI: 10.1111/jce.15389] [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: 01/22/2022] [Accepted: 01/24/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Matthew G Hanson
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Andres Enriquez
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
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22
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Shehata E, Abdel-Samie MS, Elkoumy A, Yehia A, Soliman O, Abdelghani M. Aortic Regurgitation as a Complication of Electrophysiologic Ablation Techniques: A Narrative Review. Curr Cardiol Rev 2021; 17:e051121192738. [PMID: 33829975 PMCID: PMC8950496 DOI: 10.2174/1573403x17666210408093447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 01/22/2021] [Accepted: 02/08/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Radiofrequency catheter ablation is a well-established treatment for several cardiac arrhythmias. Arrhythmias originating from the left side of the heart including ventricular and supraventricular tachycardia and ectopy can be successfully ablated through either transseptal or retrograde aortic approach. Although these techniques have a generally low rate of complications, aortic valve injury is a potential complication of ablation at the left cardiac side that warrants more investigation. OBJECTIVE The purpose of this review is to evaluate the incidence of iatrogenic aortic valve regurgitation and explore the potential mechanisms and risk factors that might contribute to aortic valve injury during radiofrequency ablation. Additionally, the course and progression of aortic regurgitation in the reported cases will be described. METHODS Authors searched PubMed for articles using the keywords "ablation" AND "aortic insufficiency" OR "aortic valve injury" OR "aortic regurgitation". Case reports and series as well as retrospective and prospective studies were included, and relevant review articles and editorial comments were used as a supplementary source of data. A total of 19 references were used and a detailed description of patient characteristics, procedural techniques, and incidence, predictors, and fate of aortic regurgitation were reported by 11 clinical studies. RESULTS There is a small risk of significant iatrogenic aortic regurgitation after radiofrequency ablation of left-sided cardiac arrhythmias, especially techniques performed via a retrograde aortic approach. CONCLUSION Although the risk is not confined to procedures applying direct energy to the aortic cusp region, a more aggressive ablation applied in the vicinity of the valvular complex seems to be associated with a higher risk. Routine post-procedural surveillance should be adopted to detect de novo aortic valve injury following radiofrequency ablation techniques.
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Affiliation(s)
- Esraa Shehata
- Cardiology Department, Nasser Institute for Research and Treatment, Cairo, Egypt;
| | | | | | - Ahmed Yehia
- Arrhythmology Unit, Cardiology Department, Ain-Shams University, Cairo, Egypt;
| | - Osama Soliman
- Galway University Hospital, SAOLTA Health Care Group, Galway, Ireland; ,National University of Ireland, Galway, Ireland;
| | - Mohammad Abdelghani
- Cardiology Department, Al-Azhar University, Cairo, Egypt; ,Cardiology Department, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands,Address correspondence to this author at the Cardiology Department Al-Azhar University, Cairo, Egypt; E-mail:
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23
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Weng S, Zhai Z, Tang M, Zhou B, Ding L, Yu F, Qi Y, Zhang H, Feng T, Zhang S. Idiopathic Ventricular Arrhythmias Ablated in Different Subregions of the Aortic Sinuses of Valsalva: Anatomical Distribution, Precordial Electrocardiographic Notch Patterns, and Bipolar Electrographic Characteristics. Front Cardiovasc Med 2021; 8:778866. [PMID: 34988128 PMCID: PMC8720962 DOI: 10.3389/fcvm.2021.778866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Little is known about the differences among ventricular arrhythmias (VAs) ablated in different subregions of the aortic sinuses of Valsalva (ASVs). We aim to investigate the distribution, precordial electrocardiographic patterns, and bipolar electrogram characteristics of VAs ablated in different subregions of the ASVs.Methods: We divided the right ASV and the left ASV into a total of 6 subregions and studied 51 idiopathic VAs ablated first time successfully in the ASVs.Results: These 51 VAs were inhomogeneously distributed among the 6 subregions, which comprised the right-lateral ASV (1/51), the right-anterior ASV (11/51), the regions along the right (13/51) and left (9/51) sides of the ASV junction, the left-anterior ASV (5/51), and the left-lateral ASV (12/51). Fractionated potentials were dominant (39/51, 76%) among the 3 types of target electrograms. From the right-lateral ASV to the left-lateral ASV, the percentage of fractionated potentials gradually decreased from 100 to 59%. A precordial rebound notch in V3-V4 or V4-V5 had sensitivity of 90.9%, specificity of 85.0%, and negative predictive value (NPV) of 97.1% to predict VAs ablated in the right-anterior ASV. A precordial rebound notch in V2-V3 had sensitivity of 50.0%, specificity of 94.9%, and NPV of 86.0% to predict VAs ablated in the left-lateral ASV.Conclusion: VA targets were mainly distributed in the anterior and the left-lateral ASVs. Fractionated potentials were common among target electrograms, especially in theright-anterolateral ASV. Precordial electrocardiographic rebound notch has high predictive accuracy in identifying different subregions of the ASVs as target ablation sites.
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Affiliation(s)
- Sixian Weng
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhengqin Zhai
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- China-Japan Friendship Hospital, Beijing, China
| | - Min Tang
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Min Tang
| | - Bin Zhou
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lei Ding
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fengyuan Yu
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yingjie Qi
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hongda Zhang
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tianjie Feng
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shu Zhang
- State Key Laboratory of Cardiovascular Disease, Department of Cardiology, Cardiovascular Institute, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Sánchez‐Millán PJ, Gutiérrez‐Ballesteros G, Molina‐Lerma M, Macías‐Ruiz R, Jiménez‐Jáimez J, Tercedor L, Álvarez M. Ablation with zero-fluoroscopy of premature ventricular complexes from aortic sinus cusps: A single-center experience. J Arrhythm 2021; 37:1497-1505. [PMID: 34887954 PMCID: PMC8637083 DOI: 10.1002/joa3.12642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/04/2021] [Accepted: 09/22/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Catheter ablation of premature ventricular complexes from aortic sinus cusps (ASC-PVC) is a complex procedure that conventionally requires coronary catheterization (CC) to localize coronary artery ostium (CAO). Little published information is available on the mapping and ablation with zero-fluoroscopy (ZF) of ASC-PVC. The aim of the study was to determine the efficacy and safety of ASC-PVC ablation with a ZF approach guided by 3D intracardiac echocardiography integration in the electroanatomical mapping system (ICE 3D-EAM). METHODS This observational study included one patient cohort treated conventionally and another treated with ICE 3D-EAM-guided ZF ablation. Clinical, efficacy, and safety outcomes were evaluated acutely and at 3 months follow-up. RESULTS The study included 21 patients with ASC-PVC: 10 in the ZF group (age 49 ± 16 years, 60% males) and 11 in the control group (age 47 ± 15 years, 27% males). Fluoroscopy was not required for any patient in the ZF group. Acute success was obtained in 80% of the ZF group vs 55% of the control group (P = .36). The recurrence rate was 30% in the ZF group vs 27% in the control group (P = 1). One nonsevere complication was observed in the ZF group (P = .48). CONCLUSIONS ZF catheter ablation of ASC-PVC guided by ICE 3D-EAM is feasible, effective, and safe.
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Affiliation(s)
- Pablo J. Sánchez‐Millán
- Arrhythmia UnitHospital Universitario Virgen de las NievesGranadaSpain
- Instituto de investigación biosanitaria de Granada (FIBAO)GranadaSpain
| | - Guillermo Gutiérrez‐Ballesteros
- Arrhythmia UnitHospital Universitario Virgen de las NievesGranadaSpain
- Instituto de investigación biosanitaria de Granada (FIBAO)GranadaSpain
| | - Manuel Molina‐Lerma
- Arrhythmia UnitHospital Universitario Virgen de las NievesGranadaSpain
- Instituto de investigación biosanitaria de Granada (FIBAO)GranadaSpain
| | - Rosa Macías‐Ruiz
- Arrhythmia UnitHospital Universitario Virgen de las NievesGranadaSpain
- Instituto de investigación biosanitaria de Granada (FIBAO)GranadaSpain
| | - Juan Jiménez‐Jáimez
- Arrhythmia UnitHospital Universitario Virgen de las NievesGranadaSpain
- Instituto de investigación biosanitaria de Granada (FIBAO)GranadaSpain
| | - Luis Tercedor
- Arrhythmia UnitHospital Universitario Virgen de las NievesGranadaSpain
- Instituto de investigación biosanitaria de Granada (FIBAO)GranadaSpain
| | - Miguel Álvarez
- Arrhythmia UnitHospital Universitario Virgen de las NievesGranadaSpain
- Instituto de investigación biosanitaria de Granada (FIBAO)GranadaSpain
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25
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Prisecaru RS, Leatu C, Riahi L, Costache V. Evaluation of five algorithms in predicting the sublocalisation of right ventricular outflow tract arrhythmia (RVOTA) when compared to 3D electroanatomical mapping origin. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2021. [DOI: 10.1186/s42444-021-00050-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Purpose
To compare the predictive accuracy of five different algorithms as verified by successful ablation site using 3D electroanatomical non-contact mapping in patients with symptomatic and asymptomatic but high ventricular burden RVOT tachycardias.
Methods
28 Consecutive patients admitted for radiofrequency catheter ablation for symptomatic and asymptomatic, but high ventricular burden idiopathic VPC were recruited for this study. All patients had previous failed or intolerant to beta-blocker and/or at least one class IC anti-arrhythmic agents, and they had normal left ventricular ejection fraction. All patients had documented monomorphic VPC with left bundle branch block morphology and an inferior axis. Concordance of the arrhythmia origin based on ECG algorithm and 3D mapping system site were further evaluated. Of the five algorithms, two algorithms with easy‐applicability and having a memorable design (Dixit and Joshi) and three algorithms with more complex and detailed design (Ito, Zhang, Pytkowski) were selected for comparisons.
Results
Assessment of the diagnostic accuracy showed that each of the five algorithms had only moderate accuracy, and the greatest accuracy was observed in the algorithm proposed by Pytkowski algorithm when assessed by a general cardiologist and Dixit algorithm when evaluated by the electrophysiologist. However, when the algorithms were compared for their accuracy, specificity, sensitivity, no significant differences were found (p = 0.99).
Conclusions
The ECG based algorithms for precise localising RVOTA origin simplify the mapping process, reduce the procedural and fluoroscopic time, and improve clinical outcomes, resulting in greater clinical utility. All the five published 12-lead ECG algorithms for ROTVA differentiation were similar in terms of the diagnostic accuracy, specificity, sensitivity and LRs.
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26
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Zhao L, Li R, Zhang J, Xie R, Lu J, Liu J, Miao C, Liu S, Cui W. S-R index in V1/V3 serves as a novel criterion to discriminate idiopathic premature ventricular contractions originating from posteroseptal right ventricular outflow tract versus right coronary cusp. J Electrocardiol 2021; 70:7-12. [PMID: 34826636 DOI: 10.1016/j.jelectrocard.2021.11.030] [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: 09/28/2021] [Revised: 11/10/2021] [Accepted: 11/15/2021] [Indexed: 10/19/2022]
Abstract
AIM The current study aimed to establish a novel electrocardiographic (ECG) criterion for discrimination of idiopathic premature ventricular contractions (PVCs) originating from posteroseptal right ventricular outflow tract (sRVOT-p) versus right coronary cusp (RCC). METHODS A total of 76 patients with idiopathic PVCs who underwent mapping and successful ablation were retrospectively included. Among them, 37 patients had PVCs from sRVOT-p origin and 39 patients from RCC origin. The surface ECGs during PVCs were recorded. S-R different index in V1/V3 was calculated with the following formula of 0.134*V3R-0.133*V1S. RESULTS ECG characteristics showed wider total QRS duration, smaller R-wave amplitude on lead V2-V5, and larger S-wave amplitude on lead V1-V3 in sRVOT-p origin than RCC origin. Lead V3 was the most common transitional lead in two groups. Receiver operating characteristic (ROC) curve analysis showed that S-wave amplitude on lead V1 exhibited the largest AUC of 0.772, followed by the AUC of R-wave amplitude on lead V3 of 0.771. Subsequently, 0.134*V3R-0.133*V1S index was obtained by multiplication, subtraction, sum, and division of these ECG measurements, which exhibited the largest AUC of 0.808. The optimal cut-off value was -0.26 for differentiating RCC from sRVOT-p origin, with the sensitivity of 78.4% and specificity of 77.8%. Moreover, 0.134*V3R-0.133*V1S index was superior to previous criteria in analysis of PVCs originating from sRVOT-p and RCC. CONCLUSIONS 0.134*V3R-0.133*V1S is a novel ECG criterion to discriminate sRVOT-p from RCC origin in patients with idiopathic PVCs, which may provide guidance for approach of radiofrequency catheter ablation.
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Affiliation(s)
- Lei Zhao
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ruibin Li
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jidong Zhang
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Ruiqin Xie
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jingchao Lu
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jinming Liu
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chenglong Miao
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Suyun Liu
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wei Cui
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China.
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27
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Styczkiewicz K, Ludwik B, Styczkiewicz M, Śledź J, Gorski M, Stec S. Implementation of zero or near-zero fluoroscopy catheter ablation for idiopathic ventricular arrhythmia originating from the aortic sinus cusp. Int J Cardiovasc Imaging 2021; 38:497-506. [PMID: 34709523 PMCID: PMC8927012 DOI: 10.1007/s10554-021-02432-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 10/02/2021] [Indexed: 11/03/2022]
Abstract
Complete elimination of fluoroscopy during radiofrequency ablation (RFA) of idiopathic ventricular arrhythmias (IVAs) originating from the aortic sinus cusp (ASC) is challenging. The aim was to assess the feasibility, safety and a learning curve for a zero-fluoroscopy (ZF) approach in centers using near-zero fluoroscopy (NOX) approach in IVA-ASC. Between 2012 and 2018, we retrospectively enrolled 104 IVA-ASC patients referred for ZF RFA or NOX using a 3-dimensional electroanatomic (3D-EAM) system (Ensite, Velocity, Abbott, USA). Acute, short and long-term outcomes and learning curve for the ZF were evaluated. ZF was completed in 62 of 75 cases (83%) and NOX in 32 of 32 cases (100%). In 13 cases ZF was changed to NOX. No significant differences were found in success rates between ZF and NOX, no major complications were noted. The median procedure and fluoroscopy times were 65.0 [45-81] and 0.0 [0-5] min respectively, being shorter for ZF than for NOX. With growing experience, the preference for ZF significantly increased-43% (23/54) in 2012-2016 vs 98% (52/53) in 2017-2018, with a simultaneous reduction in the procedure time. ZF ablation can be completed in almost all patients with IVA-ASC by operators with previous experience in the NOX approach, and after appropriate training, it was a preferred ablation technique. The ZF approach for IVA-ASC guided by 3D-EAM has a similar feasibility, safety, and effectiveness to the NOX approach.
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Affiliation(s)
- Katarzyna Styczkiewicz
- Department of Internal Medicine, Institute of Medical Sciences, Medical College, University of Rzeszów, Al. mjr.W.Kopisto 2a, 35-310, Rzeszów, Poland.
| | - Bartosz Ludwik
- Department of Cardiology, Centre for Research and Development, Regional Specialist Hospital, Wrocław, Poland
| | - Marek Styczkiewicz
- Department of Cardiology, The Pope John Paul II Province Hospital of Zamość, Zamość, Poland
| | - Janusz Śledź
- ELMedica, EP-Network, Skarzysko-Kamienna, Poland
| | - Małgorzata Gorski
- Department of Cardiology, Specialist Hospital in Wałbrzych, Wałbrzych, Poland
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28
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Di C, Letsas KP, Gao P, Wang Q, Wu Y, Lin W. Electrocardiographic and electrophysiological characteristics of idiopathic ventricular arrhythmias with acute successful ablation at the superior portion of the mitral annulus. BMC Cardiovasc Disord 2021; 21:397. [PMID: 34407753 PMCID: PMC8371855 DOI: 10.1186/s12872-021-02205-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 08/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We sought to identify the electrocardiographic and electrophysiological characteristics of ventricular arrhythmias (VAs), including idiopathic ventricular tachycardia (VT) and premature ventricular contractions (PVCs), with acute successful radiofrequency catheter ablation (RFCA) at the superior portion of the mitral annulus (SP-MA). METHODS AND RESULTS Among 437 consecutive patients who presented with VAs for RFCA, twenty-six patients with acute successful RFCA at the SP-MA were included in this study. The ratio of the amplitude of the first positive peak (if present) versus the nadir in the unipolar electrogram (EGM) was 0.00-0.03 (0.00) at the acute successful RFCA site. The time interval between the QRS onset and the maximum descending slope (D-Max) in the unipolar EGM (QRS-Uni) was 18.8 ± 13.6 ms. With bipolar mapping, the ventricular QRS (V-QRS) interval was 3.75-17.3 (11) ms, 6 (23.1%) patients showed the earliest V-QRS interval of 0 ms, and the other 20 patients (76.9%) showed a V-QRS interval of 10-54 ms. The RFCA start-to-effect time was 14.1 ± 7.2 s in 23 patients (88.5%). In the remaining 3 patients (11.5%), the mean duration of successful RFCA was not well defined due to the infrequent nature of clinical VAs during RFCA. Early (within 3 days) and late (1-year) recurrence rates were 23.1% (6 patients) and 26.9% (7 patients), respectively. VAs disappeared 3 days later due to delayed RFCA efficacy in 2 patients (7.7%). No complications occurred during the RFCA procedure or the one-year follow-up. CONCLUSIONS SP-MA VAs are a rare but distinct subgroup of VAs. Bipolar and unipolar EGM features can help to determine the optimal RFCA site, and the QRS-Uni interval may serve as a marker that could be used to guide RFCA.
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Affiliation(s)
- Chengye Di
- Cardiac Electrophysiology Unit, First Department of Cardiology, TEDA International Cardiovascular Hospital, 3rd Street, Tianjin Economic-Technological Development Area, Tianjin, 300457, China.,College of Clinical Cardiology, Tianjin Medical University, Tianjin, China.,Cardiovascular Institute, Tianjin University, Tianjin, China
| | - Konstantinos P Letsas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, Evangelismos General Hospital of Athens, 10676, Athens, Greece
| | - Peng Gao
- Cardiac Electrophysiology Unit, First Department of Cardiology, TEDA International Cardiovascular Hospital, 3rd Street, Tianjin Economic-Technological Development Area, Tianjin, 300457, China.,College of Clinical Cardiology, Tianjin Medical University, Tianjin, China.,Cardiovascular Institute, Tianjin University, Tianjin, China
| | - Qun Wang
- Cardiac Electrophysiology Unit, First Department of Cardiology, TEDA International Cardiovascular Hospital, 3rd Street, Tianjin Economic-Technological Development Area, Tianjin, 300457, China.,College of Clinical Cardiology, Tianjin Medical University, Tianjin, China.,Cardiovascular Institute, Tianjin University, Tianjin, China
| | - Yanxi Wu
- Cardiac Electrophysiology Unit, First Department of Cardiology, TEDA International Cardiovascular Hospital, 3rd Street, Tianjin Economic-Technological Development Area, Tianjin, 300457, China.,College of Clinical Cardiology, Tianjin Medical University, Tianjin, China.,Cardiovascular Institute, Tianjin University, Tianjin, China
| | - Wenhua Lin
- Cardiac Electrophysiology Unit, First Department of Cardiology, TEDA International Cardiovascular Hospital, 3rd Street, Tianjin Economic-Technological Development Area, Tianjin, 300457, China. .,College of Clinical Cardiology, Tianjin Medical University, Tianjin, China. .,Cardiovascular Institute, Tianjin University, Tianjin, China.
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29
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Gabriels JK, Abdelrahman M, Nambiar L, Kim J, Ip JE, Thomas G, Liu CF, Markowitz SM, Lerman BB, Cheung JW. Reappraisal of electrocardiographic criteria for localization of idiopathic outflow region ventricular arrhythmias. Heart Rhythm 2021; 18:1959-1965. [PMID: 34375724 DOI: 10.1016/j.hrthm.2021.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/20/2021] [Accepted: 08/01/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Electrocardiographic (ECG) criteria have been proposed to localize the site of origin of outflow region ventricular arrhythmias (VAs). Many factors influence the QRS morphology of VAs and may limit the accuracy of these criteria. OBJECTIVE The purpose of this study was to assess the accuracy of ECG criteria that differentiate right from left outflow region VAs and localize VAs within the aortic sinus of Valsalva (ASV). METHODS One hundred one patients (mean age 52 ± 16 years; 55 [54%] women) undergoing catheter ablation of right ventricular outflow tract (RVOT) or ASV VAs with a left bundle branch block, inferior axis morphology were studied. ECG measurements including V2 transition ratio, transition zone index, R-wave duration index, R/S amplitude index, V2S/V3R index, V1-3 QRS morphology, R-wave amplitude in the inferior leads were tabulated for all VAs. Comparisons were made between the predicted site of origin using these criteria and the successful ablation site. RESULTS Patients had successful ablation of 71 RVOT and 38 ASV VAs. For the differentiation of RVOT from ASV VAs, the positive predictive values and negative predictive values for all tested ECG criteria ranged from 42% to 75% and from 71% to 82%, respectively, with the V2S/V3R index having the largest area under the curve of 0.852. Morphological QRS criteria in leads V1 through V3 did not localize ASV VAs. The maximum R-wave amplitude in the inferior leads was the sole criterion demonstrating a significant difference between right ASV, right-left ASV commissure, and left ASV sites. CONCLUSION ECG criteria for differentiating right from left ventricular outflow region VAs and for localizing ASV VAs have a limited accuracy.
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Affiliation(s)
- James K Gabriels
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - Mohamed Abdelrahman
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - Lakshmi Nambiar
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - Jiwon Kim
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - James E Ip
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - George Thomas
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - Christopher F Liu
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - Steven M Markowitz
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - Bruce B Lerman
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York
| | - Jim W Cheung
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine - New York Presbyterian Hospital, New York, New York.
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30
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Left Ventricular Summit-Concept, Anatomical Structure and Clinical Significance. Diagnostics (Basel) 2021; 11:diagnostics11081423. [PMID: 34441357 PMCID: PMC8393416 DOI: 10.3390/diagnostics11081423] [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] [Received: 07/20/2021] [Revised: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 01/18/2023] Open
Abstract
The left ventricular summit (LVS) is a triangular area located at the most superior portion of the left epicardial ventricular region, surrounded by the two branches of the left coronary artery: the left anterior interventricular artery and the left circumflex artery. The triangle is bounded by the apex, septal and mitral margins and base. This review aims to provide a systematic and comprehensive anatomical description and proper terminology in the LVS region that may facilitate exchanging information among anatomists and electrophysiologists, increasing knowledge of this cardiac region. We postulate that the most dominant septal perforator (not the first septal perforator) should characterize the LVS definition. Abundant epicardial adipose tissue overlying the LVS myocardium may affect arrhythmogenic processes and electrophysiological procedures within the LVS region. The LVS is divided into two clinically significant regions: accessible and inaccessible areas. Rich arterial and venous coronary vasculature and a relatively dense network of cardiac autonomic nerve fibers are present within the LVS boundaries. Although the approach to the LVS may be challenging, it can be executed indirectly using the surrounding structures. Delivery of the proper radiofrequency energy to the arrhythmia source, avoiding coronary artery damage at the same time, may be a challenge. Therefore, coronary angiography or cardiac computed tomography imaging is strongly recommended before any procedure within the LVS region. Further research on LVS morphology and physiology should increase the safety and effectiveness of invasive electrophysiological procedures performed within this region of the human heart.
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31
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Monaci S, Gillette K, Puyol-Antón E, Rajani R, Plank G, King A, Bishop M. Automated Localization of Focal Ventricular Tachycardia From Simulated Implanted Device Electrograms: A Combined Physics-AI Approach. Front Physiol 2021; 12:682446. [PMID: 34276403 PMCID: PMC8281305 DOI: 10.3389/fphys.2021.682446] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 05/31/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Focal ventricular tachycardia (VT) is a life-threating arrhythmia, responsible for high morbidity rates and sudden cardiac death (SCD). Radiofrequency ablation is the only curative therapy against incessant VT; however, its success is dependent on accurate localization of its source, which is highly invasive and time-consuming. Objective: The goal of our study is, as a proof of concept, to demonstrate the possibility of utilizing electrogram (EGM) recordings from cardiac implantable electronic devices (CIEDs). To achieve this, we utilize fast and accurate whole torso electrophysiological (EP) simulations in conjunction with convolutional neural networks (CNNs) to automate the localization of focal VTs using simulated EGMs. Materials and Methods: A highly detailed 3D torso model was used to simulate ∼4000 focal VTs, evenly distributed across the left ventricle (LV), utilizing a rapid reaction-eikonal environment. Solutions were subsequently combined with lead field computations on the torso to derive accurate electrocardiograms (ECGs) and EGM traces, which were used as inputs to CNNs to localize focal sources. We compared the localization performance of a previously developed CNN architecture (Cartesian probability-based) with our novel CNN algorithm utilizing universal ventricular coordinates (UVCs). Results: Implanted device EGMs successfully localized VT sources with localization error (8.74 mm) comparable to ECG-based localization (6.69 mm). Our novel UVC CNN architecture outperformed the existing Cartesian probability-based algorithm (errors = 4.06 mm and 8.07 mm for ECGs and EGMs, respectively). Overall, localization was relatively insensitive to noise and changes in body compositions; however, displacements in ECG electrodes and CIED leads caused performance to decrease (errors 16-25 mm). Conclusion: EGM recordings from implanted devices may be used to successfully, and robustly, localize focal VT sources, and aid ablation planning.
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Affiliation(s)
| | - Karli Gillette
- Division of Biophysics, Medical University of Graz, Graz, Austria
| | | | | | - Gernot Plank
- Division of Biophysics, Medical University of Graz, Graz, Austria
| | - Andrew King
- King’s College London, London, United Kingdom
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias: executive summary. Europace 2021; 22:450-495. [PMID: 31995197 DOI: 10.1093/europace/euz332] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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Kiuchi K, Izawa Y, Toh H, Takami M, Fukuzawa K, Hirata K. Successful catheter ablation approach above the aortic sinus cusp eliminating a ventricular arrhythmia arising from the myocardial crescent beneath the interleaflet triangle: Late gadolinium enhancement magnetic resonance imaging assessment. Clin Case Rep 2021; 9:e04169. [PMID: 34194766 PMCID: PMC8222747 DOI: 10.1002/ccr3.4169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 03/23/2021] [Accepted: 03/30/2021] [Indexed: 11/16/2022] Open
Abstract
A 61-year-old female with 50 000 ventricular premature contractions and a reduced left ventricular ejection fraction of 35% was referred to our center. Although the origin was considered to originate from the junction between the left and right coronary cusp, a single radiofrequency application above the aortic sinus cusp could eliminate it. LGE-MRI was able to reveal the exact location of the single RF lesion.
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Affiliation(s)
- Kunihiko Kiuchi
- Section of ArrhythmiaDivision of Cardiovascular MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Yu Izawa
- Section of ArrhythmiaDivision of Cardiovascular MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Hiroyuki Toh
- Section of ArrhythmiaDivision of Cardiovascular MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Mitsuru Takami
- Section of ArrhythmiaDivision of Cardiovascular MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Koji Fukuzawa
- Section of ArrhythmiaDivision of Cardiovascular MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
| | - Ken‐ichi Hirata
- Section of ArrhythmiaDivision of Cardiovascular MedicineDepartment of Internal MedicineKobe University Graduate School of MedicineKobeJapan
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Khan F, Srinivasan NT. Catheter ablation of the valsalva region using intracardiac echocardiography guidance. Indian Pacing Electrophysiol J 2021; 21:145-146. [PMID: 33934819 PMCID: PMC8116809 DOI: 10.1016/j.ipej.2021.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
| | - Neil T Srinivasan
- Essex Cardiothoracic Centre, UK; Anglia Ruskin University (ARU) Medical School, UK.
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35
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Ioannidis P, Christoforatou E, Zografos T, Kouvelas K, Tsoumeleas A, Floros S, Kappou T, Vassilopoulos C. Ventricular ectopy from the non-coronary cusp: Pathophysiological and anatomical considerations. Indian Pacing Electrophysiol J 2021; 21:245-247. [PMID: 33887363 PMCID: PMC8263327 DOI: 10.1016/j.ipej.2021.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/27/2021] [Accepted: 04/15/2021] [Indexed: 11/02/2022] Open
Abstract
Non-coronary cusp (NCC) is a rare site for ventricular arrhythmias because it does not come into direct contact with the ventricular myocardium. Instead, the NCC comes in contact with the membranous septum near the His region. We describe a case of a young man with a ventricular ectopy who was successfully ablated in the NCC. In our case the much greater prematurity in the NCC than in the His region suggests that the arrhythmic site of origin is not in the peri-His area but most likely a myocardial extension adjoining the aortic root.
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36
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Peltzer B, Lerman BB, Cheung JW. Practical Approaches to Catheter Ablation of Idiopathic Ventricular Arrhythmias. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021. [DOI: 10.1007/s11936-020-00894-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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37
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Han J, Lee JZ, Padmanabhan D, Naksuk N, Asirvatham SJ, Munger TM, Killu AM, Madhavan M, Xiao P, Zheng LR, Cha YM. Catheter ablation of premature ventricular contractions originating from periprosthetic aortic valve regions. J Cardiovasc Electrophysiol 2020; 32:400-408. [PMID: 33305865 DOI: 10.1111/jce.14836] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 10/29/2020] [Accepted: 11/30/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Little is known about the ablation outcomes of premature ventricular contractions (PVCs) that originate from the periprosthetic aortic valve (PPAV) regions of patients with aortic valve replacement (AVR). METHODS AND RESULTS Our study had 11 patients who underwent catheter ablation for PVCs arising from the PPAV regions (bioprosthetic aortic valve, n = 5; mechanical aortic valve, n = 6). The PVC characteristics, procedure characteristics, and efficacy of ablation were compared with the control group (n = 33). At baseline, the PPAV group had a lower left ventricular ejection fraction (mean [SD], 41% [12%] vs. 51% [8%]; p = .002). The rate of acute ablation success was 90.9% in the PPAV group. Ablation sites were identified above the left coronary cusp (LCC) and right coronary cusp commissure (LRCC) in one PVC, below the prosthetic valve in eight PVCs (four below LCC and four below LRCC), and within the distal coronary sinus in two PVCs. The mean procedure time, fluoroscopy time, and radiation in the PPAV group were all significantly greater than those in the control group (all p < .05). However, the number of radiofrequency ablation energy deliveries was not different. The PPAV group had a long-term success rate compared with the control group (72.7% vs. 87.9%, p = .48) and an increase of left ventricular ejection fraction from 43% to 49% after successful PVC ablation at follow-up (p < .001). Echocardiography showed no significant change in valve regurgitation after ablation. No new atrioventricular block occurred. CONCLUSION PVCs arising from PPAV regions can be successfully ablated in patients with prior AVR, without damaging the prosthetic aortic valve and atrioventricular conduction.
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Affiliation(s)
- Jie Han
- Department of Cardiology and Atrial Fibrillation Center, The First Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Justin Z Lee
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Deepak Padmanabhan
- Electrophysiology Unit, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka, India
| | - Niyada Naksuk
- Division of Cardiology, Department of Internal Medicine, University of Illinois, Chicago, Illinois, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas M Munger
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ammar M Killu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Malini Madhavan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - PeiLin Xiao
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Liang-Rong Zheng
- Department of Cardiology and Atrial Fibrillation Center, The First Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Yong-Mei Cha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Kugamoorthy P, Spears DA. Management of tachyarrhythmias in pregnancy - A review. Obstet Med 2020; 13:159-173. [PMID: 33343692 PMCID: PMC7726166 DOI: 10.1177/1753495x20913448] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 02/16/2020] [Indexed: 11/16/2022] Open
Abstract
The most common arrhythmias detected during pregnancy include sinus tachycardia, sinus bradycardia, and sinus arrhythmia, identified in 0.1% of pregnancies. Isolated premature atrial or ventricular arrhythmias are observed in 0.03% of pregnancies. Arrhythmias may become more frequent during pregnancy or may manifest for the first time.
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Affiliation(s)
| | - Danna A Spears
- University Health Network – Toronto General Hospital, Toronto, Canada
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Sáenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Europace 2020; 21:1143-1144. [PMID: 31075787 DOI: 10.1093/europace/euz132] [Citation(s) in RCA: 230] [Impact Index Per Article: 57.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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Patloori SCS, Manickavasagam A, Chase D, Roshan J. Prognostic significance of accelerated ventricular response during radiofrequency ablation of premature ventricular complexes. Indian Pacing Electrophysiol J 2020; 20:231-236. [PMID: 32428550 PMCID: PMC7691780 DOI: 10.1016/j.ipej.2020.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 04/26/2020] [Accepted: 05/08/2020] [Indexed: 11/25/2022] Open
Abstract
Background Accelerated ventricular response is frequently observed during radiofrequency ablation (RFA) of premature ventricular complexes (PVCs). We hypothesized that acceleration indicates an appropriate site and adequate injury to the arrhythmogenic tissue, and sought to investigate its value in predicting the outcome. Methods We retrospectively analyzed RFA procedures performed for PVCs in our institution from 2011 to 2019. Results Fifty-eight patients (29 male; age 42.7 ± 15.6 years) underwent 62 RFA procedures. The most common site was the right ventricular outflow tract (67.7%). Acute success was seen in 88.7%. Accelerated ventricular response was observed in 60.0% of the successful procedures. After a median follow-up of 14.0 months (IQR: 6.0–26.6 months), 16 patients had a recurrence. Recurrence was significantly lower in the group with acceleration than in the group without acceleration (12.5% vs. 57.1%; log-rank P < 0.001). The 1-year recurrence rate was 6.5% in the acceleration group and 41.6% in the group without acceleration. On multivariable analysis the adjusted hazard ratio was 0.17 (95% CI, 0.04–0.64; Cox regression P = 0.009). The sensitivity, specificity, positive predictive, and negative predictive values of accelerated response to predict long-term success were 75.7%, 75.0%, 87.5%, and 57.2%, respectively. Conclusions The recurrence after PVC ablation is significantly lower when an accelerated response was observed at the successful location during RFA. This can be an additional useful marker of long-term success.
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Affiliation(s)
| | - Anand Manickavasagam
- Unit of Cardiac Electrophysiology and Pacing, Department of Cardiology, Christian Medical College, Vellore, India
| | - David Chase
- Unit of Cardiac Electrophysiology and Pacing, Department of Cardiology, Christian Medical College, Vellore, India
| | - John Roshan
- Unit of Cardiac Electrophysiology and Pacing, Department of Cardiology, Christian Medical College, Vellore, India.
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias: Executive summary. J Interv Card Electrophysiol 2020; 59:81-133. [PMID: 31960344 PMCID: PMC7508755 DOI: 10.1007/s10840-019-00664-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, IN, USA
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Bella PD, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. J Interv Card Electrophysiol 2020; 59:145-298. [PMID: 31984466 PMCID: PMC7223859 DOI: 10.1007/s10840-019-00663-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, IN, USA
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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Kuniewicz M, Krupiński M, Gosnell M, Budnicka K, Jakob N, Karkowski G, Urbańczyk-Zawadzka M, Lelakowski J, Walocha J. Applicability of computed tomography preoperative assessment of the LAA in LV summit ablations. J Interv Card Electrophysiol 2020; 61:357-363. [PMID: 32666410 PMCID: PMC8324620 DOI: 10.1007/s10840-020-00817-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/29/2020] [Indexed: 11/12/2022]
Abstract
Purpose Ventricular arrhythmias originating from the left ventricular summit (LVS) may present with challenges for catheter ablation. Recently, the left atrial appendage (LAA) became a new vantage point for mapping and ablating arrhythmias from that region, but data of possible usefulness is limited. Methods From September to December 2019, we retrospectively analyzed 48 consecutive patient hearts (20 male; mean age 57.9y ± 11.56) undergoing diagnostic coronary vessel imaging in 64 dual-source computer tomography angiography (CTA). Distances from the LAA to the LVS, LAA shape type, and coronary arteries in the LVS region were measured. Also, we compared the true LVS area from CTA with a calculated formula derived from LVS definition. Results The mean LVS area calculated from the formula was 291.58 mm2 (± 115.5) while the true area calculated from CT was 263.33 mm2 (± 99.49) (p = 0.44). The mean inaccessible area was 133.42 mm2 (± 72.89), accessible 95.67 mm2 (± 72.77). The mean LAA coverage over LVS was 196.08 mm2—which is approximately 75% of LVS size in general. The most common LAA shape was chicken wing (50%); windsock has the highest accessible area coverage on average (80.23%), followed by chicken wing (59.88%), broccoli (47.72%), and cactus (46.98%). The mean distance from LAA to the surface was 5.14 mm (1.5 to 10 mm) and was not correlated with BMI. LAA has a 98% coverage over the point of transition between the great cardiac vein and anterior interventricular vein. Conclusion Angio-CT assessment of the LAA over the LVS structures may be helpful in decision making before an ablation procedure. LAA appears to be a promising mapping approach in LVS arrhythmias.
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Affiliation(s)
- Marcin Kuniewicz
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland. .,Department of Electrocardiology, Institute of Cardiology, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland.
| | - M Krupiński
- Department of Radiology and Diagnostic Imaging, John Paul II Hospital, Krakow, Poland
| | - M Gosnell
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - K Budnicka
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - N Jakob
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
| | - G Karkowski
- Department of Electrocardiology, Institute of Cardiology, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
| | - M Urbańczyk-Zawadzka
- Department of Radiology and Diagnostic Imaging, John Paul II Hospital, Krakow, Poland
| | - J Lelakowski
- Department of Electrocardiology, Institute of Cardiology, John Paul II Hospital, Jagiellonian University Medical College, Krakow, Poland
| | - J Walocha
- Department of Anatomy, Jagiellonian University Medical College, Krakow, Poland
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Xiong Y, Zhu H. Electrocardiographic characteristics of idiopathic ventricular arrhythmias based on anatomy. Ann Noninvasive Electrocardiol 2020; 25:e12782. [PMID: 32592448 PMCID: PMC7679832 DOI: 10.1111/anec.12782] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 05/02/2020] [Accepted: 05/26/2020] [Indexed: 12/26/2022] Open
Abstract
Idiopathic ventricular arrhythmia (IVA) is a term used to describe a spectrum of ventricular arrhythmia without structural heart disease (SHD). IVAs contain premature ventricular contractions (PVCs), nonsustained monomorphic ventricular tachycardia (VT), and sustained VT. Electrocardiography is a fundamental and important tool to diagnose and localize IVAs. More detailed, IVAs originating from different origins exhibit characterized ECGs due to their specific anatomic backgrounds. As catheter ablation becomes widely used to eliminate these arrhythmias, its high success rate is based on accurate localization of their origins. Therefore, these ECG characteristics show great importance for precise localization of their origins and subsequently successful ablation. This review aims to sum up ECG characteristics of IVAs based on anatomy and give brief introduction of mechanisms and treatment of IVAs.
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Affiliation(s)
- Yulong Xiong
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Hongling Zhu
- Department of Cardiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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45
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Letsas KP, Dragasis S, Bazoukis G, Prappa E, Megarisiotou A, Asvestas D, Vlachos K, Mililis P, Saplaouras A, Tyrovolas K, Valkanas K, Tse G, Sideris A, Efremidis M. The aortic cusps are the predominant successful ablation site of idiopathic outflow-tract ventricular arrhythmias. J Electrocardiol 2020; 61:63-65. [PMID: 32535059 DOI: 10.1016/j.jelectrocard.2020.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 05/26/2020] [Accepted: 06/03/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Data regarding the successful ablation site of idiopathic outflow tract (OT) ventricular arrhythmias (VAs) in the modern era of mapping and ablation are limited. METHODS AND RESULTS Over a 4-year period, a total of 309 patients underwent detailed activation mapping of OT VAs including the right ventricular outflow tract (RVOT), the left ventricular outflow tract (LVOT) and the aortic cusps (AC), and the coronary venous system. 244 cases were successfully ablated at the index procedure (78.9%). The successful ablation site was more frequently located at the LVOT/ACs (51.6%) followed by RVOT (36.2%). In particular, the ACs was the predominant successful ablation site of idiopathic OT VAs (46.7%). An epicardial site of origin was predictor of ablation failure (p < 0.05). CONCLUSIONS The ACs is the predominant successful ablation site of idiopathic OT VAs. TAKE-HOME MESSAGE The aortic cusps are the predominant successful ablation site of idiopathic idiopathic outflow tract ventricular arrhythmias.
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Affiliation(s)
- Konstantinos P Letsas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece.
| | - Stylianos Dragasis
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | - George Bazoukis
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | - Efstathia Prappa
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | - Athanasia Megarisiotou
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | - Dimitrios Asvestas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | - Konstantinos Vlachos
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | - Panagiotis Mililis
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | - Athanasios Saplaouras
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | - Konstantinos Tyrovolas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | - Kosmas Valkanas
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | - Gary Tse
- Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University, People's Republic of China
| | - Antonios Sideris
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
| | - Michael Efremidis
- Second Department of Cardiology, Laboratory of Cardiac Electrophysiology, "Evangelismos" General Hospital of Athens, Greece
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Concealed structural heart disease discovered at cardiac magnetic resonance in patients with ventricular extrasystoles from ventricular outflow tract and apparently normal hearts. J Interv Card Electrophysiol 2020; 61:45-53. [PMID: 32462549 DOI: 10.1007/s10840-020-00771-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 05/04/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Outflow tract (OT) premature ventricular contractions (PVCs) are commonly found in clinical practice; in most cases, PVCs are benign and observed in structurally normal hearts, not requiring any therapeutic intervention. In this study, we therefore sought to evaluate with cardiac magnetic resonance (CMR) patients with PVC and apparently normal heart at echocardiographic examination, in order to identify possible substrates linked with higher prevalence of arrhythmias or structural heart disease. METHODS Thirty-three consecutive patients with frequent PVCs originating from the ventricular OT (right and left) were enrolled in the study and assessed by echocardiography and CMR. All patients had normal baseline electrocardiogram. RESULTS CMR showed structural changes in 5 patients out of 33; in 3 cases, areas of fibrosis limited in one case to the middle basal segments of the interventricular septum and in two patients to the middle basal segments of the inferior-lateral wall were found. In 2 other cases, however, late gadolinium enhancement showed significant anomalies characterized in one patient by extensive areas of subepicardial fibrosis of the left ventricle, suitable with arrhythmogenic left dominant dysplasia; in another patient, a marked trabeculation of left ventricular medium apical segments suitable with non-compaction myocardium was present. CONCLUSIONS CMR may identify cases of structural heart disease in subjects with OT PVCs and apparently normal electrocardiogram and echocardiogram examinations. A preliminary screening with CMR may be considered before any further invasive electrophysiology assessment and therapeutic planning.
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Compagnucci P, Volpato G, Falanga U, Cipolletta L, Conti M, Grifoni G, Verticelli L, Schicchi N, Giovagnoni A, Casella M, Guerra F, Dello Russo A. Recent advances in three-dimensional electroanatomical mapping guidance for the ablation of complex atrial and ventricular arrhythmias. J Interv Card Electrophysiol 2020; 61:37-43. [PMID: 32451799 DOI: 10.1007/s10840-020-00781-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 05/11/2020] [Indexed: 11/30/2022]
Abstract
PURPOSE To provide a brief overview of some relevant technological advances in the field of three-dimensional electroanatomical mapping (3D-EAM) that have recently entered the clinical arena and their role in guiding catheter ablation (CA) of complex atrial and ventricular arrhythmias. METHODS In this technical report, we describe the general features of three novel algorithms featured in the updated CARTO PRIME™ mapping module for CARTO®3 version 7 3D-EAM system (Biosense Webster Inc., Diamond Bar, CA, USA): local activation time (LAT) hybrid, coherent mapping and map replay modules. We also report three challenging arrhythmia cases in which CA was successfully guided by these softwares. RESULTS The LAT hybrid module was used in a case of premature ventricular complex originating from the right coronary cusp. This algorithm facilitated safe positioning of the ablation catheter away from the right coronary ostium, avoiding potential harm to this vital structure. The coherent mapping module helped to identify the critical as well as a bystander isthmus of an atrial macro-re-entrant tachycardia in a grown-up patient with congenital heart disease. The map replay module allowed rapid retrospective activation mapping of two unstable ventricular tachycardias in a case of nonischemic cocaine-associated cardiomyopathy. CONCLUSION 3D-EAM systems offer significant advantages in the management of challenging arrhythmias, and the introduction of novel algorithms underpins improvements in patients' outcomes. Given the increasing sophistication of these systems, however, a close collaboration among cardiac electrophysiologists, engineers and technicians is highly needed in order to get the best from the available technology.
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Affiliation(s)
- Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Ancona, Italy.
| | - Giovanni Volpato
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Ancona, Italy
| | - Umberto Falanga
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Ancona, Italy
| | - Laura Cipolletta
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Ancona, Italy
| | - Manuel Conti
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Ancona, Italy
| | - Gino Grifoni
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Ancona, Italy
| | - Letizia Verticelli
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Ancona, Italy
| | - Nicolò Schicchi
- Radiology Department, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Ancona, Italy
| | - Andrea Giovagnoni
- Radiology Department, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Ancona, Italy.,Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona, Italy
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Ancona, Italy.,Department of Clinical, Special and Dental Sciences, Marche Polytechnic University, Ancona, Italy
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Ancona, Italy.,Department of Biomedical Science and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, University Hospital "Ospedali Riuniti Umberto I - Lancisi - Salesi", Ancona, Italy.,Department of Biomedical Science and Public Health, Marche Polytechnic University, Ancona, Italy
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48
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Nishimura T, Beaser AD, Aziz ZA, Upadhyay GA, Ozcan C, Raiman M, Shatz DY, Besser SA, Shatz NA, Nayak HM, Tung R. Periaortic ventricular tachycardia in structural heart disease: Evidence of localized reentrant mechanisms. Heart Rhythm 2020; 17:1271-1279. [PMID: 32325198 DOI: 10.1016/j.hrthm.2020.04.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 03/31/2020] [Accepted: 04/05/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The mechanisms for scar-related ventricular tachycardia (VT) originating from the periaortic region remain incompletely characterized. OBJECTIVE The purpose of this study was to map the circuits responsible for periaortic VT in high resolution. METHODS Cases with periaortic VT (2016-2020) were analyzed to characterize the substrate and mechanisms with multielectrode mapping. Periaortic VT was defined as low-voltage and/or deceleration zones within 2 cm of the left ventriculoaortic junction with a corresponding critical site during VT. RESULTS Forty-nine periaortic monomorphic VTs were analyzed in 30 patients (25% of all patients with nonischemic cardiomyopathy). Isolated periaortic substrate was observed in 27% of patients, with 73% having concomitant scar, most commonly in the mid-septum (47%). Deceleration zones were equally prevalent on the septal and lateral portions of the periaortic region (87% vs 73%; P = .19). During activation mapping of VT (tachycardia cycle length 392 ± 105 ms), localized reentrant patterns of activation (14 mm [10-17 mm] × 10 mm [7-14 mm]) were demonstrated in 63% and 37% of VTs showed centrifugal activation, consistent with a focal breakout pattern. Ninety-three percent of VTs fulfilled criteria for a reentrant mechanism. Sixty-five percent of reentrant circuits had endocardial activation gaps within the tachycardia cycle length (3-dimensional circuitry), which were associated with higher rates of recurrence as compared with 2-dimensional complete circuits at 1 year (73% vs 37%; P = .028). CONCLUSION Periaortic VTs were observed in 25% of patients with nonischemic cardiomyopathy and scar-related VT. For the first time, localized reentry confined to this anatomically challenging region was demonstrated as the predominant mechanism by high-resolution circuit activation mapping.
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Affiliation(s)
- Takuro Nishimura
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Andrew D Beaser
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Zaid A Aziz
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Gaurav A Upadhyay
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Cevher Ozcan
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | | | - Dalise Y Shatz
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Stephanie A Besser
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | | | - Hemal M Nayak
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois
| | - Roderick Tung
- Center for Arrhythmia Care, Pritzker School of Medicine, The University of Chicago Medicine, Chicago, Illinois.
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49
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Kapa S, Mehra N, Deshmukh AJ, Friedman PA, Asirvatham SJ. Left sinus of Valsalva—Electroanatomic basis and outcomes with ablation for outflow tract arrhythmias. J Cardiovasc Electrophysiol 2020; 31:952-959. [DOI: 10.1111/jce.14388] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/03/2020] [Accepted: 02/06/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Suraj Kapa
- Department of CardiologyMayo Clinic College of Medicine Rochester Minnesota
| | - Nandini Mehra
- Department of CardiologyMayo Clinic College of Medicine Rochester Minnesota
| | | | - Paul A. Friedman
- Department of CardiologyMayo Clinic College of Medicine Rochester Minnesota
| | - Samuel J. Asirvatham
- Department of CardiologyMayo Clinic College of Medicine Rochester Minnesota
- Division of Pediatric Cardiology, Department of Pediatric and Adolescent MedicineMayo Clinic College of Medicine Rochester Minnesota
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50
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Altshuler PJ, Atluri P. Commentary: Piecing Together the Puzzle of the Aortic Root. Semin Thorac Cardiovasc Surg 2020; 32:242-243. [PMID: 32114112 DOI: 10.1053/j.semtcvs.2020.02.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/21/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Peter J Altshuler
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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