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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: 208] [Impact Index Per Article: 52.0] [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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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: 165] [Impact Index Per Article: 33.0] [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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Scanavacca MI, Sternick EB, Pisani C, Lara S, Hardy C, d’Ávila A, Correa FS, Darrieux F, Hachul D, Marcial MB, Sosa EA. Accessory Atrioventricular Pathways Refractory to Catheter Ablation. Circ Arrhythm Electrophysiol 2015; 8:128-36. [DOI: 10.1161/circep.114.002373] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Epicardial mapping and ablation of accessory pathways through a subxiphoid approach can be an alternative when endocardial or epicardial transvenous mapping has failed.
Methods and Results—
We reviewed acute and long-term follow-up of 21 patients (14 males) referred for percutaneous epicardial accessory pathway ablation. There was a median of 2 previous failed procedures. All patients were highly symptomatic, 8 had atrial fibrillation (3 with cardiac arrest) and 13 had frequent symptomatic episodes of atrioventricular reentrant tachycardia. Six patients (28.5%) had a successful epicardial ablation. Five patients (23.8%) underwent a successful repeated endocardial mapping, and ablation after epicardial mapping yielded no early activation site. Epicardial mapping was helpful in guiding endocardial ablation in 2 patients (9.5%), showing that the earliest activation was simultaneous at the epicardium and endocardium. Four patients (19%) underwent successful open-chest surgery after failing epicardial/endocardial ablation. Two patients (9.5%) remained controlled under antiarrhythmic drugs after unsuccessful endocardial/epicardial ablation. Two patients had a coronary sinus diverticulum and one a right atrium to right ventricle diverticulum. Three patients acquired postablation coronary sinus stenosis. There was no major complication related to pericardial access.
Conclusions—
Percutaneous epicardial approach is an alternative when conventional endocardial or transvenous epicardial ablation fails in the elimination of the accessory pathway. A new attempt by endocardial approach was successful in a significant number of patients. Open-chest surgery may be required in symptomatic cases refractory to endocardial–epicardial approach.
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Affiliation(s)
- Maurício Ibrahim Scanavacca
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
| | - Eduardo Back Sternick
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
| | - Cristiano Pisani
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
| | - Sissy Lara
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
| | - Carina Hardy
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
| | - André d’Ávila
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
| | - Frederico Soares Correa
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
| | - Francisco Darrieux
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
| | - Denise Hachul
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
| | - Miguel Barbero Marcial
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
| | - Eduardo A. Sosa
- From the Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil (M.I.S., C.P., S.L., C.H., F.D., D.H., M.B.M., E.A.S.); Biocor Instituto, Nova Lima, Brazil (E.B.S., F.S.C.); Instituto de Pós-Graduação, Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, Brazil (E.B.S.); and Hospital Cardiológico, Florianópolis, Santa Catarina, Brazil (A.d’.A.)
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Single-site access robot-assisted epicardial mapping with a snake robot: preparation and first clinical experience. J Robot Surg 2012; 7:103-11. [PMID: 23704857 PMCID: PMC3657081 DOI: 10.1007/s11701-012-0343-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Accepted: 02/17/2012] [Indexed: 11/27/2022]
Abstract
CardioARM, a highly flexible “snakelike” medical robotic system (Medrobotics, Raynham, MA), has been developed to allow physicians to view, access, and perform complex procedures intrapericardially on the beating heart through a single-access port. Transthoracic epicardial catheter mapping and ablation has emerged as a strategy to treat arrhythmias, particularly ventricular arrhythmias, originating from the epicardial surface. The aim of our investigation was to determine whether the CardioARM could be used to diagnose and treat ventricular tachycardia (VT) of epicardial origin. Animal and clinical studies of the CardioARM flexible robot were performed in hybrid surgical–electrophysiology settings. In a porcine model study, single-port pericardial access, navigation, mapping, and ablation were performed in nine animals. The device was then used in a small, single-center feasibility clinical study. Three patients, all with drug-refractory VT and multiple failed endocardial ablation attempts, underwent epicardial mapping with the flexible robot. In all nine animals, navigation, mapping, and ablation were successful without hemodynamic compromise. In the human study, all three patients demonstrated a favorable safety profile, with no major adverse events through a 30-day follow-up. Two cases achieved technical success, in which an electroanatomic map of the epicardial ventricle surface was created; in the third case, blood obscured visualization. These results, although based on a limited number of experimental animals and patients, show promise and suggest that further clinical investigation on the use of the flexible robot in patients requiring epicardial mapping of VT is warranted.
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YAMADA TAKUMI, DOPPALAPUDI HARISH, McELDERRY HTHOMAS, KAY GNEAL. Epicardial Macroreentrant Ventricular Tachycardia Associated with a Left Ventricular Aneurysm. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2010; 35:e13-6. [DOI: 10.1111/j.1540-8159.2010.02863.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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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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Kawamura M, Kobayashi Y, Ito H, Onuki T, Miyoshi F, Matsuyama TA, Watanabe N, Ryu S, Asano T, Miyata A, Tanno K, Katagiri T. Epicardial Ablation With Cooled Tip Catheter Close to the Coronary Arteries is Effective and Safe in the Porcine Heart if the Ventricular Potential is Being Monitored in the Epicardium and Endocardium. Circ J 2006; 70:926-32. [PMID: 16799250 DOI: 10.1253/circj.70.926] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Transthoracic epicardial ablation can be an alternative to conventional treatment for critical pathways of ventricular tachycardia located in the epicardium. However, the usefulness and safety of epicardial ablation close to the coronary arteries (CA) is not clear. The purpose of the present experimental animal study was to analyze the efficacy and safety of epicardial radiofrequency (RF) ablation close to the CA. METHODS AND RESULTS Of the left ventricle-epicardium ablated sites, 35 lesions (20 with cooling and 15 without cooling) were close to the CA (left anterior descending artery < or = 15 mm) and 33 lesions (23 with cooling and 10 without cooling) were further from the CA. For sites close to the CA, epicardial ablation was effective in 77% (15/20) with cooling and in 40% (6/15) without cooling. There was a significant difference of effective ablation between with cooling and without cooling (p < 0.05). For cooling, epicardial lesion size could be predicted by the change of endocardial ventricular potential using a basket catheter. No damage to major epicardial arteries was detected when the catheter tip was positioned 5 mm away from the CA. CONCLUSIONS Close to the CA, RF ablation with cooling is more effective than RF without cooling and is safe if the ablation sites are located 5 mm away from the major CA.
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Affiliation(s)
- Mitsuharu Kawamura
- Third Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan.
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Valderrábano M, Cesario DA, Ji S, Shannon K, Wiener I, Swerdlow CD, Oral H, Morady F, Shivkumar K. Percutaneous epicardial mapping during ablation of difficult accessory pathways as an alternative to cardiac surgery. Heart Rhythm 2005; 1:311-6. [PMID: 15851176 DOI: 10.1016/j.hrthm.2004.03.073] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2004] [Accepted: 03/23/2004] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The aim of this study was to define the role of percutaneous epicardial mapping for the ablation of previous failed ablation of accessory pathways. BACKGROUND Cardiac surgery is the only curative option for failed radiofrequency (RF) catheter ablation of accessory pathway (AP)-mediated tachycardias. We investigated a combined percutaneous epicardial and endocardial approach for failed AP ablations. METHODS We present our experience in a series of 6 cases (7 APs) with previous failed attempts at catheter ablation (median 2 attempts, range 1-4) and persistent symptomatic tachycardias. Endocardial mapping of the APs was performed using conventional techniques. Sites with local electrograms suggestive of AP location were selected. When initial endocardial mapping was not successful for ablation of the pathway, percutaneous transthoracic pericardial puncture was performed via a subxiphoid approach, and an ablation catheter was positioned at the epicardial aspect of the putative AP location for epicardial-endocardial electrogram comparison. Endocardial RF energy was applied to locations considered appropriate. Epicardial RF applications were delivered when endocardial applications failed. Coronary arteriography was performed to assess the proximity of coronary arteries to the ablation catheter. RESULTS APs were located in the right free wall (4 patients, 5 APs) and the right (1 patient) and left (1 patient) posteroseptal regions. In all patients, epicardial mapping assisted in identifying successful ablation sites. In 3 patients, the earliest atrial activation during orthodromic tachycardia was present in an epicardial electrogram. Successful AP ablation was achieved with an epicardial RF application in 2 patients, either alone or with simultaneous endocardial-epicardial delivery. In the remaining 4 patients, APs were successfully ablated endocardially after epicardial mapping. These patients represent 18% of all cases referred to our institution for ablation of previously failed accessory pathways (6/32 patients). CONCLUSIONS A combined endocardial-epicardial approach to mapping and RF ablation can facilitate successful endocardial ablation in most cases. In selected cases, APs can be ablated by epicardial delivery of RF. Epicardial mapping is an effective alternative to cardiac surgery for patients in whom prior attempts at AP ablation have failed.
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Affiliation(s)
- Miguel Valderrábano
- UCLA Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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Silva RMFL, Mont L, Nava S, Rojel U, Matas M, Brugada J. Radiofrequency Catheter Ablation for Arrhythmic Storm in Patients with An Implantable Cardioverter Defibrillator. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2004; 27:971-5. [PMID: 15271018 DOI: 10.1111/j.1540-8159.2004.00567.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The aim of the study was to analyze the usefulness of RFA in controlling arrhythmic storm due to hemodynamically stable VT in a cohort of patients with an ICD and to evaluate the incidence of arrhythmic storm among patients with an ICD. A group of 13 (3%) of 403 consecutive ICD recipients were submitted to RFA of VT during an arrhythmic storm. Two additional patients were referred from other institutions. Standard criteria were used for VT endocardial ablation. A transcatheter epicardial approach was required in three patients. A total of 18 procedures were performed in 15 patients. A mean of 13.2 +/- 9.7 pulses of RF were delivered. Clinical tachycardia was successfully ablated in 12 (80%) patients. One patient died in incessant VT, 1 patient underwent heart transplant, and 1 was treated with direct current ablation. During a mean follow-up of 12 +/- 17 months, only two patients suffered a single episode of VT. Arrhythmic storm requiring VT ablation was uncommon among patients with an ICD and occurred late after ICD implantation. The arrhythmic episode was successfully controlled in the majority of patients with endocardial or epicardial RFA.
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Affiliation(s)
- Rose M F L Silva
- Arrhythmia Section, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Catalonia, Spain
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Schweikert RA, Saliba WI, Tomassoni G, Marrouche NF, Cole CR, Dresing TJ, Tchou PJ, Bash D, Beheiry S, Lam C, Kanagaratnam L, Natale A. Percutaneous pericardial instrumentation for endo-epicardial mapping of previously failed ablations. Circulation 2003; 108:1329-35. [PMID: 12952851 DOI: 10.1161/01.cir.0000087407.53326.31] [Citation(s) in RCA: 178] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The epicardial location of an arrhythmia could be responsible for unsuccessful endocardial catheter ablation. METHODS AND RESULTS In 48 patients referred after prior unsuccessful endocardial ablation, we considered percutaneous, subxiphoid instrumentation of the pericardial space for mapping and ablation. Thirty patients had ventricular tachycardia (VT), 6 patients had a right- and 4 had a left-sided accessory pathway (AP), 4 patients had inappropriate sinus tachycardia, and 4 patients had atrial arrhythmias. Of the 30 VTs, 24 (6 with ischemic cardiomyopathy, 3 with idiopathic cardiomyopathy, and 15 with normal hearts) appeared to originate from the epicardium. Seventeen (71%) of these 24 VTs were successfully ablated with epicardial lesions. The other 7 VTs had early epicardial sites that were inaccessible, predominantly because of interference from the left atrial appendage. Six of these were successfully ablated from the left coronary cusp. In 5 of the 10 patients with an AP, the earliest activation was recorded epicardially. Three of these were right atrial appendage-to-right ventricle APs, and epicardial ablation was successful. No significant complications were observed. CONCLUSIONS Failure of endocardial ablation could reflect the presence of an epicardial arrhythmia substrate. Epicardial instrumentation and ablation appeared feasible and safe and provided an alternative strategy for the treatment of patients with a variety of arrhythmias. This was particularly true for VT, including patients without structural heart disease.
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Affiliation(s)
- Robert A Schweikert
- Department of Cardiovascular Medicine/F15, Section of Electrophysiology and Pacing, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, Ohio 44195, USA.
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Miller JM, Altemose GT, Jayachandran JV. Catheter ablation of ventricular tachycardia in patients with structural heart disease. Cardiol Rev 2001; 9:302-11. [PMID: 11696257 DOI: 10.1097/00045415-200111000-00004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/23/2001] [Indexed: 11/25/2022]
Abstract
Radiofrequency catheter ablation has revolutionized therapy of most forms of supraventricular tachycardia and ventricular tachycardia in the absence of structural heart disease by providing arrhythmia cure in almost 90% of patients. However, this treatment has not been nearly as successful in patients with ventricular tachycardia in the setting of structural heart disease, because of a number of factors. Some of these limitations are technical (imprecise mapping tools, multiple regions requiring ablation) although others are patient-related (hemodynamic instability during arrhythmia, progression of disease process). Because of these and other factors, the majority of patients in this group are treated with implantable defibrillators. Ablative therapy has an adjunctive role in their management, mainly to decrease the frequency of device therapy (particularly shocks). This review will discuss mapping and ablation techniques as well as patient selection and evaluation for this procedure.
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Affiliation(s)
- J M Miller
- Cardiology Division, Department of Medicine and Krannert Institute of Cardiology, Indiana University School of Medicine, 1800 North Capitol Avenue, Indianapolis, IN 46202, USA
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Sosa E, Scanavacca M, d'Avila A. Transthoracic epicardial catheter ablation to treat recurrent ventricular tachycardia. Curr Cardiol Rep 2001; 3:451-8. [PMID: 11602075 DOI: 10.1007/s11886-001-0066-1] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Nonsurgical epicardial transthoracic catheter ablation is a minimally invasive procedure that has proven to be efficacious for the treatment of ventricular tachycardia (VT). The usefulness of this technique depends on the prevalence of epicardial circuits, which seem more frequent in Chagasic than post-myocardial infarction VT. This approach is limited by concern regarding the potential adverse effects of radiofrequency (RF) ablation on the coronary arteries. However, the effects of RF ablation delivered in the vicinity of a major coronary artery are limited to the medial artery. Severe intimal hyperplasia and intravascular thrombosis may occur only when RF ablation is delivered above the artery. Moreover, susceptibility to damage is inversely proportional to the vessel size. Coronary artery injury is an uncommon (< 1%) complication that could be prevented by a coronary angiogram prior to ablation. Hemopericardium, another predictable complication occurring in 10% of patients, can be easily controlled in the electrophysiology laboratory.
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Affiliation(s)
- E Sosa
- Unidade Clinica de Arritmia, Instituto do Coração, Universidade de São Paulo, Av. Enéas de Carvalho Aguiar, 44-CEP = 05403-000, São Paulo, Brazil.
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Kanagaratnam L, Tomassoni G, Schweikert R, Pavia S, Bash D, Beheiry S, Neibauer M, Saliba W, Chung M, Tchou P, Natale A. Ventricular tachycardias arising from the aortic sinus of valsalva: an under-recognized variant of left outflow tract ventricular tachycardia. J Am Coll Cardiol 2001; 37:1408-14. [PMID: 11300454 DOI: 10.1016/s0735-1097(01)01127-5] [Citation(s) in RCA: 199] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To describe a normal heart left bundle branch block, inferior axis ventricular tachycardia (VT), that could not be ablated from the right or left ventricular outflow tracts. BACKGROUND Whether these VTs are epicardial and can be identified by a specific electrocardiographic pattern is unclear. METHODS Twelve patients with normal heart left bundle branch block, inferior axis VT and previously failed ablation were included in this study. Together with mapping in the right and left ventricular outflow tracts, we obtained percutaneous epicardial mapping in the first five patients and performed aortic sinus of Valsalva mapping in all patients. RESULTS No adequate pace mapping was observed in the right and left ventricular outflow tracts. Earliest ventricular activation was noted in the epicardium and the aortic cusps. All patients were successfully ablated from the aortic sinuses of Valsalva (95% CI 0% to 18%). The electrocardiographic pattern associated with this VT was left bundle branch block, inferior axis and early precordial transition with Rs or R in V2 or V3. Ventricular tachycardia from the left sinus had rS pattern in lead I, and VT from the noncoronary sinus had a notched R wave in lead I. None of the patients had complications and all remained arrhythmia-free at a mean follow-up of 8 +/- 2.6 months. CONCLUSIONS Normal heart VT with left bundle branch block, inferior axis and early precordial transition can be ablated in the majority of patients from either the left or the noncoronary aortic sinus of Valsalva.
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Affiliation(s)
- L Kanagaratnam
- Department of Cardiology, Cleveland Clinic Foundation, Ohio 44195, USA
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Lam C, Schweikert R, Kanagaratnam L, Natale A. Radiofrequency ablation of a right atrial appendage-ventricular accessory pathway by transcutaneous epicardial instrumentation. J Cardiovasc Electrophysiol 2000; 11:1170-3. [PMID: 11059983 DOI: 10.1111/j.1540-8167.2000.tb01765.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Epicardial location of accessory AV pathways may be responsible for the failure of conventional endocardial radiofrequency catheter ablation. Transcutaneous epicardial instrumentation provides access to the normal pericardium with no need for invasive thoracotomy or thoracoscopy. We report the case of successful epicardial mapping and ablation of a right atrial appendage-ventricular connection using a percutaneous epicardial approach, after repeated failure of endocardial ablation attempts.
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Affiliation(s)
- C Lam
- Department of Cardiology, The Cleveland Clinic Foundation, Ohio 44195, USA
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Osswald S. Epicardial mapping and radiofrequency catheter ablation of ischemic ventricular tachycardia using the CARTO system. J Cardiovasc Electrophysiol 2000; 11:495. [PMID: 10809509 DOI: 10.1111/j.1540-8167.2000.tb00352.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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