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Shinoda Y, Shatz NA, Tung R. Successful ablation of premature ventricular contractions from "late" activation site in cardiac sarcoidosis: Evidence suggestive of a reentrant mechanism. Heart Rhythm 2024; 21:670-673. [PMID: 38280619 DOI: 10.1016/j.hrthm.2024.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 12/25/2023] [Accepted: 01/05/2024] [Indexed: 01/29/2024]
Affiliation(s)
- Yasutoshi Shinoda
- The University of Arizona College of Medicine-Phoenix, Banner University Medical Center, Phoenix, Arizona
| | | | - Roderick Tung
- The University of Arizona College of Medicine-Phoenix, Banner University Medical Center, Phoenix, Arizona.
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2
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Milaras N, Kordalis A, Tsiachris D, Sakalidis A, Ntalakouras I, Pamporis K, Dourvas P, Apostolos A, Sotiriou Z, Arsenos P, Archontakis S, Tsioufis K, Gatzoulis K, Sideris S. Ischemia testing and revascularization in patients with monomorphic ventricular tachycardia: A relic of the past? Curr Probl Cardiol 2024; 49:102358. [PMID: 38169203 DOI: 10.1016/j.cpcardiol.2023.102358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 12/18/2023] [Indexed: 01/05/2024]
Abstract
Testing for myocardial ischemia in patients presenting with sustained monomorphic Ventricular Tachycardia(VT) even without evidence of acute myocardial infarction is a tempting strategy that is frequently utilized in clinical practice. Monomorphic VT is mainly caused by re-entry around chronic myocardial scar and active ischemia has no role in its pathogenesis, thus making testing for ischemia futile, at least in theory. This systematic literature review sought to address the usefulness of ischemia testing (mainly coronary angiography) in patients presenting with monomorphic VT through 8 selected studies after evaluating a total of 130 published manuscripts. Particularly, we sought to unveil whether coronary angiography and possibly concomitant revascularization leads to lesser tachycardia recurrence. Our conclusion can be summarized as follows: this approach whether combined with revascularization or not, does not seem to reduce VT recurrence nor does it affect mortality in such patients. Even though most of the published literature points at this direction, validation from randomized controlled trials is imperative.
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Affiliation(s)
- Nikias Milaras
- State Department of Cardiology, "Hippokration" General Hospital of Athens, Greece; School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Vasilissis Sofias 114, Athens 11527, Greece.
| | - Athanasios Kordalis
- School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Vasilissis Sofias 114, Athens 11527, Greece
| | - Dimitrios Tsiachris
- School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Vasilissis Sofias 114, Athens 11527, Greece
| | - Athanasios Sakalidis
- School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Vasilissis Sofias 114, Athens 11527, Greece
| | - Ioannis Ntalakouras
- State Department of Cardiology, "Hippokration" General Hospital of Athens, Greece
| | | | - Panagiotis Dourvas
- State Department of Cardiology, "Hippokration" General Hospital of Athens, Greece
| | - Anastasios Apostolos
- School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Vasilissis Sofias 114, Athens 11527, Greece
| | - Zoi Sotiriou
- School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Vasilissis Sofias 114, Athens 11527, Greece
| | - Petros Arsenos
- School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Vasilissis Sofias 114, Athens 11527, Greece
| | - Stefanos Archontakis
- State Department of Cardiology, "Hippokration" General Hospital of Athens, Greece
| | - Konstantinos Tsioufis
- School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Vasilissis Sofias 114, Athens 11527, Greece
| | - Konstantinos Gatzoulis
- School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Vasilissis Sofias 114, Athens 11527, Greece
| | - Skevos Sideris
- State Department of Cardiology, "Hippokration" General Hospital of Athens, Greece
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3
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Ciaccio EJ, Anter E, Coromilas J, Wan EY, Yarmohammadi H, Wit AL, Peters NS, Garan H. Structure and function of the ventricular tachycardia isthmus. Heart Rhythm 2022; 19:137-153. [PMID: 34371192 DOI: 10.1016/j.hrthm.2021.08.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/22/2021] [Accepted: 08/01/2021] [Indexed: 12/24/2022]
Abstract
Catheter ablation of postinfarction reentrant ventricular tachycardia (VT) has received renewed interest owing to the increased availability of high-resolution electroanatomic mapping systems that can describe the VT circuits in greater detail, and the emergence and need to target noninvasive external beam radioablation. These recent advancements provide optimism for improving the clinical outcome of VT ablation in patients with postinfarction and potentially other scar-related VTs. The combination of analyses gleaned from studies in swine and canine models of postinfarction reentrant VT, and in human studies, suggests the existence of common electroanatomic properties for reentrant VT circuits. Characterizing these properties may be useful for increasing the specificity of substrate mapping techniques and for noninvasive identification to guide ablation. Herein, we describe properties of reentrant VT circuits that may assist in elucidating the mechanisms of onset and maintenance, as well as a means to localize and delineate optimal catheter ablation targets.
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Affiliation(s)
- Edward J Ciaccio
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York; ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom.
| | - Elad Anter
- Department of Cardiovascular Medicine, Cardiac Electrophysiology, Cleveland Clinic, Cleveland, Ohio
| | - James Coromilas
- Department of Medicine, Division of Cardiovascular Disease and Hypertension, Rutgers University, New Brunswick, New Jersey
| | - Elaine Y Wan
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Hirad Yarmohammadi
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Andrew L Wit
- Department of Pharmacology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Nicholas S Peters
- ElectroCardioMaths Programme, Imperial Centre for Cardiac Engineering, Imperial College London, London, United Kingdom
| | - Hasan Garan
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, New York
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4
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto S, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 guideline on non-pharmacotherapy of cardiac arrhythmias. J Arrhythm 2021; 37:709-870. [PMID: 34386109 PMCID: PMC8339126 DOI: 10.1002/joa3.12491] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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5
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Varma N. Perimitral ventricular tachycardia associated with remote inferior myocardial infarction. J Cardiovasc Electrophysiol 2021; 32:2228-2237. [PMID: 34191359 DOI: 10.1111/jce.15143] [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: 03/06/2021] [Revised: 05/31/2021] [Accepted: 06/18/2021] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Circuits underlying ventricular tachycardias (VTs) accompanying remote inferior myocardial infarction (IMI) are regarded to be located in the scar. Rotation around the mitral annulus (MA) had also been postulated. We tested whether entrainment mapping could confirm whether MA rotation in VTs post-IMI represented a "driving circuit." METHODS Three patients with IMI (male, left ventricular ejection fraction range 13%-40%) with hemodynamically tolerated VT (cycle length 365-690 ms) were studied with activation and entrainment mapping of the MA. RESULTS Patients showed QRS morphologies reported for VTs following IMI: LBBB (left bundle branch block) pattern and/or right bundle pattern. Entrainment revealed the entire MA perimeter constituted the circuit, that is, macroreentry (path length greater than 13 cm in one case). Areas showing prolonged fractionated electrograms (accounting for over 50% of tachycardia cycle length) demonstrated concealed entrainment indicative of slow conduction through (and not around) the scar. Concealed entrainment was observed along the MA, with similar stimulus-QRS intervals when pacing during normal sinus rhythm. Radiofrequency ablation of the inferior isthmus from scar to MA (epicardially in one case) abolished tachycardia. In follow-up, two patients had no VT recurrence and maintained NYHA Class 1 functional status during several years of follow-up. The other patient continued to deteriorate with rapidly progressive HF, had recurrent VT within 3 months, proceeding to transplant within 9 months. Our findings confirm a single-loop perimitral circuit, which is largely (if not exclusively) protected by anatomical barriers. This differs from the established "figure-of-8" VT model. CONCLUSION Single-loop macroreentrant mitral annular circuits may underlie some VTs following inferior wall infarcts.
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Affiliation(s)
- Niraj Varma
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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6
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto SI, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 Guideline on Non-Pharmacotherapy of Cardiac Arrhythmias. Circ J 2021; 85:1104-1244. [PMID: 34078838 DOI: 10.1253/circj.cj-20-0637] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Haruhiko Abe
- Department of Heart Rhythm Management, University of Occupational and Environmental Health, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital
| | - Toshiyuki Ishikawa
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University
| | - Katsuhiko Imai
- Department of Cardiovascular Surgery, Kure Medical Center and Chugoku Cancer Center
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kaoru Okishige
- Department of Cardiology, Yokohama City Minato Red Cross Hospital
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Morio Shoda
- Department of Cardiology, Tokyo Women's Medical University
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Yoshihiro Seo
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui
| | | | - Yuji Nakazato
- Department of Cardiovascular Medicine, Juntendo University Urayasu Hospital
| | - Takashi Nishimura
- Department of Cardiac Surgery, Tokyo Metropolitan Geriatric Hospital
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | | | - Yuji Murakawa
- Fourth Department of Internal Medicine, Teikyo University Hospital Mizonokuchi
| | - Teiichi Yamane
- Department of Cardiology, Jikei University School of Medicine
| | - Takeshi Aiba
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Koichi Inoue
- Division of Arrhythmia, Cardiovascular Center, Sakurabashi Watanabe Hospital
| | - Yuki Iwasaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kikuya Uno
- Arrhythmia Center, Chiba Nishi General Hospital
| | - Michio Ogano
- Department of Cardiovascular Medicine, Shizuoka Medical Center
| | - Masaomi Kimura
- Advanced Management of Cardiac Arrhythmias, Hirosaki University Graduate School of Medicine
| | | | - Shingo Sasaki
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine
| | | | - Tsuyoshi Shiga
- Department of Cardiology, Tokyo Women's Medical University
| | - Tsugutoshi Suzuki
- Departments of Pediatric Electrophysiology, Osaka City General Hospital
| | - Yukio Sekiguchi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Kyoko Soejima
- Arrhythmia Center, Second Department of Internal Medicine, Kyorin University Hospital
| | - Masahiko Takagi
- Division of Cardiac Arrhythmia, Department of Internal Medicine II, Kansai Medical University
| | - Masaomi Chinushi
- School of Health Sciences, Faculty of Medicine, Niigata University
| | - Nobuhiro Nishi
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hitoshi Hachiya
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | | | | | - Yasushi Miyauchi
- Department of Cardiovascular Medicine, Nippon Medical School Chiba-Hokusoh Hospital
| | - Aya Miyazaki
- Department of Pediatric Cardiology, Congenital Heart Disease Center, Tenri Hospital
| | - Tomoshige Morimoto
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Hiro Yamasaki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | | | - Takeshi Kimura
- Department of Cardiology, Graduate School of Medicine and Faculty of Medicine, Kyoto University
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
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7
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Tung R, Raiman M, Liao H, Zhan X, Chung FP, Nagel R, Hu H, Jian J, Shatz DY, Besser SA, Aziz ZA, Beaser AD, Upadhyay GA, Nayak HM, Nishimura T, Xue Y, Wu S. Simultaneous Endocardial and Epicardial Delineation of 3D Reentrant Ventricular Tachycardia. J Am Coll Cardiol 2020; 75:884-897. [PMID: 32130924 DOI: 10.1016/j.jacc.2019.12.044] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 12/12/2019] [Accepted: 12/16/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Mechanisms of scar-related ventricular tachycardia (VT) are largely based on computational and animal models that portray a 2-dimensional view. OBJECTIVES The authors sought to delineate the human VT circuit with a 3-dimensional perspective from recordings obtained by simultaneous endocardial and epicardial mapping. METHODS High-resolution mapping was performed during 97 procedures in 89 patients with structural heart disease. Circuits were characterized by systematic isochronal analysis to estimate the dimensions of the isthmus and extent of the exit region recorded on both myocardial surfaces. RESULTS A total of 151 VT morphologies were mapped, of which 83 underwent simultaneous endocardial and epicardial mapping; 17% of circuits activated in a 2-dimensional plane, restricted to 1 myocardial surface. Three-dimensional activation patterns with nonuniform transmural propagation were observed in 61% of circuits with only 4% showing transmurally uniform activation, and 18% exhibiting focal activation patterns consistent with mid-myocardial reentry. The dimensions of the central isthmus were 17 mm (12 to 28 mm) × 10 mm (9 to 19 mm) with 55% exhibiting a minimal dimension of <1.5 cm. QRS activation was transmural in 63% and located 43 mm (34 to 52 mm) from the central isthmus. On the basis of 6 proposed definitions for epicardial VT, the prevalence of an epicardial circuit ranged from 21% to 80% in ischemic cardiomyopathy and 28% to 77% in nonischemic cardiomyopathy. CONCLUSIONS A 2D perspective oversimplifies the electrophysiological circuit responsible for reentrant human VT and simultaneous endocardial and epicardial mapping facilitates inferences about mid-myocardial activation. Intricate activation patterns are frequently observed on both myocardial surfaces, and the epicardium is functionally involved in the majority of circuits. Human reentry may exist within isthmus dimensions smaller than 1 cm, whereas QRS activation is often transmural and remote from the critical isthmus target. A 3-dimensional perspective of the VT circuit may enhance the precision of ablative therapy and may support a greater role for adjunctive strategies and technology to address arrhythmogenic tissue harbored in the mid-myocardium and subepicardium.
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Affiliation(s)
- Roderick Tung
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois; Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China.
| | | | - Hongtao Liao
- Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xianzhang Zhan
- Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Fa Po Chung
- Taipei Veterans General Hospital, Taipei, Taiwan
| | | | - Hongde Hu
- West China Hospital, Sichuan University, Chengdu, China
| | - Jiang Jian
- West China Hospital, Sichuan University, Chengdu, China
| | - Dalise Y Shatz
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois
| | - Stephanie A Besser
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois
| | - Zaid A Aziz
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois
| | - Andrew D Beaser
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois
| | - Gaurav A Upadhyay
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois
| | - Hemal M Nayak
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois
| | - Takuro Nishimura
- University of Chicago Medicine, Center for Arrhythmia Care, Division of Cardiology, Department of Medicine, Pritzker School of Medicine, Chicago, Illinois
| | - Yumei Xue
- Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shulin Wu
- Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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8
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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: 219] [Impact Index Per Article: 54.8] [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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9
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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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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. Heart Rhythm 2019; 17:e2-e154. [PMID: 31085023 PMCID: PMC8453449 DOI: 10.1016/j.hrthm.2019.03.002] [Citation(s) in RCA: 179] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Indexed: 01/10/2023]
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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Abstract
Myocardial injury, mechanical stress, neurohormonal activation, inflammation, and/or aging all lead to cardiac remodeling, which is responsible for cardiac dysfunction and arrhythmogenesis. Of the key histological components of cardiac remodeling, fibrosis either in the form of interstitial, patchy, or dense scars, constitutes a key histological substrate of arrhythmias. Here we discuss current research findings focusing on the role of fibrosis, in arrhythmogenesis. Numerous studies have convincingly shown that patchy or interstitial fibrosis interferes with myocardial electrophysiology by slowing down action potential propagation, initiating reentry, promoting after-depolarizations, and increasing ectopic automaticity. Meanwhile, there has been increasing appreciation of direct involvement of myofibroblasts, the activated form of fibroblasts, in arrhythmogenesis. Myofibroblasts undergo phenotypic changes with expression of gap-junctions and ion channels thereby forming direct electrical coupling with cardiomyocytes, which potentially results in profound disturbances of electrophysiology. There is strong evidence that systemic and regional inflammatory processes contribute to fibrogenesis (i.e., structural remodeling) and dysfunction of ion channels and Ca2+ homeostasis (i.e., electrical remodeling). Recognizing the pivotal role of fibrosis in the arrhythmogenesis has promoted clinical research on characterizing fibrosis by means of cardiac imaging or fibrosis biomarkers for clinical stratification of patients at higher risk of lethal arrhythmia, as well as preclinical research on the development of antifibrotic therapies. At the end of this review, we discuss remaining key questions in this area and propose new research approaches. © 2017 American Physiological Society. Compr Physiol 7:1009-1049, 2017.
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Affiliation(s)
- My-Nhan Nguyen
- Baker Heart and Diabetes Institute, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Helen Kiriazis
- Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Xiao-Ming Gao
- Baker Heart and Diabetes Institute, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Xiao-Jun Du
- Baker Heart and Diabetes Institute, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
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Tschabrunn CM, Roujol S, Nezafat R, Faulkner-Jones B, Buxton AE, Josephson ME, Anter E. A swine model of infarct-related reentrant ventricular tachycardia: Electroanatomic, magnetic resonance, and histopathological characterization. Heart Rhythm 2015; 13:262-73. [PMID: 26226214 DOI: 10.1016/j.hrthm.2015.07.030] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Indexed: 01/24/2023]
Abstract
BACKGROUND Human ventricular tachycardia (VT) after myocardial infarction usually occurs because of subendocardial reentrant circuits originating in scar tissue that borders surviving myocardial bundles. Several preclinical large animal models have been used to further study postinfarct reentrant VT, but with varied experimental methodologies and limited evaluation of the underlying substrate or induced arrhythmia mechanism. OBJECTIVE We aimed to develop and characterize a swine model of scar-related reentrant VT. METHODS Thirty-five Yorkshire swine underwent 180-minute occlusion of the left anterior descending coronary artery. Thirty-one animals (89%) survived the 6-8-week survival period. These animals underwent cardiac magnetic resonance imaging followed by electrophysiology study, detailed electroanatomic mapping, and histopathological analysis. RESULTS Left ventricular (LV) ejection fraction measured using CMR imaging was 36% ± 6.6% with anteroseptal wall motion abnormality and late gadolinium enhancement across 12.5% ± 4.1% of the LV surface area. Low voltage measured using endocardial electroanatomic mapping encompassed 11.1% ± 3.5% of the LV surface area (bipolar voltage ≤1.5 mV) with anterior, anteroseptal, and anterolateral involvement. Reentrant circuits mapped were largely determined by functional rather than fix anatomical barriers, consistent with "pseudo-block" due to anisotropic conduction. Sustained monomorphic VT was induced in 28 of 31 swine (90%) (67 VTs; 2.4 ± 1.1; range 1-4) and characterized as reentry. VT circuits were subendocardial, with an arrhythmogenic substrate characterized by transmural anterior scar with varying degrees of fibrosis and myocardial fiber disarray on the septal and lateral borders. CONCLUSION This is a well-characterized swine model of scar-related subendocardial reentrant VT. This model can serve as the basis for further investigation in the physiology and therapeutics of humanlike postinfarction reentrant VT.
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Affiliation(s)
- Cory M Tschabrunn
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine
| | | | | | - Beverly Faulkner-Jones
- Surgical Pathology Division, Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Alfred E Buxton
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine
| | - Mark E Josephson
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine
| | - Elad Anter
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine.
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13
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Mavrogeni S, Petrou E, Kolovou G, Theodorakis G, Iliodromitis E. Prediction of ventricular arrhythmias using cardiovascular magnetic resonance. Eur Heart J Cardiovasc Imaging 2013; 14:518-25. [PMID: 23324829 DOI: 10.1093/ehjci/jes302] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Ventricular tachycardia (VT) is the commonest cause of sudden cardiac death (SCD) in developed countries. Coronary artery disease (CAD) is the most frequent cause of VT in individuals over the age of 30, while hypertrophic cardiomyopathy (HCM), myocarditis and congenital heart disease in those below 30 years of age. Cardiac magnetic resonance (CMR), a non-invasive, non-radiating technique, can reliably detect the changes in ventricular volumes and the ejection fraction that can be predictive of VT/SCD. Furthermore, the capability of CMR to perform tissue characterization and detect oedema, fat and fibrotic substrate, using late gadolinium enhanced images (LGE), can predict VT/SCD in both ischaemic and non-ischaemic cardiomyopathy. The extent of LGE in HCM is correlated with risk factors of SCD and the likelihood of inducible VT. In idiopathic-dilated cardiomyopathy, the presence of midwall fibrosis, assessed by CMR, also predicts SCD/VT. Additionally, in arrhythmogenic right ventricle (RV) dysplasia/cardiomyopathy, CMR has an excellent correlation with histopathology and predicted inducible VT on programmed electrical stimulation, suggesting a possible role in evaluation and diagnosis of these patients. A direct correlation between LGE and VT prediction has been identified only in chronic Chagas' heart disease, but not in viral myocarditis. In CAD, infarct size is the strongest predictor of VT inducibility. The peri-infarct zone may also play a role; however, further studies are needed for definite conclusions. Left ventricle, RV, right ventricular outflow tract (RVOT) function, pulmonary regurgitation and LGE around the infundibular patch and RV anterior wall play an important role in the VT prediction in repaired Tetralogy of Fallot. Finally, in treated transposition of great arteries, the extent of LGE in the systemic RV correlates with age, ventricular dysfunction, electrophysiological parameters and adverse clinical events, suggesting prognostic importance.
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Affiliation(s)
- Sophie Mavrogeni
- Onassis Cardiac Surgery Center, 50 Esperou Street, P. Faliro, Athens 175-61 Greece.
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14
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CHILLOU CHRISTIANDE, MAGNIN-POULL ISABELLE, ANDRONACHE MARIUS, SACHER FREDERIC, GROBEN LAURENT, ABDELAAL AHMED, MURESAN LUCIAN, JARMOUNI SOUMAYA, SCHWARTZ JEROME, JAÏS PIERRE, ALIOT ETIENNE. Showing Up Channels for Postinfarct Ventricular Tachycardia Ablation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2012; 35:897-904. [DOI: 10.1111/j.1540-8159.2012.03429.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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15
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Scott PA, Morgan JM, Carroll N, Murday DC, Roberts PR, Peebles CR, Harden SP, Curzen NP. The extent of left ventricular scar quantified by late gadolinium enhancement MRI is associated with spontaneous ventricular arrhythmias in patients with coronary artery disease and implantable cardioverter-defibrillators. Circ Arrhythm Electrophysiol 2011; 4:324-30. [PMID: 21493964 DOI: 10.1161/circep.110.959544] [Citation(s) in RCA: 99] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Characterization of sudden cardiac death (SCD) risk remains a challenge in the application of implantable cardioverter-defibrillator (ICD) therapy. Late gadolinium enhancement cardiac MRI (LGE-CMR) can accurately identify myocardial scar. We performed a retrospective, single-center observational study to evaluate the association between the extent and distribution of left ventricular scar, quantified using LGE-CMR, and the burden of ventricular arrhythmias in patients with coronary artery disease and ICDs. METHODS AND RESULTS All patients included (2006 to 2009) had undergone LGE-CMR before ICD implantation. Scar (defined as myocardium with a signal intensity ≥50% of the maximum in scar tissue) was characterized in terms of percent scar, scar surface area, and number of transmural left ventricular scar segments. The end point was appropriate ICD therapy. Sixty-four patients (mean age, 66±11 years; male sex, 51) were included. During 19±10 months follow-up, appropriate ICD therapy occurred in 19 (30%) patients. In Cox regression analyses, both percent scar (hazard ratio per 10%, 1.75; 95% CI, 1.09 to 2.81; P=0.02) and number of transmural scar segments (hazard ratio per segment, 1.40; 95% CI, 1.15 to 1.70; P=0.001) were significantly associated with the occurrence of appropriate ICD therapy. CONCLUSIONS In this pilot study, the extent of myocardial scar characterized by LGE-CMR was significantly associated with the occurrence of spontaneous ventricular arrhythmias. We hypothesize that scar quantification by LGE-CMR may prove a valuable risk stratification tool for the occurrence of ventricular arrhythmias, which may have implications for patient selection for ICD therapy.
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Affiliation(s)
- Paul A Scott
- Wessex Cardiothoracic Unit, Southampton University Hospitals NHS Trust, UK.
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Aliot EM, Stevenson WG, Almendral-Garrote JM, Bogun F, Calkins CH, Delacretaz E, Bella PD, Hindricks G, Jais P, Josephson ME, Kautzner J, Kay GN, Kuck KH, Lerman BB, Marchlinski F, Reddy V, Schalij MJ, Schilling R, Soejima K, Wilber D. EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias: Developed in a partnership with the European Heart Rhythm Association (EHRA), a Registered Branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA). Europace 2009; 11:771-817. [DOI: 10.1093/europace/eup098] [Citation(s) in RCA: 283] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Haqqani HM, Marchlinski FE. Electrophysiologic substrate underlying postinfarction ventricular tachycardia: characterization and role in catheter ablation. Heart Rhythm 2009; 6:S70-6. [PMID: 19631910 DOI: 10.1016/j.hrthm.2009.04.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2009] [Indexed: 10/20/2022]
Abstract
The electrophysiologic substrate underlying the development of ventricular tachycardia (VT) in patients with prior infarction has been studied in depth. An increased understanding of its composition and role in the maintenance of reentrant VT has led to the development of substrate modification approaches to ablation of unmappable VT. The area of low bipolar voltage that corresponds to the subendocardial projection of the scar as well as specific potential targets within it have been defined. These targets are selected because they may be involved in forming, or are in close proximity to, critical diastolic isthmuses during VT. The targets include sites of good pacemaps in the border zone, corridors of relatively preserved voltage within dense scar, regions between electrically unexcitable scar, isolated potentials, very late potentials, and regions with good pacemaps which display long stimulus to QRS delays. Ablation strategies have been designed based on these targets, mostly incorporating linear lesions to transect putative isthmus sites. This review examines the role that the electrophysiologic substrate plays in the mechanism of scar-related VT and how this substrate is mapped, defined, and ablated.
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Affiliation(s)
- Haris M Haqqani
- Cardiovascular Division, University of Pennsylvania Health System, Philadelphia, Pennsylvania 19004, USA
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19
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Wilber DJ. Catheter ablation of ventricular tachycardia: Two decades of progress. Heart Rhythm 2008; 5:S59-63. [DOI: 10.1016/j.hrthm.2008.02.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Indexed: 11/28/2022]
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20
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Li YG, Wang QS, Israel CW, Grönefeld G, Lu SB, Ehrlich JR, Hohnloser SH. Quantitative analysis of the duration of slow conduction in the reentrant circuit of ventricular tachycardia after myocardial infarction. J Cardiovasc Electrophysiol 2008; 19:920-7. [PMID: 18399972 DOI: 10.1111/j.1540-8167.2008.01155.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Few data are available to define the circuits in ventricular tachycardia (VT) after myocardial infarction and the conduction time (CT) through the zone of slow conduction (SCZ). This study assessed the CT of the SCZ and identified different reentrant circuits. METHODS During VTs, concealed entrainment (CE) was attempted. The SCZ was identified by a difference between postpacing interval (PPI) and VT cycle length (VTcl) < or =30 ms. Since the CT in the normally conducting part of the VT circuit is constant during VT and CE, a CE site within the reentrant circuit with (S-QRS)/PPI > or = 50% was classified as an inner reentry in which the entire circuit was within the scar, and a CE site with (S-QRS)/PPI < 50% as a common reentry in which part of the circuit was within the scar and part out of the scar. RESULTS CE was achieved in 20 VTs (12 patients). Six VTs (30%) with a (S-QRS)/PPI > or =50% were classified as inner reentry and 14 VTs (70%) with a (S-QRS)/PPI <50% during CE mapping as common reentry. The EG-QRS interval (308 +/- 73 ms vs 109 +/- 59 ms, P < 0.0001) was significantly longer and the incidence of systolic potentials higher (4/6 vs 0/12, P < 0.001) in the inner reentry group. For the 14 VTs with a common reetry, the CT of the SCZ was 348 +/- 73 ms, while the CT in the normal area was 135 +/- 50 ms. CONCLUSION According to the proposed classification, 30% of VTs after myocardial infarction had an entire reentrant circuit within the scar. In VTs with a common reentrant circuit, the CT of the SCZ is approximately four times longer than the CT in the normal area, accounting for more than 70% of VTcl.
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Affiliation(s)
- Yi-Gang Li
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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21
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Hsia HH, Lin D, Sauer WH, Callans DJ, Marchlinski FE. Anatomic characterization of endocardial substrate for hemodynamically stable reentrant ventricular tachycardia: Identification of endocardial conducting channels. Heart Rhythm 2006; 3:503-12. [PMID: 16648052 DOI: 10.1016/j.hrthm.2006.01.015] [Citation(s) in RCA: 133] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2005] [Accepted: 01/12/2006] [Indexed: 11/21/2022]
Abstract
BACKGROUND Detailed anatomic characterization of endocardial substrate of ventricular tachycardia (VT) is limited. OBJECTIVES The purpose of this study was to determine the endocardial dimensions and local electrogram voltage characteristics of the reentrant circuit. VT-related conducting channels corresponding to zones of slow conduction may be identified. METHODS Electroanatomic mapping was performed in 26 patients with uniform VT. Entrainment mapping was performed in 53 VTs, of which 19 entrance, 37 isthmus, 48 exit, and 32 outer loop sites were identified. The color display of voltage maps was adjusted to identify conducting channels associated with VT circuits. A conducting channel was defined as a path of multiple orthodromically activated sites within the VT circuit that demonstrated an electrogram amplitude higher than that of surrounding areas as evidenced by voltage color differences. RESULTS Forty-seven (84%) of 56 entrance or isthmus sites were located within dense scar (<0.5 mV). Nearly all exits (92%) were located in abnormal endocardium (<1.5 mV), with more than half (54%) located in the border zone (0.5-1.5 mV). VT-related conducting channels was identified in 18 of 32 VTs with detailed mapping (average length 32 +/- 22 mm). The voltage threshold in the conducting channels ranges from 0.1 to 0.7 mV (mean 0.33 +/- 0.15 mV). CONCLUSION (1) Most entrance and isthmus sites of hemodynamically stable VT are located in dense scar, whereas exits are located in the border zone. (2) VT-related conducting channels may be identified by careful voltage threshold adjustment. These findings have important implications regarding strategies for substrate-based VT ablation.
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Affiliation(s)
- Henry H Hsia
- Cardiovascular Medicine Division, Stanford University, Stanford, California 94305-5233, USA.
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Affiliation(s)
- Mark E Josephson
- Cardiovascular Division, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
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Josephson ME. Electrophysiology of Ventricular Tachycardia:. A Historical Perspective. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2003; 26:2052-67. [PMID: 14516353 DOI: 10.1046/j.1460-9592.2003.00320.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Mark E Josephson
- Department of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215, USA.
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Yamaura M, Aizawa Y, Chinushi M, Washizuka T, Uchiyama H, Kitazawa H. Abrupt loss of constant fusion during entrainment of ventricular tachycardia at a critical paced cycle length. JAPANESE HEART JOURNAL 2001; 42:67-78. [PMID: 11324808 DOI: 10.1536/jhj.42.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Sustained monomorphic ventricular tachycardia (VT) can be frequently entrained and interrupted with rapid pacing and the mechanism of the pacing-induced interruption is considered to be due to orthodromic block. This study focused on the incidence of VT which was interrupted at a critical cycle length and was characterized by an abrupt loss of constant fusion in the surface electrocardiogram (ECG), and the role of orthodromic block as the cause of such characteristic change and interruption of VT was analyzed. Among 45 consecutive patients with symptomatic VT, rapid pacing was performed in 43 VTs of 39 patients. The exit was mapped as the earliest site of the activation during VT and an electrode catheter was located at the site. Rapid pacing was performed at progressively shorter cycle lengths in steps of 10 msec until VT was interrupted and the timing of the orthodromic and direct capture was compared at the exit. Abrupt loss of constant fusion was observed in 25 of 39 patients (64.1%): and the loss was invariably associated with interruption of VT. When the timings of the activation of the exit were compared, which were measured from the preceding (n-1) stimulus as the time reference, the direct capture was relatively delayed compared to that of the orthodromic capture. This finding suggests that orthodromic block is the cause of the direct capture as well as the pacing-induced interruption of VT. In the remaining 13 patients (35.9%), the surface ECG showed a gradual transition into the fully paced QRS morphology. The direct capture was confirmed in the non-fused beats, but it was not necessarily associated with interruption of VT. The interval from the stimulus to the entrained electrogram at the exit showed a gradual prolongation until the exit was finally captured directly from the pacing site. The confirmation of constant fusion followed by abrupt loss in ECG can be a reliable hallmark of orthodromic block as the cause of the interruption of VT during transient entrainment at a critical paced cycle length.
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Affiliation(s)
- M Yamaura
- First Department of Internal Medicine, Niigata University School of Medicine, Japan
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25
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Affiliation(s)
- S C Krishnan
- Harvard Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Boston 02215, USA
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26
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Ciaccio EJ, Scheinman MM, Wit AL. Relationship of specific electrogram characteristics during sinus rhythm and ventricular pacing determined by adaptive template matching to the location of functional reentrant circuits that cause ventricular tachycardia in the infarcted canine heart. J Cardiovasc Electrophysiol 2000; 11:446-57. [PMID: 10809499 DOI: 10.1111/j.1540-8167.2000.tb00341.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION It would be advantageous, for ablation therapy, to localize reentrant circuits causing ventricular tachycardia by quantifying electrograms obtained during sinus rhythm (SR) or ventricular pacing (VP). In this study, adaptive template matching (ATM) was used to localize reentrant circuits by measuring dynamic electrogram shape using SR and VP data. METHODS AND RESULTS Four days after coronary occlusion, reentrant ventricular tachycardia was induced in the epicardial border zone of canine hearts by programmed electrical stimulation. Activation maps of circuits were constructed using electrograms recorded from a multichannel array to ascertain block line location. Electrogram recordings obtained during SR/VP then were used for ATM analysis. A template electrogram was matched with electrograms on subsequent cycles by weighting amplitude, vertical shift, duration, and phase lag for optimal overlap. Sites of largest cycle-to-cycle variance in the optimal ATM weights were found to be adjacent to block lines bounding the central isthmus during reentry (mean 61.1% during SR; 63.9% during VP). The distance between the mean center of mass of the ten highest ATM variance peaks and the narrowest isthmus width was determined. For all VP data, the center of mass resided in the isthmus region occurring during reentry. CONCLUSION ATM high variance measured from SR/VP data localizes functional block lines forming during reentry. The center of mass of the high variance peaks localizes the narrowest width of the isthmus. Therefore, ATM methodology may guide ablation catheter position without resorting to reentry induction.
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Affiliation(s)
- E J Ciaccio
- Department of Pharmacology, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA.
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Ciaccio EJ, Scheinman MM, Fridman V, Schmitt H, Coromilas J, Wit AL. Dynamic changes in electrogram morphology at functional lines of block in reentrant circuits during ventricular tachycardia in the infarcted canine heart: a new method to localize reentrant circuits from electrogram features using adaptive template matching. J Cardiovasc Electrophysiol 1999; 10:194-213. [PMID: 10090223 DOI: 10.1111/j.1540-8167.1999.tb00661.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Fractionated, low-amplitude or long-duration electrograms have limited specificity for locating reentrant circuits causing ventricular tachycardia (VT). In this study a new method is described, adaptive template matching (ATM), based on the quantification of beat-to-beat changes in electrograms, for locating functional reentrant circuits that are relatively stable and cause monomorphic VT. METHODS AND RESULTS Monomorphic VTs were induced in 4-day-old infarcted canine hearts by programmed stimulation and reentrant circuits mapped in the epicardial border zone with a 196 or 312 bipolar electrode array. For ATM analysis, a template electrogram from each electrode, during an early cycle, was matched with all subsequent (input) electrograms at the same site by weighting the inputs of amplitude, duration, average baseline, and phase lag. The mean square error (MSE) between template and input was the criterion used to adapt the weights, and was also a measure of changes in electrogram shape that occur from cycle to cycle. The variance of each of the weighting parameters at all electrode sites were plotted on a representation of the electrode array, and the location of the functional lines of block bounding the central common pathway of reentrant circuits with figure-of-eight characteristics, overlaid on the ATM map. Peaks of high variance were found to be coincident with functional lines of block during all tachycardia episodes. CONCLUSION Specific beat-to-beat changes in electrograms occur at functional lines of block in reentrant circuits that can be quantified by ATM analysis, suggesting that these regions might be located without activation mapping. The method might be useful to guide ablation catheter position.
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Affiliation(s)
- E J Ciaccio
- Department of Pharmacology, Center for Biomedical Engineering, College of Physicians and Surgeons, Columbia University, New York, New York 10032, USA.
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Rothman SA, Hsia HH, Cossú SF, Chmielewski IL, Buxton AE, Miller JM. Radiofrequency catheter ablation of postinfarction ventricular tachycardia: long-term success and the significance of inducible nonclinical arrhythmias. Circulation 1997; 96:3499-508. [PMID: 9396447 DOI: 10.1161/01.cir.96.10.3499] [Citation(s) in RCA: 96] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Radiofrequency (RF) catheter ablation is effective therapy for monomorphic ventricular tachycardia (VT) in patients without structural heart disease. In patients with postinfarction VT; however, this procedure has been used predominantly as adjunctive therapy, targeting only the patient's clinically documented arrhythmia. By targeting all inducible, sustained VT morphologies, we sought to determine the utility of RF catheter ablation as a primary cure in patients who present with hemodynamically tolerated VT. METHODS AND RESULTS RF ablation was attempted in 35 patients with a previous myocardial infarction and recurrent, hemodynamically tolerated VT. A mean of 3.9+/-2.7 VTs were induced per patient (range, 1 to 10). The clinically documented arrhythmia was successfully ablated in 30 of 35 patients (86%), and on follow-up electrophysiological testing, 11 patients had no inducible VT and were discharged without other therapy. Nineteen patients had inducible "nonclinical" arrhythmias on follow-up testing, and the majority underwent cardiac defibrillator implantation. Freedom from recurrent arrhythmias, including sudden death, was 91% in patients without inducible VT and 53% in patients with persistently inducible "nonclinical" arrhythmias (P<.05; mean follow-up, 17+/-12 and 12+/-11 months, respectively). CONCLUSIONS In patients with well-tolerated VT, RF catheter ablation may be useful as a primary cure if no other ventricular arrhythmias are inducible on follow-up testing. Ablation of all hemodynamically tolerated arrhythmias should be attempted in patients with multiple inducible VT morphologies because of the high rate of recurrence of unablated VTs in these patients.
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Affiliation(s)
- S A Rothman
- Temple University School of Medicine, Philadelphia, Pa, USA.
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Stevenson WG, Friedman PL, Sager PT, Saxon LA, Kocovic D, Harada T, Wiener I, Khan H. Exploring postinfarction reentrant ventricular tachycardia with entrainment mapping. J Am Coll Cardiol 1997; 29:1180-9. [PMID: 9137211 DOI: 10.1016/s0735-1097(97)00065-x] [Citation(s) in RCA: 251] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Ventricular tachycardia late after myocardial infarction is usually due to reentry in the infarct region. These reentry circuits can be large, complex and difficult to define, impeding study in the electrophysiology laboratory and making catheter ablation difficult. Pacing through the electrodes of the mapping catheter provides a new approach to mapping. When pacing stimuli capture the effects on the tachycardia depend on the location of the pacing site relative to the reentry circuit. The effects observed allow identification of various portions of the reentry circuit, without the need for locating the entire circuit. Isthmuses where relatively small lesions produced by radiofrequency catheter ablation can interrupt reentry can often be identified. A classification that divides reentry circuits into one or more functional components helps to conceptualize the reentry circuit and predicts the likelihood that heating with radiofrequency current will terminate tachycardia. These methods are helping to define human reentry circuits.
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Affiliation(s)
- W G Stevenson
- Department of medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts 12115, USA.
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Gonska BD, Cao K, Raab J, Eigster G, Kreuzer H. Radiofrequency catheter ablation of right ventricular tachycardia late after repair of congenital heart defects. Circulation 1996; 94:1902-8. [PMID: 8873666 DOI: 10.1161/01.cir.94.8.1902] [Citation(s) in RCA: 99] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Ventricular arrhythmias after repair of congenital heart defects are a common finding and possibly contribute to sudden death in these patients. Optimal antiarrhythmic management has not yet been defined. METHODS AND RESULTS The study population consisted of 16 patients in whom ventricular arrhythmias occurred 11 to 42 years after complete surgical repair of congenital heart defects. Fifteen patients had a history of symptomatic sustained or nonsustained ventricular tachycardia, and 1 had frequent nonsustained ventricular tachycardia. The diagnostic mapping procedure to identify the origin of the arrhythmia included pace mapping during sinus rhythm, activation mapping, and pacing interventions during ventricular tachycardia. Catheter ablation was carried out by means of radiofrequency energy in the temperature-controlled mode. The follow-up period was 6 to 33 months (mean, 16 months). A right ventricular origin of the tachycardia in the surgically corrected area could be determined in all patients. Catheter ablation was carried out without complications. Immediate noninducibility was achieved in 15 of the 16 patients. One patient in whom the tachycardia was again inducible at repeat stimulation 1 week later was successfully treated with amiodarone. Eleven patients were taken off antiarrhythmic drugs. During follow-up, none of them had a recurrence of the tachycardia that had been ablated. CONCLUSIONS In patients with symptomatic or frequent ventricular tachycardia late after complete surgical repair of congenital heart defects, catheter ablation by means of radiofrequency energy is feasible and safe and thus might be taken into consideration for these patients. Short-term follow-up results are promising.
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Affiliation(s)
- B D Gonska
- Department of Cardiology, University Hospital Göttingen, Germany
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Kawamura Y, Pagé PL, Cardinal R, Savard P, Nadeau R. Mapping of septal ventricular tachycardia: clinical and experimental correlations. J Thorac Cardiovasc Surg 1996; 112:914-25. [PMID: 8873717 DOI: 10.1016/s0022-5223(96)70091-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In patients with chronic myocardial infarction, ventricular tachycardia originating in the interventricular septum may account for a significant number of arrhythmia recurrences after direct ablative operations. We used total computer-assisted cardiac mapping (epicardial sock, left and right ventricular endocardial balloon electrode arrays) to assess whether tachycardia originating in deep or right-sided layers of the interventricular septum is associated with a specific pattern of epicardial activation sequence. We performed these studies during operations in 18 patients and during experiments in 12 dogs in which a septal myocardial infarction was produced by ligating the anterior septal coronary artery. Intraseptal needle electrodes were plunged into the septum of all animal preparations to generate pace-mapping data and to obtain intraseptal recordings (six preparations) during reentrant ventricular tachycardia induced by programmed stimulation. In addition, pace-mapping data of infarcted canine heart preparations were compared with those of nine healthy heart preparations. In the clinical study, 31 ventricular tachycardias with a septal site of origin were analyzed. Twenty tachycardias displayed an epicardial breakthrough in the area of the interventricular groove, whereas 11 had an epicardial breakthrough in the right ventricular free wall. Biventricular endocardial mapping revealed that left septal endocardial activation preceded right septal activation in the former and that right septal activation occurred earlier in the latter. In the experimental study, 14 ventricular tachycardias (cycle length 146 +/- 34 msec) were induced by programmed stimulation in 11 infarcted heart preparations. Eight tachycardias displaying an epicardial breakthrough on the right ventricle were found to originate in the right ventricular septal subendocardial layers, whereas six tachycardias in which the epicardial breakthrough occurred on the anterior interventricular groove originated in the left ventricular septal subendocardial layers. The epicardial breakthrough preceded the left ventricular endocardial breakthrough in six tachycardias (85.7%) originating in intermediate or right ventricular septal layers, but in only one of five tachycardias originating in the left ventricular septal layers. In the pace-mapping study, the epicardial breakthrough shifted progressively from the right ventricular free wall toward the interventricular groove area in response to pacing from the right, intermediate, and left ventricular thirds of the basal septum. This relationship was similar for infarcted and noninfarcted hearts, although transseptal conduction time was prolonged in infarcted hearts (45 +/- 10 msec vs 33 +/- 7 msec, p < 0.01). Therefore the information integrated from the localization of the epicardial breakthrough and the relative timing between the epicardial and the left ventricular endocardial breakthroughs can be used to estimate the depth of the site of origin of septal ventricular tachycardias. This study confirms that a three-dimensional view of the substratum of ventricular tachycardia can be derived from simultaneous epicardial and left ventricular endocardial mapping and can provide a superior basis for therapeutic interventions.
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Affiliation(s)
- Y Kawamura
- Centre de Recherche de l'Hôpital du Sacré-Coeur de Montréal, Quebec,Canada
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Katritsis D, Heald S, Ahsan A, Anderson MH, Camm AJ, Ward DE, Rowland E. Catheter ablation for successful management of left posterior fascicular tachycardia: an approach guided by recording of fascicular potentials. HEART (BRITISH CARDIAC SOCIETY) 1996; 75:384-8. [PMID: 8705767 PMCID: PMC484316 DOI: 10.1136/hrt.75.4.384] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To assess whether catheter ablation of fascicular tachycardia can be facilitated by the recording of sharp deflections arising from the mid-septum---inferior apical septum of the left ventricle. PATIENTS AND METHODS Seven consecutive patients (mean age 29 (range 16-43) years) with ventricular tachycardia originating from the left posterior fascicle underwent electrophysiology study and detailed mapping of endocardial activation. Selection of ablation sites in the last five patients was based on the recording, during left posterior fascicular tachycardia and sinus rhythm, of a discrete potential preceding the earliest ventricular electrogram, which was thought to represent conduction through the posterior fascicle. RESULTS Patients were treated with low energy direct current or radiofrequency current ablation. The median fluoroscopy and procedure times were 23 (range 6-42) min and 110 (range 50-176) min, respectively. In a follow up period of 4 to 16 months, six patients were asymptomatic and one had minor symptoms. No patient had any change in intraventricular conduction. Similar potentials were also recorded from the left posterobasal septum in three of eight patients who underwent catheter ablation of left free wall accessory pathways. CONCLUSION Fascicular potentials can be reproducibly recorded in left posterior fascicular tachycardia and may serve as a reliable marker for successful ablation procedures. The relation of these potentials with the substrate of the tachycardia, however, remains obscure.
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Affiliation(s)
- D Katritsis
- Department of Cardiological Sciences, St George's Hospital Medical School, London
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Cohen TJ, Goldner BG, Jadonath R, Horwitz L, Quan W. Development of an interactive computer-guided method for radiofrequency catheter ablation of ventricular tachycardia. Pacing Clin Electrophysiol 1996; 19:472-6. [PMID: 8848395 DOI: 10.1111/j.1540-8159.1996.tb06518.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The purpose of this study was to develop a simple computer-guided approach to localizing ventricular tachycardias during ventricular mapping. Six patients with sustained monomorphic ventricular tachycardia were connected to a 32-lead computer body surface mapping system. Isoarea maps of induced ventricular tachycardia were recorded. Then a pacing probe was placed in either the right or left ventricle, and maps were generated from a variety of sites. Differences between ventricular tachycardia and pace map maxima X, Y coordinates were utilized to guide catheter manipulation and localization. In 6 of 6 patients (100%) this method appeared to provide a systematic approach to ventricular tachycardia localization. Computer-generated correlations as well as the X, Y coordinates of the QRS isoarea maxima were used to determine proximity to the ventricular tachycardia foci and direct catheter manipulation. In the next three patients this method was applied prospectively to help guide catheter manipulation during ventricular tachycardia (two right ventricular outflow tract tachycardias, and one left ventricular tachycardia). After a mean of 4.0 +/- 1.7 radiofrequency applications, ventricular tachycardia was no longer inducible, and at 7 +/- 0 months follow-up there have been no arrhythmia recurrences. We conclude that online computerized body surface mapping can assist in localizing ventricular tachycardia. Differences in maxima during pace maps and in-situ ventricular tachycardias can help with catheter manipulation as well as with more precise identification of focal tachycardias. This technique appears to hold the promise of a simple computer-guided method that may facilitate radiofrequency catheter ablation.
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Affiliation(s)
- T J Cohen
- Department of Medicine, North Shore University Hospital-Cornell University Medical College, Manhasset, New York, USA
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Wilber DJ, Kopp DE, Glascock DN, Kinder CA, Kall JG. Catheter ablation of the mitral isthmus for ventricular tachycardia associated with inferior infarction. Circulation 1995; 92:3481-9. [PMID: 8521570 DOI: 10.1161/01.cir.92.12.3481] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Intraoperative mapping studies suggest that an isthmus of myocardium between the mitral valve annulus and the border of inferior myocardial infarction may play a role in the genesis of ventricular tachycardia. We examined the frequency with which a slow conduction zone within the mitral isthmus was critical to the maintenance of ventricular tachycardia associated with remote inferior infarction in patients undergoing catheter ablation. METHODS AND RESULTS In 4 of 12 patients, a critical zone of slow conduction was identified within the mitral isthmus. In each of these patients, two characteristic and morphologically distinct tachycardias were induced: a left bundle (rS in V1, R in V6), left superior axis morphology and a right bundle (R in V1, QS in V6), right superior axis morphology (cycle length, 610 to 320 ms). In each patient, a zone of slow conduction, shared by both morphologies, was characterized by diastolic potentials with electrogram-QRS intervals of 85 to 161 ms (21% to 47% of tachycardia cycle length) and entrainment with concealed fusion during pacing associated with stimulus-QRS intervals of 81 to 400 ms (20% to 91% of tachycardia cycle length). In each patient, a single radiofrequency energy application at the shared site of slow conduction eliminated inducibility of both morphologies. During follow-up of 1 to 11 months, no patient had recurrent tachycardia. CONCLUSIONS The mitral isthmus contains a critical region of slow conduction in some patients with ventricular tachycardia after inferior myocardial infarction, providing a vulnerable and anatomically localized target for catheter ablation. Characteristic tachycardia morphologies may provide clinical markers for this underlying mechanism.
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Affiliation(s)
- D J Wilber
- Section of Cardiology, University of Chicago Hospitals, IL 60637, USA
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Aizawa Y, Chinushi M, Naitoh N, Kitazawa H, Washizuka T, Uchiyama H, Shibata A. Catheter ablation of ventricular tachycardia with radiofrequency currents, with special reference to the termination and minor morphologic change of reinduced ventricular tachycardia. Am J Cardiol 1995; 76:574-9. [PMID: 7677080 DOI: 10.1016/s0002-9149(99)80158-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
During catheter ablation with radiofrequency (RF) currents, the incidence of the termination of reentrant ventricular tachycardia (VT) during application of RF energy and the morphologic change of the reinduced VT were analyzed. Twenty-five patients (20 men and 5 women, aged 44 +/- 17 years) were studied. After induction of monomorphic sustained VT, the ablation site was determined by endocardial activation mapping, identification of isolated mid-diastolic potential, and pacing during tachycardia. Thirty-six monomorphic VTs were induced in 25 patients and terminated with programmed stimulation. The cycle length was 323 +/- 55 ms and all VTs were entrained with rapid ventricular pacing. The target site was the earliest site of activation of VT in 26 VTs in 16 patients, and the area of slow conduction in 10 VTs in 9 patients. VT was terminated soon after the application of RF currents in 33 VTs in 22 patients at 6.0 +/- 3.1 seconds, and VT was induced immediately after the cessation of RF currents in 11 patients. Of these, 4 patients with idiopathic left ventricular VT had an alternation in the QRS configuration before catheter ablation and required repeat ablation of the other VT morphology. In the other 7 patients, such morphology was not observed before ablation, but was observed in VT induced when the original VT was terminated. Repeated attempts of catheter ablation 2 to 9 times at the remapped site was, however, successful in 7 of 8 VTs.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- Y Aizawa
- First Department of Internal Medicine, Niigata University, Japan
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Miller JM, Tyson GS, Hargrove WC, Vassallo JA, Rosenthal ME, Josephson ME. Effect of subendocardial resection on sinus rhythm endocardial electrogram abnormalities. Circulation 1995; 91:2385-91. [PMID: 7729025 DOI: 10.1161/01.cir.91.9.2385] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Patients with sustained ventricular tachycardia after acute myocardial infarction frequently have characteristic abnormalities of left ventricular endocardial electrical activity, including fractionated (prolonged, multicomponent, low-amplitude), split (having discrete widely separated deflections), and late (extending after the end of the QRS complex) electrograms. The exact cause and source of these electrograms are not clear. METHODS AND RESULTS In this study, endocardial electrograms from 18 patients were recorded with a 20-electrode array from the same area immediately before and immediately after resection of subendocardial tissue at the time of surgery for ventricular tachycardia. Electrograms could be compared before and after resection from 298 of 360 (83%) of the electrodes. Before resection, split electrograms were present in 130 (44%) and late components in 81 (27%) of the recordings. Recordings made after resection showed fewer abnormalities, including complete absence of split electrograms as well as all previously recorded late components (P < .02). Mean electrogram amplitude increased from 0.5 +/- 0.8 to 1.0 +/- 1.6 mV (P < .0001) because of removal of the attenuating effect of endocardial scar; mean duration decreased from 112 +/- 38 to 65 +/- 27 ms (P < .0001) mainly because of loss of late and split components. Overall electrogram contour was very similar aside from these changes. CONCLUSIONS These data show that (1) some of the signal recorded on the endocardial surface is derived from deeper tissue layers and (2) split and late electrogram components appear to be generated by cells in the superficial endocardial layers, since they are eradicated by removal of this tissue. These findings correspond well with previous histological studies of resection specimens that show bundles of surviving muscle cells separated by layers of dense scar that act as an insulator.
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Affiliation(s)
- J M Miller
- Temple University Hospital, Philadelphia, Pa 19140, USA
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Gonska BD, Cao K, Schaumann A, Dorszewski A, von zur Mühlen F, Kreuzer H. Catheter ablation of ventricular tachycardia in 136 patients with coronary artery disease: results and long-term follow-up. J Am Coll Cardiol 1994; 24:1506-14. [PMID: 7930283 DOI: 10.1016/0735-1097(94)90147-3] [Citation(s) in RCA: 130] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES This study attempted to determine the feasibility and long-term efficacy of catheter ablation by means of either radiofrequency or direct current energy in a selected group of patients with coronary artery disease. BACKGROUND Catheter ablation of ventricular tachycardia has proved to be highly effective in patients with idiopathic and bundle branch reentrant ventricular tachycardia. In patients with coronary artery disease and recurrent sustained ventricular tachycardia resistant to medical antiarrhythmic management, the value of catheter ablation has not yet been established. METHODS One hundred thirty-six patients with coronary artery disease and one configuration of monomorphic sustained ventricular tachycardia underwent radiofrequency (72 patients) or direct current catheter ablation (64 patients). The mapping procedure to localize an adequate site for ablation included pace mapping during sinus rhythm, endocardial activation mapping, identification of isolated mid-diastolic potentials and pacing interventions during ventricular tachycardia. RESULTS Primary success was achieved in 102 (75%) of 136 patients (74% of 72 undergoing radiofrequency and 77% of 64 with direct current ablation). Complications were noted in 12% of patients. During a mean (+/- SD) follow-up period of 24 +/- 13 months (range 3 to 68), ventricular tachycardia recurred in 16% of patients. CONCLUSIONS Catheter ablation of ventricular tachycardia in coronary artery disease is feasible in patients with one configuration of monomorphic sustained ventricular tachycardia. There is no significant difference with respect to the type of energy applied. The follow-up data show that in a selected group of patients with coronary artery disease, catheter ablation offers a therapy alternative.
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Affiliation(s)
- B D Gonska
- Department of Cardiology, University Hospital, Göttingen, Germany
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Callans DJ, Schwartzman D, Gottlieb CD, Marchlinski FE. Insights into the electrophysiology of ventricular tachycardia gained by the catheter ablation experience: "learning while burning". J Cardiovasc Electrophysiol 1994; 5:877-94. [PMID: 7874333 DOI: 10.1111/j.1540-8167.1994.tb01126.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The success of catheter ablation has significantly improved the treatment of patients with cardiac arrhythmias and has established electrophysiology as an increasingly interventional subspecialty. Some members of the electrophysiology community have expressed concern that this success has been purchased at the cost of undermining what had been our primary concern: understanding the anatomic and physiologic basis of arrhythmia syndromes. In many laboratories, endpoints such as case load and primary success have eclipsed physiologic investigation. Despite these trends, however, catheter ablation is not inherently at odds with investigation and education. On the contrary, because the lesions delivered with current techniques are much more discrete than the effects of antiarrhythmic agents or surgical ablation, catheter ablation can be used as a research tool directed toward a more precise understanding of arrhythmia substrates. Conscious attempts at "learning while burning" have already provided important and unique information about arrhythmia pathogenesis.
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Affiliation(s)
- D J Callans
- Clinical Electrophysiology Laboratory, Philadelphia Heart Institute, Presbyterian Medical Center, PA 19104
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SippensGroenewegen A, Spekhorst H, van Hemel NM, Kingma JH, Hauer RN, de Bakker JM, Grimbergen CA, Janse MJ, Dunning AJ. Localization of the site of origin of postinfarction ventricular tachycardia by endocardial pace mapping. Body surface mapping compared with the 12-lead electrocardiogram. Circulation 1993; 88:2290-306. [PMID: 8222124 DOI: 10.1161/01.cir.88.5.2290] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND The purpose of this study was to assess the value of body surface mapping and the standard 12-lead ECG in localizing the site of origin of postinfarction ventricular tachycardia (VT) during endocardial pace mapping of the left ventricle. METHODS AND RESULTS Simultaneous recordings of 62-lead body surface QRS integral maps and scalar 12-lead ECG tracings were obtained in 16 patients with prior myocardial infarction during a total of 26 distinct VT configurations and during subsequent left ventricular catheter pace mapping at 9 to 24 different endocardial sites. Anatomic pacing site locations were computed by means of a biplane cineradiographic method and plotted on a polar projection of the left ventricle. The QRS integral map and the QRS complexes of the 12 standard leads of each VT morphology obtained in a particular patient were compared independently with the different paced QRS integral maps and paced QRS complexes of the 12-lead ECG generated in that same patient. The stimulus site locations of the best matching paced QRS integral map and paced QRS complexes of the 12-lead ECG were indicated on the polar projection and subsequently compared with the endocardial location of the corresponding site of VT origin identified during intraoperative (surgical ablation) or catheter activation sequence mapping (catheter ablation). The localization resolution of pace mapping was established separately for each electrocardiographic technique by computing the size of endocardial areas with similar morphological features of the QRS complex. Pace mapping advocated with body surface mapping or the 12-lead ECG enabled adequate reproduction of the VT QRS morphology in 24 of 26 VTs (92%) and 25 of 26 VTs (96%), respectively. Activation sequence mapping identified the site of origin in 12 of 26 previously observed VT configurations (46%). Ten and 11 VTs were localized by activation sequence mapping and pace mapping combined with body surface mapping or the 12-lead ECG, respectively. Pace mapping applied with body surface mapping identified the site of origin correctly (distance < or = 2 cm) in 8 of 10 compared VTs (80%); an adjacent site (distance between 2 and 4 cm) or a disparate site (distance > or = 4 cm) was identified in the remaining 2 of 10 VTs (20%). Pace mapping used with the 12-lead ECG localized the site of origin correctly in 2 of 11 VTs (18%); the site of origin was identified correctly next to an additional adjacent site in 5 of 11 VTs (55%); and an adjacent site or a disparate site was found in 1 of 11 VTs (9%) and 2 of 11 VTs (18%), respectively. The difference in localization accuracy of both electrocardiographic techniques was statistically significant (P = .02). The mean size of endocardial areas where a comparable QRS morphology was obtained during pace mapping was 6.0 +/- 4.5 cm2 with the application of body surface mapping and 15.1 +/- 12.0 cm2 with the use of the 12-lead ECG. CONCLUSIONS These results demonstrate that application of the 62-lead instead of the 12-lead ECG during endocardial pace mapping enhances the localization resolution of this mapping technique and enables more precise identification of the site of arrhythmogenesis in the majority of compared postinfarction VT episodes.
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Affiliation(s)
- A SippensGroenewegen
- Department of Clinical and Experimental Cardiology, Academic Medical Center, University of Amsterdam, The Netherlands
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Buxton AE, Kleiman RB, Kindwall KE, Josephson ME. Endocardial mapping during sinus rhythm in patients with coronary artery disease and nonsustained ventricular tachycardia. Am J Cardiol 1993; 71:695-8. [PMID: 8447267 DOI: 10.1016/0002-9149(93)91012-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Programmed stimulation in patients with nonsustained ventricular tachycardia (VT) and coronary artery disease (CAD) induces sustained VT in 30 to 50% of patients. The presence of inducible, sustained VT identifies patients at high risk for sudden death. This study sought to determine whether patients with nonsustained VT who have inducible, sustained VT would have differences of left ventricular endocardial activation and conduction compared with those of patients without inducible, sustained VT. Thirty-six patients with CAD referred for evaluation of nonsustained VT underwent programmed ventricular stimulation and catheter mapping of left ventricular endocardial activation. Using previously validated methods, electrograms were classified as normal, abnormal or fractionated based on measurement of local electrogram duration and amplitude. Programmed stimulation induced sustained, uniform VT in 16 of 36 patients (44%). Patients with inducible, sustained, uniform VT had significantly more sites with abnormal (48%) and fractionated (5.5%) electrograms than did those without inducible VT (35% abnormal and 0.4% fractionated; p = 0.05 and 0.01, respectively). Patients with inducible VT had a mean of 15% of mapped sites displaying late electrograms versus only 3% in those without inducible VT (p < 0.01). The duration of the longest local electrogram in patients with inducible, sustained, uniform VT was 128 ms compared with 100 ms in those without inducible VT (p < 0.001). Thus, patients with CAD presenting with nonsustained VT who have inducible, sustained, uniform VT have significantly greater degrees of local conduction slowing and delayed activation than do those without inducible, sustained, uniform VT. These observations support reentry as the mechanism of the induced arrhythmias in these patients.
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Affiliation(s)
- A E Buxton
- Clinical Electrophysiology Laboratory, Hospital of the University of Pennsylvania, Philadelphia
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Morady F, Harvey M, Kalbfleisch SJ, el-Atassi R, Calkins H, Langberg JJ. Radiofrequency catheter ablation of ventricular tachycardia in patients with coronary artery disease. Circulation 1993; 87:363-72. [PMID: 8425285 DOI: 10.1161/01.cir.87.2.363] [Citation(s) in RCA: 284] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Radiofrequency (RF) ablation of idiopathic ventricular tachycardia (VT) has been demonstrated to be highly efficacious, but the efficacy of RF ablation of VT in patients with coronary artery disease has been unknown. Therefore, the purpose of this study was to determine the feasibility of RF ablation of VT in patients with coronary artery disease. METHODS AND RESULTS Fifteen consecutive patients with coronary artery disease and a history of myocardial infarction underwent an attempt at RF ablation of 16 hemodynamically stable monomorphic VTs that had been documented clinically on a 12-lead ECG and that had not been successfully managed by pharmacological or device therapy. One VT was incessant, five occurred more than 25 times, and the remainder occurred two to 20 times. An additional four VTs that had not been documented clinically also were targeted for ablation. The mean age of the patients was 68 +/- 7 years (+/- SD), and their mean left ventricular ejection fraction was 0.27 +/- 0.08. The mean cycle length of the 20 VTs targeted for ablation was 438 +/- 82 msec. Ablation sites were selected based on endocardial activation mapping, pace mapping, identification of an isolated mid-diastolic potential, or concealed entrainment. Sixteen of the 20 VTs (80%) were successfully ablated in 11 of 15 patients (73%), using a mean of 4.2 +/- 3 applications of RF energy, and no recurrences of the ablated VTs occurred during 9.1 +/- 3.3 months of follow-up. The mean duration of the ablation procedures was 128 +/- 30 minutes. No complications occurred in any of the patients. CONCLUSIONS The results of this study demonstrate that RF ablation of hemodynamically stable VT is feasible as adjunctive therapy in selected patients with coronary artery disease.
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Affiliation(s)
- F Morady
- Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor 48109-0022
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Klein LS, Shih HT, Hackett FK, Zipes DP, Miles WM. Radiofrequency catheter ablation of ventricular tachycardia in patients without structural heart disease. Circulation 1992; 85:1666-74. [PMID: 1572025 DOI: 10.1161/01.cir.85.5.1666] [Citation(s) in RCA: 351] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Radiofrequency energy has been used safely and successfully to eliminate accessory pathways in patients with the Wolff-Parkinson-White syndrome and the substrate for atrioventricular nodal reentrant tachycardia. However, this form of ablation has had only limited success in eliminating ventricular tachycardia in patients with structural heart disease. In contrast, direct-current catheter ablation has been used successfully to eliminate ventricular tachycardia in patients with and without structural heart disease. The purpose of this study was to test whether radiofrequency energy can safely and effectively ablate ventricular tachycardia in patients without structural heart disease. METHODS AND RESULTS Sixteen patients (nine women and seven men; mean age, 38 years; range, 18-55 years) without structural heart disease who had ventricular tachycardia underwent radiofrequency catheter ablation to eliminate the ventricular tachycardia. Two patients presented with syncope, nine with presyncope, and five with palpitations only. Mean duration of symptoms was 6.7 years (range, 0.5-20 years). Radiofrequency catheter ablation successfully eliminated ventricular tachycardia in 15 of 16 patients (94%). Sites of ventricular tachycardia origin included the high right ventricular outflow tract (12 patients), the right ventricular septum near the tricuspid valve (three patients), and the left ventricular septum (one patient). The only ablation failure was in a patient whose ventricular tachycardia arose from a region near the His bundle. An accurate pace map, early local endocardial activation, and firm catheter contact with endocardium were associated with successful ablation. Radiofrequency ablation did not cause arrhythmias, produced minimal cardiac enzyme rise, and resulted in no detectable change in cardiac function by Doppler echocardiography. CONCLUSIONS Radiofrequency catheter ablation of ventricular tachycardia in patients without structural heart disease is effective and safe and may be considered as early therapy in these patients.
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Affiliation(s)
- L S Klein
- Krannert Institute of Cardiology, Department of Medicine, Indiana University School of Medicine, Indianapolis
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Anderson KP, Walker R, Ershler PR, Fuller M, Dustman T, Menlove R, Karwandee SV, Lux RL. Determination of local myocardial electrical activation for activation sequence mapping. A statistical approach. Circ Res 1991; 69:898-917. [PMID: 1934344 DOI: 10.1161/01.res.69.4.898] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Electrical activation sequence mapping requires accurate identification of local activation, but because extracellular recordings do not exclusively reflect local events, complex electrograms may be difficult to interpret. In such cases, the assignment of local activation is subject to error that could affect interpretation of the resulting activation maps. The purpose of this investigation was to develop an approach that would provide quantitative indexes of error in the determination of local activation. An electrode array with 64 closely spaced unipolar electrodes was used to record from the left ventricular surface during open heart surgery. Electrograms with multiple deflections were recorded from four patients with scarred myocardium; two other patients with normal myocardial function served as controls. Each of 784 deflections was scored on the basis of three features: evidence for propagation, the configuration of the bipolar signal, and the effect of changing from the chest to an average reference. Local activation was considered probable if evidence for all three features was present and improbable if none of the three features was present. Deflections that were ambiguous with respect to this standard were excluded. Of over 30 test variables analyzed, the three with the greatest power to discriminate signals due to local activation from those due to distant activity were 1) a linear combination of the extracellular potential plus the ratio of the second derivative and the extracellular potential, 2) the second derivative, and 3) the minimum (greatest negative) first derivative. For each of these variables, the threshold value providing the greatest performance was identified by the maximum quality of efficiency, an index of agreement. This statistical approach provides an objective basis for determining local activation and provides a quantitative assessment of error that could enhance interpretation of electrical activation sequence maps.
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Affiliation(s)
- K P Anderson
- Cardiology Division, University of Utah Medical Center, Salt Lake City 84132
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Littmann L, Svenson RH, Gallagher JJ, Selle JG, Zimmern SH, Fedor JM, Colavita PG. Functional role of the epicardium in postinfarction ventricular tachycardia. Observations derived from computerized epicardial activation mapping, entrainment, and epicardial laser photoablation. Circulation 1991; 83:1577-91. [PMID: 2022017 DOI: 10.1161/01.cir.83.5.1577] [Citation(s) in RCA: 122] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Conventionally, monomorphic sustained ventricular tachycardia in patients with remote myocardial infarction is believed to originate from the subendocardium. In a previous study, we demonstrated that electrical activation patterns during ventricular tachycardia occasionally suggest a subepicardial rather than subendocardial reentry. METHODS AND RESULTS This study prospectively evaluated the functional role of the epicardium in postinfarction ventricular tachycardia with complex intraoperative techniques including computerized electrical activation mapping, entrainment, observation of changes in activation pattern during successful epicardial laser photoblation, and histological study. Five of 10 consecutive patients undergoing intraoperative computerized activation mapping had 10 ventricular tachycardia morphologies displaying epicardial diastolic activation These 10 "epicardial" ventricular tachycardias revealed the following global activation patterns: monoregional spread (two), figure-eight activation (five), and circular macroreentry (three). Entrainment of ventricular tachycardia using epicardial stimulation was successfully performed from an area of slow diastolic conduction in four tachycardia morphologies. During entrainment, global activation remained undisturbed with recordings showing a long stimulus to QRS interval, unchanged QRS morphology, and pacing capture of all components of the reentry circuit. Neodymium:yttrium aluminum garnet laser photocoagulation was delivered during ventricular tachycardia to epicardial sites of presumed reentry. Epicardial photoablation terminated five of five figure-eight tachycardias, two of three circular macroreentry tachycardias but not the monoregional tachycardias. Electrophysiological recordings during epicardial laser photocoagulation demonstrated progressive prolongation of ventricular tachycardia cycle length and apparent interruption of the presumed reentrant circuit. Histological evaluation of the reentrant region (three patients) showed a rim of surviving myocardium under the epicardial surface. CONCLUSIONS This study suggests that 1) chronic postinfarction ventricular tachycardia may result from subepicardial macroreentry, 2) slow conduction within the reentry circuit can be localized by computerized mapping and epicardial entrainment, and 3) ventricular tachycardia interruption by laser photocoagulation results from conduction delay and block within critical elements of the reentrant pathway. Viable subepicardial muscle fibers may constitute the underlying pathology.
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Kadish AH, Schmaltz S, Morady F. A comparison of QRS complexes resulting from unipolar and bipolar pacing: implications for pace-mapping. Pacing Clin Electrophysiol 1991; 14:823-32. [PMID: 1712960 DOI: 10.1111/j.1540-8159.1991.tb04113.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
UNLABELLED To examine differences in QRS configuration produced by bipolar versus unipolar pacing, 12-lead electrocardiograms recorded during bipolar (distal cathode) pacing with 5- and 10-mm interelectrode distances were compared to electrocardiograms recorded during unipolar cathodal pacing from the distal catheter pole. Pacing was performed at a cycle length of 500 msec using each of the two bipolar configurations at current strengths equal to late diastolic threshold, twice threshold and 10 mA. The pacing site was at the right ventricular apex in 15 patients and at various left ventricular locations in 14 patients. The electrocardiograms recorded during bipolar and unipolar pacing were compared by two independent observers for minor QRS configuration changes, major configuration changes and amplitude changes. Minor configuration differences between unipolar and bipolar pacing occurred occasionally when the interelectrode distance during bipolar pacing was 5 mm (mean +/- S.D. 0.5 +/- 1.2 leads per electrocardiogram). However, when the interelectrode distance was 10 mm, minor configuration differences were seen more commonly (1.3 +/- 2.0 leads per electrocardiogram; P less than 0.05 vs 5-mm distance). Major configuration differences were uncommon with either configuration at all current strengths. Pacing at 10 mA produced a larger number of configuration differences than pacing at either threshold or twice threshold (P less than 0.05). Amplitude differences were seen in a mean of 1.9 +/- 2.1 leads per electrocardiogram with the 5-mm interelectrode distance and a mean of 2.9 +/- 2.1 leads using the 10-mm interelectrode distance (P less than 0.05). IN CONCLUSION (1) bipolar ventricular pacing can result in QRS complexes that are different from those obtained with unipolar pacing at the same catheter location, presumably due to an anodal contribution during bipolar pacing; (2) increasing the interelectrode distance and stimulus intensity increases these differences; and (3) because the proximal electrode's contribution to depolarization can alter the QRS configuration during pacing in a variable way, the use of bipolar pace-mapping to localize sites of origin of ventricular tachycardia may result in less spatial resolution than unipolar pace-mapping.
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Affiliation(s)
- A H Kadish
- Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor
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Desai JM, Nyo H, Vera Z, Seibert JA, Vogelsang PJ. Orthogonal electrode catheter array for mapping of endocardial focal site of ventricular activation. Pacing Clin Electrophysiol 1991; 14:557-76. [PMID: 1710061 DOI: 10.1111/j.1540-8159.1991.tb02828.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Precise location of the endocardial site of origin of ventricular tachycardia may facilitate surgical and catheter ablation of this arrhythmia. The endocardial catheter mapping technique can locate the site of ventricular tachycardia within 4-8 cm2 of the earliest site recorded by the catheter. This report describes an orthogonal electrode catheter array (OECA) for mapping and radiofrequency ablation (RFA) of endocardial focal site of origin of a plunge electrode paced model of ventricular activation in dogs. The OECA is an 8 F five pole catheter with four peripheral electrodes and one central electrode (total surface area 0.8 cm2. In eight mongrel dogs, mapping was performed by arbitrarily dividing the left ventricle (LV) into four segments. Each segment was mapped with OECA to find the earliest segment. Bipolar and unipolar electrograms were obtained. The plunge electrode (not visible on fluoroscopy) site was identified by the earliest wave front arrival times of -30 msec or earlier at two or more electrodes (unipolar electrograms) with reference to the earliest recorded surface ECG (I, AVF, and V1). Validation of the proximity of the five electrodes of the OECA to the plunge electrode was performed by digital radiography and RFA. Pathological examination was performed to document the proximity of the OECA to the plunge electrode and also for the width, depth, and microscopic changes of the ablation. To find the segment with the earliest LV activation a total of 10 +/- 3 (mean +/- SD) positions were mapped. Mean arrival times at the two earlier electrodes were -39 +/- 4 msec and -35 +/- 3 msec. Digital radiography showed the plunge electrode to be within the area covered by all five electrodes in all eight dogs. The plunge electrode was within 1 cm2 area of the region of RFA in all eight dogs. The width and depth of ablation were 5 +/- 3.5 and 7 +/- 3.5 mm, respectively. Microscopic changes revealed coagulative necrosis, hemorrhage, and inflammatory changes in all RFAs. In conclusion, the OECA can map the endocardial focal site of origin of paced ventricular activation within 1 cm2 area in a canine model. RFA from the OECA can cause discrete ablations representing all five electrodes or cross-shaped ablation connecting central electrode to all four peripheral electrodes. This catheter holds promise for extending surgical and clinical catheter ablation procedures.
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Affiliation(s)
- J M Desai
- Division of Cardiovascular Medicine, University of California, School of Medicine, Davis
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Morady F, Kadish AH, DiCarlo L, Kou WH, Winston S, deBuitlier M, Calkins H, Rosenheck S, Sousa J. Long-term results of catheter ablation of idiopathic right ventricular tachycardia. Circulation 1990; 82:2093-9. [PMID: 2242533 DOI: 10.1161/01.cir.82.6.2093] [Citation(s) in RCA: 187] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Ten consecutive patients with recurrent episodes of symptomatic, idiopathic, sustained monomorphic ventricular tachycardia (VT) originating in the right ventricle underwent an attempt at catheter ablation of the ventricular tachycardia. There were seven women and three men, with a mean age of 39 +/- 14 years (+/- SD). None of the patients had any evidence of structural heart disease. The VT had a left bundle branch block configuration and an inferior axis in each patient, and the mean cycle length was 313 +/- 75 msec. Based on the methods of induction of the VT and the response of the VT to verapamil, the VT mechanism was presumed to be reentry in six patients, triggered activity in three patients, and catecholamine-sensitive automaticity in one patient. Sites for ablation were guided by pace mapping, and an appropriate target site was identified in the right ventricular outflow tract in each patient. From one to three shocks of 100-360 J (mean total, 336 +/- 195 J) were delivered from a defibrillator between the tip of the ablation catheter (cathode) and a patch electrode on the anterior chest (anode). An electrophysiology test 7-9 days after ablation demonstrated that VT was still inducible in only one patient, who was treated with amiodarone. One other patient had a recurrence of VT 3 weeks after ablation and was treated with verapamil. Eight of 10 patients were not treated with antiarrhythmic medications and have had no episodes of symptomatic VT during 15-68 months of follow-up (mean follow-up, 33 +/- 18 months). There were no acute or long-term complications.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- F Morady
- Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor 48109-0022
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Affiliation(s)
- P J Podrid
- Boston University School of Medicine, Massachusetts
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