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Jena A, Iqbal M, Baek YS, Lee KN, Rho SY, Shim JM, Choi JI, Kim YH. Unipolar and bipolar electrogram characteristics of recurrent cases of idiopathic ventricular arrhythmias undergoing repeat catheter ablation. Indian Pacing Electrophysiol J 2021; 22:12-16. [PMID: 34823016 PMCID: PMC8811281 DOI: 10.1016/j.ipej.2021.11.005] [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: 09/12/2021] [Revised: 11/02/2021] [Accepted: 11/18/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction Activation mapping guided catheter ablation (CA) of ventricular arrhythmias (VAs) is limited in some cases when it is only relied on bipolar electrogram (EGM). We hypothesized that activation mapping with use of combined bipolar and unipolar EGM facilitates to identify the focal origin of VAs and results in reduction of recurrence rate of CA of VAs. Methods We analyzed the data of patients undergoing repeat ablations for idiopathic out-flow tract VAs. The EGM of the 1 st and 2 nd ablations were compared for earliest local activation time (LAT), presence of discrete potentials, and polarity reversal, unipolar potential morphology (QS or non-QS), potential amplitude and activation slope. Results Thirty-seven patients were included. The Local activation time was significantly earlier in the 2nd ablation as compared to the 1st procedure (36.90 msec vs 31.85 msec, P < 0.01). The incidence of discrete potentials and polarity reversal were similar in both procedures (51% vs 57%, P = 0.8 and 62% in both the occasions, respectively). The unipolar voltage was similar in both occasions (6.94 mV vs 7.22 mV in repeat ablations, P = 0.7). The recurrence rate (5.7%) was significantly lower with routine use of combined unipolar and bipolar EGMs, as compared to the use of bipolar EGM alone (16.7%) Conclusions Use of both bipolar and unipolar electrograms helps in better delineation of the sites of earliest activation for effective ablation of VAs. Use of unipolar electrograms in addition to bipolar electrograms is associated with lower long term recurrence rate. In patients undergoing redo ablations for idiopathic OTVAs, a slow-rapid initial QS morphology with its earlier timing prior to onset of QRS on unipolar EGM facilitate identification of early activation sites and improves success of CA. Bipolar EGM chracteristics like polarity reversal and presence of discrete potentials have no additive efficacy in redo CA cases. A slow-rapid initial QS morphology with its earlier timing to QRS onset may improve the success of CA in idiopathic OTVAs.
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Affiliation(s)
- Anupam Jena
- Kalinga Institute of Medical Sciences, Republic of Korea
| | - Mohammad Iqbal
- Korea University Medical Center, Seoul, Republic of Korea
| | - Yong-Soo Baek
- Korea University Medical Center, Seoul, Republic of Korea
| | - Kwang-No Lee
- Korea University Medical Center, Seoul, Republic of Korea
| | | | - Jae Min Shim
- Korea University Medical Center, Seoul, Republic of Korea
| | - Joing Il Choi
- Korea University Medical Center, Seoul, Republic of Korea
| | - Young-Hoon Kim
- Korea University Medical Center, Seoul, Republic of Korea.
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Prognostic value of time dependent voltage abatement during remote magnetic navigation guided ablation in idiopathic right ventricular outflow tract arrhythmias. COR ET VASA 2021. [DOI: 10.33678/cor.2020.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Qiu X, Zhang N, Luo Q, Liu A, Ji Y, Ye J, Lin C, Ling T, Chen K, Pan W, Zhao J, Jin Q, Wu L. Remote magnetic navigation facilitates the ablations of frequent ventricular premature complexes originating from the outflow tract and the valve annulus as compared to manual control navigation. Int J Cardiol 2019; 267:94-99. [PMID: 29957265 DOI: 10.1016/j.ijcard.2018.03.105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/17/2018] [Accepted: 03/21/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the role of remote magnetic navigation (RMN) in the ablation of ventricular premature complexes (VPCs) arising from outflow tracts (OT) and valve annuli by comparing to manual control navigation (MCN). METHODS A total of 152 patients with frequent VPCs were prospectively enrolled. 64 (42%) patients underwent ablation guided by RMN. Acute success rate was defined as the complete elimination and non-inducibility of clinical VPCs during the procedure. RESULTS Overall, acute success rate of RMN group was not different from MCN group (87.5% vs 84.1%, p = 0.56). Compared to MCN group, the fluoroscopic time of OT-VPCs ablation in the RMN group was significantly reduced by 67% (2.9 ± 2.3 min vs 8.9 ± 9.7 min, p = 0.006), and the ablation applications in successful cases were significantly reduced (11 ± 7 vs 15 ± 11, p = 0.018). Compared to MCN, RMN significantly decreased ablation applications (15 ± 9 vs 23 ± 9, p = 0.013) in the acute success rates of ablating VPCs of valve annulus, and has a trend of a higher success rate for VPCs arising from tricuspid annulus (10/11 vs 7/12, p = 0.193). No complications occurred in the RMN group. Three cases of cardiac tamponade and one case of transient atrioventricular block occurred in the MCN group (p = 0.22). After a mean follow up of 16.2 months, 2/56 and 3/74 patients had a recurrence of VPCs in the RMN group and MCN group respectively (p = 0.75). CONCLUSIONS When compared to MCN, RMN-guided ablation for VPCs was just as effective and safe, with the added benefit of reduced fluoroscopic time and fewer ablation applications.
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Affiliation(s)
- Xiaowei Qiu
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Department of Cardiology, Shanghai Ruijin Hospital Luwan Branch, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ning Zhang
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qingzhi Luo
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ao Liu
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi Ji
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiawen Ye
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Changjian Lin
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tianyou Ling
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Kang Chen
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wenqi Pan
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jianrong Zhao
- Department of Cardiology, Shanghai Ruijin Hospital Luwan Branch, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qi Jin
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Liqun Wu
- Department of Cardiology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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Yamada S, Chung FP, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Chao TF, Liao JN, Lin CH, Lin CY, Chang YT, Chang TY, Te ALD, Chen SA. Electrocardiographic features of failed and recurrent right ventricular outflow tract catheter ablation of idiopathic ventricular arrhythmias. J Cardiovasc Electrophysiol 2017; 29:127-137. [PMID: 28988456 DOI: 10.1111/jce.13359] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/16/2017] [Accepted: 09/29/2017] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Various ECG algorithms have been proposed to identify the origin of idiopathic outflow tract (OT)-ventricular arrhythmia (VA). However, electrocardiographic features of failed and recurrent right ventricular outflow tract (RVOT) ablation of idiopathic OT-VAs have not been clearly elucidated. METHODS AND RESULTS A total of 264 consecutive patients (mean age: 44.0 ± 13.0 years, 96 male) undergoing RVOT ablation for OT-VAs with a transition ≥V3 , including 241 patients (91.6%) with initially successful procedures and 23 patients (8.4%) with failed ablation. Detailed clinical characteristics and ECG features were analyzed and compared between the two groups. VAs with failed RVOT ablation had larger peak deflection index (PDI), longer V2 R wave duration (V2 Rd), smaller V2 S wave amplitude, higher R/S ratio in V2 , higher V3 R wave amplitude, and larger V2 transition ratio than those with successful ablation. Multivariate analysis demonstrated that PDI, V2 Rd, V2 transition ratio, and pacemapping score acquired during mapping independently predicted failed ablation (P = 0.01, P = 0.01, P = 0.01, and P < 0.001, respectively). In 31 recurrent cases (12.8%) after initially successful ablation, multivariate Cox regression analysis showed that only the earliest activation time acquired during mapping predicted the recurrences after successful ablation (P = 0.001). The recurrent cases displayed different ECG features comparing with those with failed ablation. CONCLUSION The electrocardiographic features of failed RVOT ablation of idiopathic OT-VAs with a transition ≥V3 were characterized by PDI, V2 Rd, V2 transition ratio, and pacemapping score acquired during mapping, unlike the recurrent RVOT ablation.
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Affiliation(s)
- Shinya Yamada
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Fa-Po Chung
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Shih-Lin Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Li-Wei Lo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Yu-Feng Hu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Ta-Chuan Tuan
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Jo-Nan Liao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Chung-Hsing Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chin-Yu Lin
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Yao-Ting Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Ting-Yung Chang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - Abigail Louise D Te
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
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Balla C, Ali H, Cappato R. Ventricular tachycardia as the first manifestation of disease: an element with different clinical settings. J Cardiovasc Med (Hagerstown) 2017; 18 Suppl 1:e77-e82. [PMID: 28151771 DOI: 10.2459/jcm.0000000000000452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Cristina Balla
- aArrhythmia and Electrophysiology Research Center, IRCCS Humanitas Research Hospital, Rozzano, Milan bArrhythmia and Electrophysiology Unit II, Humanitas Gavazzeni Clinics, Bergamo cDepartment of Cardiology, SS. ma Annunziata Hospital, Azienda Unità Sanitaria Locale Ferrara, Cento, Ferrara, Italy
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Liu Y, Fang Z, Yang B, Kojodjojo P, Chen H, Ju W, Cao K, Chen M, Zhang F. Catheter Ablation of Fascicular Ventricular Tachycardia: Long-Term Clinical Outcomes and Mechanisms of Recurrence. Circ Arrhythm Electrophysiol 2015; 8:1443-51. [PMID: 26386017 PMCID: PMC4676513 DOI: 10.1161/circep.115.003080] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 09/03/2015] [Indexed: 11/23/2022]
Abstract
Supplemental Digital Content is available in the text. Fascicular ventricular tachycardia (FVT) is a common form of sustained idiopathic left ventricular tachycardia with an Asian preponderance. This study aimed to prospectively investigate long-term clinical outcomes of patients undergoing ablation of FVT and identify predictors of arrhythmia recurrence.
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Affiliation(s)
- Yaowu Liu
- From the Section of Pacing and Electrophysiology, Division of Cardiology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, China (Y.L., Z.F., B.Y., H.C., W.J., K.C., M.C., F.Z.); and Heart Center, National University Hospital, Singapore, Singapore (P.K.)
| | - Zhen Fang
- From the Section of Pacing and Electrophysiology, Division of Cardiology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, China (Y.L., Z.F., B.Y., H.C., W.J., K.C., M.C., F.Z.); and Heart Center, National University Hospital, Singapore, Singapore (P.K.)
| | - Bing Yang
- From the Section of Pacing and Electrophysiology, Division of Cardiology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, China (Y.L., Z.F., B.Y., H.C., W.J., K.C., M.C., F.Z.); and Heart Center, National University Hospital, Singapore, Singapore (P.K.)
| | - Pipin Kojodjojo
- From the Section of Pacing and Electrophysiology, Division of Cardiology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, China (Y.L., Z.F., B.Y., H.C., W.J., K.C., M.C., F.Z.); and Heart Center, National University Hospital, Singapore, Singapore (P.K.)
| | - Hongwu Chen
- From the Section of Pacing and Electrophysiology, Division of Cardiology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, China (Y.L., Z.F., B.Y., H.C., W.J., K.C., M.C., F.Z.); and Heart Center, National University Hospital, Singapore, Singapore (P.K.)
| | - Weizhu Ju
- From the Section of Pacing and Electrophysiology, Division of Cardiology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, China (Y.L., Z.F., B.Y., H.C., W.J., K.C., M.C., F.Z.); and Heart Center, National University Hospital, Singapore, Singapore (P.K.)
| | - Kejiang Cao
- From the Section of Pacing and Electrophysiology, Division of Cardiology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, China (Y.L., Z.F., B.Y., H.C., W.J., K.C., M.C., F.Z.); and Heart Center, National University Hospital, Singapore, Singapore (P.K.)
| | - Minglong Chen
- From the Section of Pacing and Electrophysiology, Division of Cardiology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, China (Y.L., Z.F., B.Y., H.C., W.J., K.C., M.C., F.Z.); and Heart Center, National University Hospital, Singapore, Singapore (P.K.)
| | - Fengxiang Zhang
- From the Section of Pacing and Electrophysiology, Division of Cardiology, the First Affiliated Hospital with Nanjing Medical University, Nanjing, China (Y.L., Z.F., B.Y., H.C., W.J., K.C., M.C., F.Z.); and Heart Center, National University Hospital, Singapore, Singapore (P.K.).
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Catheter ablation of idiopathic ventricular tachycardia in children using the EnSite NavX system with/without fluoroscopy. Cardiol Young 2014; 24:886-92. [PMID: 24018141 DOI: 10.1017/s1047951113001364] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Curative therapy of idiopathic ventricular tachycardia remains a challenge in interventional electrophysiology. The aim of this study was to demonstrate the utility of an EnSite NavX system in the catheter ablation of idiopathic ventricular tachycardia in children. PATIENTS AND METHODS In all, 17 children with idiopathic ventricular tachycardia underwent electrophysiological studies using the EnSite NavX system guidance. RESULTS The mean patient age was 13 ± 2.4 years (range: 7.8-17.9) and the mean patient weight was 52.3 ± 11.9 kg (range: 32-75). The origin of ventricular tachycardia was in the right ventricular outflow tract in nine patients, in the left ventricle in six, near the bundle of His/right bundle branch in one, and in the left aortic cusp in one. The mean procedure and fluoroscopy times were 169.3 ± 43.2 minutes and 8 ± 10.8 minutes, respectively. No fluoroscopy was used in six patients. The mean radiation exposure was 33.1 ± 56.4 mGy. Acute success was achieved in 14 patients (82%). The focus of ventricular tachycardia was epicardial in two failed procedures. During a mean follow-up of 8.5 ± 7.6 months, ventricular tachycardia recurred in three patients, two of whom underwent a second procedure. Except for one patient who developed transient right bundle branch block, no complications were seen. CONCLUSION Catheter ablation of idiopathic ventricular tachycardia in children can be performed safely and effectively with low fluoroscopy exposure using the EnSite NavX system.
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Chung FP, Chong E, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Chao TF, Liao JN, Huang YC, Chi PC, Chan CS, Chen YY, Huang HK, Chen SA. Different characteristics and electrophysiological properties between early and late recurrences after acute successful catheter ablation of idiopathic right ventricular outflow tract arrhythmias during long-term follow-up. Heart Rhythm 2014; 11:1760-9. [DOI: 10.1016/j.hrthm.2014.06.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Indexed: 10/25/2022]
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Zhang F, Yang B, Chen H, Ju W, Kojodjojo P, Cao K, Chen M. Magnetic versus manual catheter navigation for mapping and ablation of right ventricular outflow tract ventricular arrhythmias: A randomized controlled study. Heart Rhythm 2013; 10:1178-83. [DOI: 10.1016/j.hrthm.2013.05.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2013] [Indexed: 11/17/2022]
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Hoffmayer KS, Gerstenfeld EP. Diagnosis and Management of Idiopathic Ventricular Tachycardia. Curr Probl Cardiol 2013; 38:131-58. [DOI: 10.1016/j.cpcardiol.2013.02.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Calvo N, Jongbloed M, Zeppenfeld K. Radiofrequency catheter ablation of idiopathic right ventricular outflow tract arrhythmias. Indian Pacing Electrophysiol J 2013; 13:14-33. [PMID: 23329871 PMCID: PMC3540113 DOI: 10.1016/s0972-6292(16)30585-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Idiopathic ventricular arrhythmias (VA) consist of various subtypes of VA that occur in the absence of clinically apparent structural heart disease. Affected patients account for approximately 10% of all patients referred for evaluation of ventricular tachycardia (VT). Arrhythmias arising from the outflow tract (OT) are the most common subtype of idiopathic VA and more than 70-80% of idiopathic VTs or premature ventricular contractions (PVCs) originate from the right ventricular (RV) OT. Idiopathic OT arrhythmias are thought to be caused by adenosine-sensitive, cyclic adenosine monophosphate (cAMP) mediated triggered activity and, in general, manifest at a relatively early age. Usually they present as salvos of paroxysmal ventricular ectopic beats and are rarely life-threatening. When highly symptomatic and refractory to antiarrhythmic therapy or causative for ventricular dysfunction, ablation is a recommended treatment with a high success rate and a low risk of complications.
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Affiliation(s)
- Naiara Calvo
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
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Liang JJ, Huang H, Huang CX, Yang B, Wan J, Tang YH, Okello E. Same ablation may be used for frequent premature ventricular contractions and supraventricular tachycardia. Med Hypotheses 2009; 73:818-20. [DOI: 10.1016/j.mehy.2009.03.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2009] [Revised: 03/23/2009] [Accepted: 03/24/2009] [Indexed: 11/25/2022]
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Clyne CA, Athar H, Shah A, Kahr R, Rentas A. Thermal mapping of right ventricular outflow tract tachycardia. Pacing Clin Electrophysiol 2007; 30:343-51. [PMID: 17367353 DOI: 10.1111/j.1540-8159.2007.00674.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Acute and long-term success of catheter ablation of right ventricular outflow tract tachycardia (RVOT VT) may be limited by the inability to reproduce the arrhythmia at the time of activation (AM) and pace mapping (PM). We have observed early initiation of the clinical VT when subtherapeutic radiofrequency (RF) energy was applied to the target area (TA), defined as a 2-cm(2) area around a pace match. We describe a novel approach using thermal mapping (TM) to guide the ablation of RVOT VT. METHODS Thirteen patients (10 female, mean age 46.2 +/- 13.7 years) with symptomatic VT of left bundle branch block (LBBB) inferior axis morphology and no structural heart disease underwent standard electrophysiologic evaluation with PM (n = 13), AM (n = 13), and 3D noncontact mapping (n = 4). Thermal mapping was performed after standard techniques failed to induce stable sustained VT for mapping in all 13 patients: RF was applied for 5-10 seconds in the TA to achieve a tip temperature of 45-50 degrees C. At sites where morphologically consistent with the clinical VT was induced, RF was applied at target temperature between 50 and 60 degrees C for 30-60 seconds. TM was repeated before and after intravenous Isoproterenol infusion until no further VT could be induced by low temperature application. RESULTS Noninducibility was achieved in all 13 patients. During a mean follow-up of 29 months (9-69 months), all patients remain arrhythmia-free, off antiarrhythmic medications. CONCLUSION Thermal mapping is a safe and effective adjunctive technique for the mapping and ablation of RVOT VT when sustained tolerated clinical VT cannot be induced.
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Affiliation(s)
- Christopher A Clyne
- Henry Low Heart Center at Hartford Hospital, and University of Connecticut School of Medicine, Hartford, Connecticut, USA.
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Abstract
Idiopathic ventricular tachycardia (VT) is an uncommon form of VT that is seen in patients without structural heart disease. It is commonly seen in young patients and usually has a benign course. Recent studies have delineated the mechanisms and anatomical locations of this form of VT. Recognition of various forms of idiopathic VT based on characteristic QRS morphology from the 12-lead electrocardiogram (ECG) has important prognostic and therapeutic implications. The understanding of the mechanisms of idiopathic VT has led to the use of specific antiarrhythmic drugs targeting particular arrhythmias. Recent technological advances in the field of mapping and catheter ablation have led to a suitable alternative to drug therapy with a very high cure rate. This review describes the clinical features, ECG recognition, and management of idiopathic monomorphic VT.
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Greil GF, Gass M, Kuehlkamp V, Botnar RM, Wolf I, Miller S, Sieverding L. Radiofrequency ablation of right ventricular outflow tract tachycardia using a magnetic resonance 3D model for interactive catheter guidance. Clin Res Cardiol 2006; 95:610-3. [PMID: 16998745 DOI: 10.1007/s00392-006-0431-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Accepted: 06/26/2006] [Indexed: 10/24/2022]
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Krittayaphong R, Sriratanasathavorn C, Dumavibhat C, Pumprueg S, Boonyapisit W, Pooranawattanakul S, Phrudprisan S, Kangkagate C. Electrocardiographic predictors of long-term outcomes after radiofrequency ablation in patients with right-ventricular outflow tract tachycardia. ACTA ACUST UNITED AC 2006; 8:601-6. [PMID: 16772366 DOI: 10.1093/europace/eul067] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIMS The objectives of this study were to identify electrocardiographic (ECG) predictors of long-term outcomes after radiofrequency (RF) ablation in patients with right-ventricular outflow tract (RVOT) tachycardia. METHODS AND RESULTS We correlated ECG characteristics with RF ablation outcomes in 144 patients with RVOT tachycardia who underwent RF ablation for >1 year. Unfavourable RF ablation outcomes were predefined as unsuccessful RF ablation or recurrence of tachycardia requiring repeated ablation. RF ablation was not successful in 11 (7.6%) patients and 16 (12%) patients had arrhythmia recurrence requiring repeated ablation. Average follow-up time was 72.2+/-28.4 months. Selected parameters from univariate analysis included number of RF applications, pacemapping, application of bonus burn, procedure time, monophasic R-wave in lead I, QS pattern in leads I and aVL, QRS duration in leads II and V(2), and right axis deviation, in ventricular tachycardia. From logistic regression analysis, only monophasic R-wave in lead I remained in the final equation (P=0.004, odds ratio 12.9). CONCLUSION Monophasic R-wave in lead I during RVOT tachycardia is associated with unfavourable outcomes after RF ablation. This finding may help clinicians in the selection of patients for RF ablation and for the prediction of RF ablation outcome.
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Affiliation(s)
- Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand.
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Joshi S, Wilber DJ. Ablation of Idiopathic Right Ventricular Outflow Tract Tachycardia: Current Perspectives. J Cardiovasc Electrophysiol 2005; 16 Suppl 1:S52-8. [PMID: 16138887 DOI: 10.1111/j.1540-8167.2005.50163.x] [Citation(s) in RCA: 155] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Ventricular tachycardia (VT) arising from the right ventricular outflow tract (RVOT) in the absence of overt structural heart disease is a common entity. Exclusion of occult structural disease such as arrhythmogenic right ventricular cardiomyopathy is critical as this diagnosis impacts both ablation outcomes and long-term prognosis. VT is most commonly due to triggered activity. Induction of the target arrhythmia in the laboratory is often problematic, and is frequently facilitated by catecholamine infusion. Recent data indicate that high-density three-dimensional activation mapping facilitates identification of target sites for ablation, and that the spatial resolution of pacemapping may be more limited than previously recognized. A standard 12-lead electrocardiogram is useful in providing an initial approximation of the site of origin within the outflow tract, and may contain subtle clues to potentially confounding foci on the left ventricular endocardial or epicardial surface. When sufficient arrhythmia is present to permit mapping, successful ablation can be expected in 90-95% of patients, with a recurrence risk of approximately 5%. In experienced centers, major complications are <or=1% and outcomes should approach those obtained for the common forms of supraventricular tachycardia.
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Affiliation(s)
- Sandeep Joshi
- Cardiovascular Institute, Loyola University Medical Center, Maywood, Illinois 60153, USA
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Azegami K, Wilber DJ, Arruda M, Lin AC, Denman RA. Spatial Resolution of Pacemapping and Activation Mapping in Patients with Idiopathic Right Ventricular Outflow Tract Tachycardia. J Cardiovasc Electrophysiol 2005; 16:823-9. [PMID: 16101622 DOI: 10.1111/j.1540-8167.2005.50041.x] [Citation(s) in RCA: 100] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The purpose of this study was to compare the spatial resolution of activation mapping and pacemapping in patients undergoing ablation of idiopathic ventricular tachycardia (VT) arising from the right ventricular outflow tract (RVOT). A direct comparison of the two techniques has not been undertaken. METHODS AND RESULTS Electroanatomical activation maps of the RVOT were obtained during VT in 15 patients. Pacemaps were obtained from multiple sites, tagged on the activation map, and scored according the degree of concordance between the paced QRS configuration and that of VT. The site of successful ablation was considered the VT site of origin. Initial endocardial activation away from the site of origin was rapid; the mean area of myocardium activated within the first 10 msec (early activation area, EAA) was 3.0 +/- 1.6 cm(2) (range: 1.3-6.4 cm(2)). Best pacemap scores were always obtained adjacent to the site of origin. Pacemap concordance, and the probability of an exact pacemap match significantly decreased with increasing distance of the pacing site from the site of origin (P < 0.01). All patients had more than one pacing site yielding a best pacemap score. The greatest distance between such sites in an individual patient ranged from 11 to 26 mm (mean: 18 +/- 5 mm), and was strongly correlated with the size of the EAA (r = 0.77, P < 0.001). CONCLUSIONS Pacemapping and activation mapping provide similar localizing information. The spatial resolution of each technique is modest, varies between patients, and may be optimized by three-dimensional data display.
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Affiliation(s)
- Koji Azegami
- Cardiovascular Institute, Loyola University Medical Center, Maywood, Illinois, USA
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Tanner H, Wolber T, Schwick N, Fuhrer J, Delacretaz E. Electrocardiographic Pattern as a Guide for Management and Radiofrequency Ablation of Idiopathic Ventricular Tachycardia. Cardiology 2005; 103:30-6. [PMID: 15528898 DOI: 10.1159/000081849] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2003] [Accepted: 05/08/2004] [Indexed: 11/19/2022]
Abstract
BACKGROUND Idiopathic ventricular tachycardia (VT) often originates from the right ventricular outflow tract (RVOT), but foci deep to the endocardium, in the epicardium, or in the left ventricle are not uncommon. Although these extra-RVOT foci can be targeted with ablation, risks involved are higher and success rates lower. Simple electrocardiographic (ECG) criteria allowing (1) discrimination of RVOT foci from extra-RVOT foci and (2) assessment of the chance of success of a right heart ablation procedure are desirable. METHODS Twenty-five consecutive patients referred for radiofrequency (RF) ablation of idiopathic VT or severely symptomatic idiopathic ventricular premature contractions were included. Localization of VT origin and success rates of VT ablation in the RVOT were analyzed according to the ECG pattern. RESULTS The analysis of the R wave in V2 was the strongest single predictor of whether the VT had an RVOT or an extra-RVOT origin. An R wave amplitude < or =30% of the QRS amplitude designated the VT focus in the RVOT with positive and negative predictive values of 95 and 100%, respectively. Analysis of R wave duration in V2 had similar predictive values, whereas the R/S transition zone in precordial leads had slightly lower predictive values. Seventeen of 20 arrhythmias (85%) with an R wave amplitude < or =30% of the QRS amplitude in V2 could be successfully abolished by an exclusively right heart procedure. CONCLUSIONS The analysis of ECG pattern makes it possible to guide the management of patients with idiopathic VT in predicting the arrhythmias that can be safely targeted with RF ablation from the RVOT with high success rates.
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Affiliation(s)
- Hildegard Tanner
- Swiss Cardiovascular Center Bern, University Hospital, Bern, Switzerland
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Tierney SP, Wilber DJ. Catheter Ablation of Ventricular Tachycardia. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2003; 5:377-385. [PMID: 12941206 DOI: 10.1007/s11936-003-0044-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Most patients with ventricular tachycardia (VT) associated with structural heart disease should receive an implantable cardioverter-defibrillator as initial therapy. Patients with symptomatic recurrences of tachycardia, including those with multiple defibrillator shocks, are considered for ablation. The vigor with which antiarrhythmic drug therapy is pursued as antecedent therapy to ablation depends on patient factors (eg, medical comorbidity, type of heart disease, number and hemodynamic tolerance of tachycardias) and the previous history of antiarrhythmic drug exposure (eg, side effects, inefficacy). In patients with mild left ventricular dysfunction and well-tolerated tachycardia, ablation may be offered as primary definitive therapy in selected individuals. In patients without structural heart disease, ablation is usually offered as primary definitive therapy to highly symptomatic patients, and is strongly recommended for patients with recurrent tachycardia following initial attempts at drug suppression. Optimal outcome of VT ablation depends on the availability of an experienced team and sophisticated facilities to accommodate the technical challenges associated with the broad spectrum of clinical presentations and arrhythmia mechanisms. Historically, major complications have been reported in up to 10% of patients, including death, stroke, cardiac tamponade, complete heart block, and myocardial infarction. In our own experience with VT ablation over the past 10 years, major complications occurred in three (1.8%) of 168 patients with structural heart disease and one (0.7%) of 142 patients without structural heart disease.
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Affiliation(s)
- Sean P. Tierney
- Cardiovascular Institute, Loyola University Medical Center, 2160 S. 1st Avenue, Maywood, IL 60153, USA.
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Vestal M, Wen MS, Yeh SJ, Wang CC, Lin FC, Wu D. Electrocardiographic predictors of failure and recurrence in patients with idiopathic right ventricular outflow tract tachycardia and ectopy who underwent radiofrequency catheter ablation. J Electrocardiol 2003; 36:327-32. [PMID: 14661169 DOI: 10.1016/j.jelectrocard.2003.08.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This study reports new electrocardiographic (ECG) predictors of radiofrequency catheter ablation failure and recurrence in idiopathic right ventricular outflow tract (RVOT) ventricular tachycardia (VT) or ectopy based on 91 consecutive patients. Procedural success and failure rates were 85% (77/91) and 15% (14/91), respectively. Twenty three percent (18/77) had recurrence during the follow-up period of 1 to 120 months (mean 56 +/- 31 months). Baseline RVOT VT/ectopy on 12-lead ECG taken prior to ablation from 91 patients were retrospectively analyzed. Ablation performed with RVOT ectopy (isolated ectopies, bigeminy, trigeminy, or couplets) as template arrhythmia was more likely to fail (30% vs. 8%, P =.02) as opposed to RVOT VT (sustained or nonsustained). VT/ectopy-QRS morphology variation was more observed in failed ablations (36% vs. 7%, P =.001). Significantly wider mean VT/ectopy QRS in leads I, II, AVR, V2, V3, V5, and V6 were noted in failed ablation group. Mean R wave amplitude reached statistical significance only in lead II (22.0 +/- 5.1 mV for failed vs. 17.8 +/- 5.2 mV for successful outcomes; P =.009). QRS morphologic variation (47% vs. 16%; P =.009) was the only statistically significant ECG to be more common in patients with arrhythmia recurrence. In conclusion, ablation with ectopy over VT as template arrhythmia, presence of QRS morphologic variation, wider mean QRS width, and taller mean R-wave amplitude in lead II were identified ECG predictors of failed RVOT VT/Ectopy ablation. The only ECG predictor of recurrence was the presence of RVOT VT or ectopy QRS morphologic variation.
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Affiliation(s)
- Marivic Vestal
- Department of Medicine, Second Section of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taipei, Taiwan
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Fung JWH, Chan HCK, Chan JYS, Chan WWL, Kum LCC, Sanderson JE. Ablation of nonsustained or hemodynamically unstable ventricular arrhythmia originating from the right ventricular outflow tract guided by noncontact mapping. Pacing Clin Electrophysiol 2003; 26:1699-705. [PMID: 12877703 DOI: 10.1046/j.1460-9592.2003.t01-1-00255.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Conventional activation or pacemapping is effective in guiding ablation of ventricular tachyarrhythmia originating from right ventricular outflow tract (RVOT). However, in selected patients with hemodynamically unstable or nonsustained tachycardia, noncontact mapping may be an effective alternative method to guide ablation in RVOT. Five patients with symptomatic hypotension during ventricular tachycardia (VT) or nonsustained tachyarrhythmia originating from the RVOT had radiofrequency ablation guided by noncontact mapping. All patients had a history of syncope and the tachyarrhythmias were refractory to antiarrhythmic therapy. Four patients had spontaneous sustained VT of a cycle length from 250 to 300 ms and one had symptomatic ventricular ectopic beats. Two patients were diagnosed to have arrhythmogenic right ventricular cardiomyopathy (ARVC). Sustained VT with hypotension was induced in two patients and nonsustained VT in three patients. Isopotential color maps were used to locate the earliest activation site of the tachyarrhythmia in RVOT. Three patients had tachyarrhythmia exit sites at the septal region and two at lateral region of RVOT. Low voltage area and diastolic activity were detected in the two patients with ARVC. Radiofrequency ablation guided by noncontact mapping was performed during sinus rhythm in all patients. The number of ablation attempts ranged from 1 to 14. After follow-up for 12 +/- 5.8 months, there was no recurrence of tachyarrhythmia and syncope in all five patients. Noncontact mapping is a safe and effective alternative method to guide ablation of hemodynamically unstable or nonsustained ventricular arrhythmia originating from RVOT.
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Affiliation(s)
- Jeffrey W H Fung
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China.
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Friedman PA, Asirvatham SJ, Grice S, Glikson M, Munger TM, Rea RF, Shen WK, Jahanghir A, Packer DL, Hammill SC. Noncontact mapping to guide ablation of right ventricular outflow tract tachycardia. J Am Coll Cardiol 2002; 39:1808-12. [PMID: 12039496 DOI: 10.1016/s0735-1097(02)01864-8] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES [corrected] The aim of this study was to determine whether noncontact mapping is feasible in the right ventricle and assess its utility in guiding ablation of difficult-to-treat right ventricular outflow tract (RVOT) ventricular tachycardia (VT). BACKGROUND In patients without inducible arrhythmia, RVOT VT may be difficult to ablate. Noncontact mapping permits ablation guided by a single tachycardia complex, which may facilitate ablation of difficult cases. However, the mapping system may be geometry-dependent, and it has not been validated in the unique geometry of the RVOT. METHODS Ten patients with left bundle inferior axis VT, no history of myocardial infarction and normal left ventricular function underwent noncontact guided ablation; seven had failed previous ablation and three had received a defibrillator. All noncontact maps were analyzed by a blinded reviewer to determine whether the arrhythmia focus was epicardial and to predict on the basis of the map whether arrhythmia would recur. RESULTS The procedure was acutely successful in 9 of 10 patients. During a mean follow-up of 11 months, 7 of 9 patients remained arrhythmia-free. Both patients in whom the blinded reviewer predicted failure had arrhythmia recurrence: one due to epicardial origin with multiple endocardial exit sites and one due to discordance between site of lesion placement and earliest activation on noncontact map. CONCLUSIONS Mechanisms of ablation failure in RVOT VT include absence of sustained arrhythmia, difficulty with substrate localization and epicardial origin of arrhythmia. In this study, noncontact mapping was safely and effectively used to guide ablation of patients with difficult-to-treat RVOT VT.
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Affiliation(s)
- Paul A Friedman
- Division of Cardiovascular Disease, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Farré J, Cabrera JA, Romero J, Rubio JM. Therapeutic decision tree for patients with sustained ventricular tachyarrhythmias or aborted cardiac arrest: a critical review of the Antiarrhythmics Versus Implantable Defibrillator trial and the Canadian Implantable Defibrillator Study. Am J Cardiol 2000; 86:44K-51K. [PMID: 11084100 DOI: 10.1016/s0002-9149(00)01291-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Antiarrhythmic drugs, mainly amiodarone and sotalol, radiofrequency catheter ablation, and the implantable cardioverter defibrillator (ICD) are the 3 therapeutic options in patients with sustained ventricular tachycardia (VT) or ventricular fibrillation (VF). Idiopathic VT, incessant VT, frequently recurring, hemodynamically stable VT, and VT based on bundle branch reentry, are candidates for radiofrequency catheter ablation. Patients with high-risk ventricular tachyarrhythmias should receive ICDs as initial therapy. Two studies, the Antiarrhythmics Versus Implantable Defibrillator trial (AVID) and the Canadian Implantable Defibrillator Study (CIDS) have tried to approach the problem of these high-risk ventricular tachyarrhythmias. Although at 3 years, the ICD in AVID demonstrated a significant relative risk reduction over amiodarone of 31.5%, CIDS could not duplicate this finding. At 3 years, the relative risk reduction conferred by the ICD over amiodarone in CIDS was only 13.7%. A careful analysis of both studies suggests that CIDS was insufficiently powered to demonstrate statistically significant benefits similar to those shown by AVID, and furthermore, seemed to include an undetermined number of low-risk VT patients. The problem in the CIDS trial in this regard was the recruitment of patients in whom the inclusion criteria were met by the arrhythmias induced during the electrophysiology stimulation study, but which did not exist in real life. In addition CIDS included 14% of patients with (1) undocumented syncope and inducible monomorphic sustained VT; or (2) long runs of spontaneous nonsustained VT. Under these circumstances, the therapeutic implications of AVID remain unchallenged.
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Affiliation(s)
- J Farré
- Department of Cardiology, Fundación Jiménez Díaz, Madrid, Spain
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Abstract
Idiopathic ventricular tachycardia (VT) is characterized by two predominant forms. The most common form originates from the right ventricular outflow tract and presents as repetitive monomorphic VT or exercise-induced VT. The tachycardia is adenosine sensitive and is thought to be because of cAMP-mediated triggered activity. The other major form of idiopathic VT is owing to verapamil-sensitive intrafascicular re-entrant tachycardia, which most often originates in the region of the left posterior fascicle. Both forms of idiopathic VT can be readily treated with radiofrequency catheter ablation.
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Affiliation(s)
- B B Lerman
- Department of Medicine, New York Hospital-Cornell University Medical Center, New York, USA.
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Flemming MA, Oral H, Kim MH, Tse HF, Pelosi F, Michaud GF, Knight BP, Strickberger SA, Morady F. Electrocardiographic predictors of successful ablation of tachycardia or bigeminy arising in the right ventricular outflow tract. Am J Cardiol 1999; 84:1266-8, A9. [PMID: 10569344 DOI: 10.1016/s0002-9149(99)00546-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Among various electrocardiographic variables, the QRS duration in V2 was found to be the best discriminator of outcome in patients undergoing radiofrequency catheter ablation of the right ventricular outflow tract tachycardia and/or bigeminy. If the QRS duration is <160 ms in lead V2, the probability of successful ablation is lower than if the QRS duration is longer.
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Affiliation(s)
- M A Flemming
- Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor 48109-0022, USA
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