1
|
Tavazzi G, Dammassa V, Colombo CNJ, Arbustini E, Castelein T, Balik M, Vandenbriele C. Mechanical circulatory support in ventricular arrhythmias. Front Cardiovasc Med 2022; 9:987008. [PMID: 36304552 PMCID: PMC9593033 DOI: 10.3389/fcvm.2022.987008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/15/2022] [Indexed: 11/27/2022] Open
Abstract
In atrial and ventricular tachyarrhythmias, reduced time for ventricular filling and loss of atrial contribution lead to a significant reduction in cardiac output, resulting in cardiogenic shock. This may also occur during catheter ablation in 11% of overall procedures and is associated with increased mortality. Managing cardiogenic shock and (supra) ventricular arrhythmias is particularly challenging. Inotropic support may exacerbate tachyarrhythmias or accelerate heart rate; antiarrhythmic drugs often come with negative inotropic effects, and electrical reconversions may risk worsening circulatory failure or even cardiac arrest. The drop in native cardiac output during an arrhythmic storm can be partly covered by the insertion of percutaneous mechanical circulatory support (MCS) devices guaranteeing end-organ perfusion. This provides physicians a time window of stability to investigate the underlying cause of arrhythmia and allow proper therapeutic interventions (e.g., percutaneous coronary intervention and catheter ablation). Temporary MCS can be used in the case of overt hemodynamic decompensation or as a “preemptive strategy” to avoid circulatory instability during interventional cardiology procedures in high-risk patients. Despite the increasing use of MCS in cardiogenic shock and during catheter ablation procedures, the recommendation level is still low, considering the lack of large observational studies and randomized clinical trials. Therefore, the evidence on the timing and the kinds of MCS devices has also scarcely been investigated. In the current review, we discuss the available evidence in the literature and gaps in knowledge on the use of MCS devices in the setting of ventricular arrhythmias and arrhythmic storms, including a specific focus on pathophysiology and related therapies.
Collapse
Affiliation(s)
- Guido Tavazzi
- Department of Clinical, Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy,Department of Anaesthesia, Intensive Care and Pain Therapy, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy,*Correspondence: Guido Tavazzi
| | - Valentino Dammassa
- PhD in Experimental Medicine, University of Pavia, Pavia, Italy,Adult Intensive Care Unit, Royal Brompton Hospital, London, United Kingdom
| | | | - Eloisa Arbustini
- Centre for Inherited Cardiovascular Diseases, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Thomas Castelein
- Cardiovascular Center, Onze-Lieve-Vrouwziekenhuis Hospital, Aalst, Belgium
| | - Martin Balik
- Department of Anesthesiology and Intensive Care, First Medical Faculty and General University Hospital, Charles University in Prague, Prague, Czechia
| | - Christophe Vandenbriele
- Adult Intensive Care Unit, Royal Brompton Hospital, London, United Kingdom,Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium,Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| |
Collapse
|
2
|
Chung FP, Liao YC, Lin YJ, Chang SL, Lo LW, Hu YF, Tuan TC, Chao TF, Liao JN, Lin CY, Chang TY, Vicera JJB, Chin CG, Wu CI, Liu CM, Lee PT, Huang TC, Lugtu IC, Chen SA. Outcome of rescue ablation in patients with refractory ventricular electrical storm requiring mechanical circulation support. J Cardiovasc Electrophysiol 2019; 31:9-17. [PMID: 31808239 DOI: 10.1111/jce.14309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 12/02/2019] [Accepted: 12/02/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND The management of refractory electrical storm (ES) requiring mechanical circulation support (MCS) remains a clinical challenge in structural heart disease (SHD). OBJECTIVE The study sought to explore the 30-day and 1-year outcome of rescue ablation for refractory ES requiring MCS in SHD. METHODS A total of 81 patients (mean age: 55.3 ± 18.9, 73 men [90.1%]) undergoing ablation were investigated, including 26 patients with ES requiring MCS (group 1) and 55 patients without (group 2). The 30-day and 1-year outcome, including mortality and recurrent ventricular tachyarrhythmias (VAs) receiving appropriate implantable cardioverter defibrillators therapies, were assessed. RESULTS The patients in group 1 were characterized by older age, more ischemic cardiomyopathies, worse left ventricular ejection fraction, and more comorbidities. Thirty days after ablation, overall events were seen in 15 patients (mortality in 10 and recurrent VA in 7), including pumping failure-related mortality in 6 (60%). During a 30-day follow-up, higher mortality was noted in group 1. After a 1-year follow-up, in spite of the higher mortality in group 1 (P < .001), the overall events and VA recurrences were similar between these two groups (P = .154 and P = .466, respectively). There was a significant reduction of VA burden in both groups and two patients had recurrent ES. CONCLUSION Higher 30-day mortality was observed in patients undergoing rescue ablation for refractory ES requiring MCS, and pumping failure was the major cause of periprocedural death. Rescue ablation successfully prevented VA recurrences and resulted in a comparable 1-year prognosis between ES with and without MCS.
Collapse
Affiliation(s)
- Fa-Po Chung
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ying-Chieh Liao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of medicine, Division of cardiology, Changhua Christian Hospital, Changhua, Taiwan
| | - Yenn-Jiang Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Lin Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Li-Wei Lo
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Yu-Feng Hu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ta-Chuan Tuan
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Tze-Fan Chao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jo-Nan Liao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chin-Yu Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Ting-Yung Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jennifer Jeanne B Vicera
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,University of Santo Tomas Hospital, Manila, Philippines
| | - Chye-Gen Chin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Cheng-I Wu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chih-Min Liu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Po-Tseng Lee
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,National Cheng-Kung University Hospital, Tainan, Taiwan
| | - Ting-Chun Huang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,National Cheng-Kung University Hospital, Tainan, Taiwan
| | - Isaiah C Lugtu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Shih-Ann Chen
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Cardiovascular Research Center, Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| |
Collapse
|
3
|
Nonischemic cardiomyopathy substrate and ventricular tachycardia in the setting of coronary artery disease. Heart Rhythm 2013; 10:1622-7. [DOI: 10.1016/j.hrthm.2013.08.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Indexed: 11/20/2022]
|
4
|
Carbucicchio C, Ahmad Raja N, Di Biase L, Volpe V, Dello Russo A, Trivedi C, Bartoletti S, Zucchetti M, Casella M, Russo E, Santangeli P, Moltrasio M, Tundo F, Fassini G, Natale A, Tondo C. High-density substrate-guided ventricular tachycardia ablation: role of activation mapping in an attempt to improve procedural effectiveness. Heart Rhythm 2013; 10:1850-8. [PMID: 24055940 DOI: 10.1016/j.hrthm.2013.09.059] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Indexed: 01/29/2023]
Abstract
BACKGROUND Advanced techniques of electroanatomical mapping efficiently guide ventricular tachycardia (VT) ablation strategies; in this context, the adjunctive value of combining activation mapping (AMap) to improve accuracy has not been elucidated. OBJECTIVE To investigate whether conventional AMap further contributes to the identification of critical sites of VT reentry and whether this translates into a more effective ablation outcome in a cohort of patients undergoing VT ablation. METHODS We prospectively enrolled 126 patients (mean age 65.3 ± 10.5 years; left ventricular ejection fraction 33.3% ± 7.2%) with ischemic (n = 89) or idiopathic (n = 37) dilated cardiomyopathy undergoing endocardial (n = 105) or endo-epicardial (n = 21) electroanatomical mapping and ablation. A substrate-guided strategy targeting surrogate markers of reentry was accomplished in all patients, but the feasibility and efficacy of AMap was preliminarily assessed for all induced VTs focusing on early VT suppression obtained during radiofrequency delivery. VT-free survival was assessed by ICD interrogation. RESULTS AMap successfully guided ablation in 62 of 104 (59.6%) patients with inducible VT(s). At 1 year, 6 of 126 (4.8%) patients died; VT recurred in 28 of 126 (22.2%) patients. No significant difference in VT recurrence rate was observed between patients in whom AMap proved effective versus those in whom substrate-guided ablation was not corroborated by AMap (16 of 62 [25.8%] vs 12 of 64 [18.8%]; log-rank test, P = .3). CONCLUSIONS Our findings support the efficacy of a substrate-guided strategy targeting specific markers of arrhythmogenicity identified during sinus rhythm. AMap proves highly efficient acutely but does not improve overall VT-free survival, suggesting that in patients with advanced cardiac disease, life-threatening arrhythmias can be successfully treated by ablation in sinus rhythm, thus limiting procedural risks.
Collapse
Affiliation(s)
- Corrado Carbucicchio
- Cardiac Arrhythmia Research Centre, Centro Cardiologico Monzino, IRCCS, Milan, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
5
|
Bunch TJ, Mahapatra S, Madhu Reddy Y, Lakkireddy D. The role of percutaneous left ventricular assist devices during ventricular tachycardia ablation. Europace 2013; 14 Suppl 2:ii26-ii32. [PMID: 22832915 DOI: 10.1093/europace/eus210] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Ventricular tachycardia (VT) is a common but serious arrhythmia that significantly adds to the morbidity and mortality of patients with structural heart disease. Percutaneous catheter ablation has evolved to be standard therapy to prevent recurrent implantable cardioverter defibrillator shocks from VT in patients on antiarrhythmia medications. Procedural outcomes in patients with structural heart disease are often limited by haemodynamically unstable VT. Although substrate- and pace-mapping techniques have become increasingly popular for VT ablation, these approaches can often times may not address inducible clinical and non-clinical VTs. Activation and entrainment mapping can help the operator target VT exit sites in a precise fashion minimizing the amount of radiofrequency ablation needed for a successful ablation. An evolving alternative strategy that allows induction and mapping of VT in the setting of severe cardiomyopathy and haemodynamic instability is through maintaining perfusion with a percutaneous ventricular assist device (pVAD). This review will discuss these pVAD technologies, distinguish technical applications of use, highlight the published clinical experience, provide a clinical approach for support device selection, and discuss use of these technologies with current mapping and navigational systems.
Collapse
Affiliation(s)
- T Jared Bunch
- Intermountain Heart Rhythm Specialists, Intermountain Heart Institute, Intermountain Medical Center, Murray, UT 84095, USA.
| | | | | | | |
Collapse
|
6
|
Ablation of unstable ventricular dysrhythmias guided by non contact mapping system among patients with cardiomyopathy in a growing single center experience. Egypt Heart J 2012. [DOI: 10.1016/j.ehj.2012.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
7
|
Bunch TJ, Darby A, May HT, Ragosta M, Lim DS, Taylor AM, DiMarco JP, Ailawadi G, Revenaugh JR, Weiss JP, Mahapatra S. Efficacy and safety of ventricular tachycardia ablation with mechanical circulatory support compared with substrate-based ablation techniques. Europace 2011; 14:709-14. [PMID: 22080473 DOI: 10.1093/europace/eur347] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Catheter ablation of ventricular tachycardia (VT) can be limited by haemodynamic instability. In these cases, substrate-based ablation is typically performed. An alternative is to perform activation and entrainment mapping during VT supported by a percutaneous left ventricular assist device (pVAD). We sought to compare the complication and success rates of pVAD-assisted VT ablation with scar-based techniques. METHODS AND RESULTS Thirteen consecutive patients with haemodynamically unstable VT underwent pVAD-assisted ablation (pVAD group) and were retrospectively compared with 18-matched patients undergoing a substrate-based VT ablation (non-pVAD group). There was no significant difference in age or ejection fraction between the groups although pVAD patients tended to have more shocks in the preceding months. Procedure times were longer for the pVAD group. The number of monomorphic VTs induced was greater in the pVAD group (3.2 vs. 1.6, P= 0.04); however, after ablation, there was no difference in inducibility between the pVAD and non-pVAD group (10 of 13 vs. 12 of 18; 77 vs. 67%, P = 0.69). There was no difference in acute complications including stroke or death. At 9 ± 3 months, 1-year freedom from implantable cardioverter-defibrillator (ICD) shocks/therapies for sustained VT were similar (P= 0.96). In multivariable analysis, the absence of atrial fibrillation (hazard ratio=0.15, P= 0.04) was associated with a lower incidence of ICD shocks. CONCLUSIONS In high-risk patients, pVAD-assisted VT ablation guided by activation and entrainment mapping is a feasible alternative to substrate mapping and allows outcomes comparable to substrate mapping.
Collapse
Affiliation(s)
- T Jared Bunch
- Intermountain Medical Center, Salt Lake City, UT, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
Alzand BSN, Timmermans CCMM, Wellens HJJ, Dennert R, Philippens SAM, Portegijs PJM, Rodriguez LM. Unmappable ventricular tachycardia after an old myocardial infarction. Long-term results of substrate modification in patients with an implantable cardioverter defibrillator. J Interv Card Electrophysiol 2011; 31:149-56. [PMID: 21340515 PMCID: PMC3141830 DOI: 10.1007/s10840-011-9549-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Accepted: 01/26/2011] [Indexed: 01/15/2023]
Abstract
Purpose The frequent occurrence of ventricular tachycardia can create a serious problem in patients with an implantable cardioverter defibrillator. We assessed the long-term efficacy of catheter-based substrate modification using the voltage mapping technique of infarct-related ventricular tachycardia and recurrent device therapy. Methods The study population consisted of 27 consecutive patients (age 68 ± 8 years, 25 men, mean left ventricular ejection fraction 31 ± 9%) with an old myocardial infarction and multiple and/or hemodynamically not tolerated ventricular tachycardia necessitating repeated device therapy. A total of 31 substrate modification procedures were performed using the three-dimensional electroanatomical mapping system. Patients were followed up for a median of 23.5 (interquartile range 6.5–53.2) months before and 37.8 (interquartile range 11.7–71.8) months after ablation. Antiarrhythmic drugs were not changed after the procedure, and were stopped 6 to 9 months after the procedure in patients who did not show ventricular tachycardia recurrence. Results Median ventricular tachycardias were 1.6 (interquartile range 0.7–6.7) per month before and 0.2 (interquartile range 0.00–1.3) per month after ablation (P = 0.006). Nine ventricular fibrillation episodes were registered in seven patients before and two after ablation (P = 0.025). Median antitachycardia pacing decreased from 1.6 (interquartile range 0.01–5.5) per month before to 0.18 (interquartile range 0.00–1.6) per month after ablation (P = 0.069). Median number of shocks decreased from 0.19 (interquartile range 0.04–0.81) per month before to 0.00 (interquartile range 0.00–0.09) per month after ablation (P = 0.001). One patient had a transient ischemic attack during the procedure, and another developed pericarditis. Nine patients died during follow-up, eight patients due to heart failure and one patient during valve surgery. Conclusion Catheter-based substrate modification using voltage mapping results in a long-lasting reduction of cardioverter defibrillator therapy in patients with multiple and/or hemodynamically not tolerated infarct-related ventricular tachyarrhythmia.
Collapse
Affiliation(s)
- B S N Alzand
- Department of Cardiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
9
|
Usefulness of a limited linear ablation of post-myocardial infarction ventricular tachycardia using a standardized approach based on sinus rhythm mapping. Am J Cardiol 2010; 105:1235-9. [PMID: 20403472 DOI: 10.1016/j.amjcard.2009.12.038] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2009] [Revised: 12/04/2009] [Accepted: 12/04/2009] [Indexed: 11/24/2022]
Abstract
The ablation of ventricular tachycardia (VT) can be achieved using anatomically guided approaches using differentiated mapping and ablation techniques. The aim of this study was to evaluate the efficacy of limited linear ablation in the VT exit region identified during sinus rhythm mapping alone. One hundred fifteen consecutive patients presenting for ablation of post-myocardial infarction VT were included. After induction of the target VT during invasive electrophysiology, left ventricular substrate mapping during sinus rhythm to identify scar and border zone on the basis of endocardial bipolar voltage was performed. The exit site of the target VT was regionalized by a simplified vector pace mapping approach and targeted using limited linear ablation within the scar border zone. Seventy-seven percent of all inducible VT was successfully ablated. In 71 patients (62%), no sustained VT was inducible at the end of ablation procedure (complete success). During a median follow-up period of 16 + or - 10 months, 89 patients (77%) had no documented sustained ventricular arrhythmia. Seven patients (2%) had recurrences of the initially ablated VT, and 16 (14%) had new-onset VT. Patients with complete success had a significantly lower number of ventricular arrhythmia reoccurrences than patients with incomplete ablation success (11% vs 37%, p = 0.002). In conclusion, postinfarct VT was effectively ablated in 97% of patients without mapping during ongoing VT using a simplified regional linear ablation approach targeting the scar border zone. Freedom from any ventricular arrhythmia was achieved in 77% of patients during midterm follow-up.
Collapse
|
10
|
Raymond JM, Sacher F, Winslow R, Tedrow U, Stevenson WG. Catheter Ablation for Scar-related Ventricular Tachycardias. Curr Probl Cardiol 2009; 34:225-70. [DOI: 10.1016/j.cpcardiol.2009.01.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
11
|
|
12
|
Ciaccio EJ, Chow AW, Kaba RA, Davies DW, Segal OR, Peters NS. Detection of the diastolic pathway, circuit morphology, and inducibility of human postinfarction ventricular tachycardia from mapping in sinus rhythm. Heart Rhythm 2008; 5:981-91. [PMID: 18598952 DOI: 10.1016/j.hrthm.2008.03.062] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2006] [Accepted: 03/31/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The purpose of this study was to determine whether sinus rhythm activation maps could be used to detect the origin and characteristics of reentrant ventricular tachycardia in postinfarction patients. METHODS In each of 11 post-myocardial infarction patients, unipolar electrograms were acquired at 256 virtual endocardial sites using noncontact mapping. Electrograms were marked for activation time and mapped on a three-dimensional grid. Spatial differences in sinus rhythm activation time were correlated to isthmus characteristics and to activation through the diastolic pathway during tachycardia on the basis of the presence of contiguous lines of slow conduction and block. RESULTS Twenty tachycardia morphologies were analyzed. Fourteen sustained reentrant circuit morphologies occurred in nine patients, with dual morphologies having a shared isthmus occurring in five of nine patients. Dual morphologies were caused by changes in entrance-exit point location about a common isthmus. One transient circuit morphology of <10 beats occurred in three of nine patients also having sustained reentry. The estimated isthmus determined from sinus rhythm activation overlapped the diastolic pathway determined from tachycardia maps with 83.8% sensitivity and 89.2% specificity. The mean difference in sinus rhythm activation time across the isthmus border was larger in transient compared with sustained morphologies (32.8 +/- 9.5 ms vs. 22.8 +/- 1.8 ms), with smaller isthmus size (4.8 +/- 1.1 cm(2) vs. 10.0 +/- 1.1 cm(2); P < .05), narrower entrance-exit points (7.0 +/- 1.5 mm vs. 9.3 +/- 0.8 mm; P < .05), and greater activation time difference across them (16.3 +/- 3.5 ms vs. 10.1 +/- 1.0 ms; P < .05). CONCLUSION In post-myocardial infarction patients, the reentry isthmus can be localized in the endocardial border zone from sinus rhythm activation maps. Nonsustained reentry occurs when isthmus size is small and entrance-exit points are narrow and more electrically discontinuous.
Collapse
Affiliation(s)
- Edward J Ciaccio
- Department of Pharmacology, Columbia University, New York, New York 10032, USA.
| | | | | | | | | | | |
Collapse
|
13
|
Delacrétaz E. Target sites for catheter ablation of unmappable ventricular tachycardia during sinus rhythm. Heart Rhythm 2006; 3:513-5. [PMID: 16648053 DOI: 10.1016/j.hrthm.2006.02.001] [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] [Received: 01/30/2006] [Indexed: 11/17/2022]
|
14
|
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.
Collapse
Affiliation(s)
- Henry H Hsia
- Cardiovascular Medicine Division, Stanford University, Stanford, California 94305-5233, USA.
| | | | | | | | | |
Collapse
|
15
|
Abstract
Catheter ablation therapy for ventricular tachycardia has evolved over the past 20 years to become the first-line therapy. This development has been facilitated by technology that has allowed better anatomic and electrophysiologic correlations. A better understanding of radiofrequency (RF) ablation has led to safer and more effective treatments, allowing it to become a potent diagnostic and therapeutic tool in clinical cardiac electrophysiology. As more knowledge is gained about the mechanisms of arrhythmias through RF ablations, and better mapping technology and more effective methods for energy delivery become available, catheter ablation will become relevant for an increasing number of arrhythmias. This article addresses advances and applications of RF ablation to the treatment of ventricular arrhythmias in a variety of heart diseases.
Collapse
Affiliation(s)
- Paveljit S Bindra
- Hospital of the University of Pennsylvania, 9th Floor Founders-Cardiology, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | | |
Collapse
|
16
|
Verma A, Kilicaslan F, Schweikert RA, Tomassoni G, Rossillo A, Marrouche NF, Ozduran V, Wazni OM, Elayi SC, Saenz LC, Minor S, Cummings JE, Burkhardt JD, Hao S, Beheiry S, Tchou PJ, Natale A. Short- and long-term success of substrate-based mapping and ablation of ventricular tachycardia in arrhythmogenic right ventricular dysplasia. Circulation 2005; 111:3209-16. [PMID: 15956125 DOI: 10.1161/circulationaha.104.510503] [Citation(s) in RCA: 168] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Multiple morphologies, hemodynamic instability, or noninducibility may limit ventricular tachycardia (VT) ablation in patients with arrhythmogenic right ventricular dysplasia (ARVD). Substrate-based mapping and ablation may overcome these limitations. We report the results and success of substrate-based VT ablation in ARVD. METHODS AND RESULTS Twenty-two patients with ARVD were studied. Traditional mapping for VT was limited because of multiple/changing VT morphologies (n=14), nonsustained VT (n=10), or hemodynamic intolerance (n=5). Sinus rhythm CARTO mapping was performed to define areas of "scar" (<0.5 mV) and "abnormal" myocardium (0.5 to 1.5 mV). Ablation was performed in "abnormal" regions, targeting sites with good pace maps compared with the induced VT(s). Linear lesions were created in these areas to (1) connect the scar/abnormal region to a valve continuity or other scar or (2) encircle the scar/abnormal region. Eighteen patients had implanted cardioverter defibrillators, 15 had implanted cardioverter defibrillator therapies, and 7 had sustained VT (6 with syncope). VTs (3+/-2 per patient) were induced (cycle length, 339+/-94 ms), and scar was identified in all patients. Scar areas were related to the tricuspid annulus, proximal right ventricular outflow tract, and anterior/inferior-apical walls. Lesions connected abnormal regions to the annulus (n=12) or other scars (n=4) and/or encircled abnormal regions (n=13). Per patient, a mean of 38+/-22 radiofrequency lesions was applied. Short-term success was achieved in 18 patients (82%). VT recurred in 23%, 27%, and 47% of patients after 1, 2, and 3 years' follow-up, respectively. CONCLUSIONS Substrate-based ablation of VT in ARVD can achieve a good short-term success rate. However, recurrences become increasingly common during long-term follow-up.
Collapse
Affiliation(s)
- Atul Verma
- Section of Pacing and Electrophysiology, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
Ciaccio EJ, Tosti AC, Scheinman MM. Method to Predict Isthmus Location in Ventricular Tachycardia Caused by Reentry with a Double-Loop Pattern. J Cardiovasc Electrophysiol 2005; 16:528-36. [PMID: 15877625 DOI: 10.1046/j.1540-8167.2005.40638.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND During electrophysiologic study, induction and mapping of clinical reentrant ventricular tachycardia can be difficult. Hence, analysis of sinus-rhythm electrograms for reentry localization is of potential clinical relevance. Herein is described a method of sinus-rhythm electrogram shape analysis, that does not require arbitrary threshold values, for localization of double-loop reentrant circuits that drive clinical tachycardias. METHODS AND RESULTS Reentrant ventricular tachycardia was induced by premature stimulation in 23 postinfarction canine hearts 4-5 days after left anterior descending (LAD) ligation. Sinus-rhythm activation maps were constructed from bipolar electrograms acquired at 196-312 sites in the epicardial border zone. The timing of all electrogram peak deflections during one cycle of sinus rhythm was determined, and the mean (MPD) and deviation (DPD) were taken, respectively, as estimates of the time of activation wavefront crossing, and the duration of local electrical activity. These variables were then mapped on a computerized grid. The line of most uniform and sharp MPD gradient predicted the propagation direction through the double-loop reentrant circuit isthmus that would occur upon tachycardia induction. The sharpest transitions in DPD bounding this line predicted the positions of arcs of block that would border the reentrant circuit isthmus during tachycardia. The actual and estimated isthmuses overlapped by a mean of 84.1 +/- 3.8%. In six experiments lacking inducible reentrant tachycardia, no line of sharp MPD gradient was present in the MPD maps. CONCLUSIONS Analysis of multiple sinus-rhythm deflections can localize the reentrant ventricular tachycardia isthmus without introduction of arbitrary threshold points and peak choices that may lead to error.
Collapse
Affiliation(s)
- Edward J Ciaccio
- Department of Pharmacology, Columbia University, New York, NY 10032, USA.
| | | | | |
Collapse
|
18
|
Nieminen MS, Böhm M, Cowie MR, Drexler H, Filippatos GS, Jondeau G, Hasin Y, López-Sendón J, Mebazaa A, Metra M, Rhodes A, Swedberg K. Guías de Práctica Clínica sobre el diagnóstico y tratamiento de la insuficiencia cardíaca aguda. Versión resumida. Rev Esp Cardiol 2005; 58:389-429. [PMID: 15847736 DOI: 10.1157/13073896] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Markku S Nieminen
- Division of Cardiology, Helsinki University Central Hospital, Helsinki, Finland. markku.nieminen.hus.fi
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Brunckhorst CB, Delacretaz E, Soejima K, Maisel WH, Friedman PL, Stevenson WG. Identification of the Ventricular Tachycardia Isthmus After Infarction by Pace Mapping. Circulation 2004; 110:652-9. [PMID: 15289385 DOI: 10.1161/01.cir.0000138107.11518.af] [Citation(s) in RCA: 137] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Ventricular tachycardia (VT) isthmuses can be defined by fixed or functional block. During sinus rhythm, pace mapping near the exit of an isthmus should produce a QRS similar to that of VT. Pace mapping at sites proximal to the exit may produce a similar QRS with a longer stimulus-to-QRS interval (S-QRS). The aim of the study was to determine whether a VT isthmus could be identified and followed by pace mapping.
Methods and Results—
Left ventricular pace mapping during sinus rhythm was performed at 819 sites in 11 patients with VT late after infarction, and corresponding CARTO maps were reconstructed. An isthmus site was defined by entrainment and/or VT termination by ablation. Pace-mapping data were analyzed from the identified isthmus site and from sites at progressively increasing distances from this initial isthmus site. Sites where pace mapping produced the same QRS with different S-QRS delays were identified to attempt to trace the course of the isthmus. In 11 patients, 13 confluent low-voltage infarct regions were present. In all these regions, parts of VT isthmuses were identified by pace mapping. In 11 of 13 of the identified isthmus parts, the QRS morphology of the pace map matched a VT QRS. In 10 of 11 patients, radiofrequency ablation rendered clinical VTs noninducible. Successful ablation sites were localized within an isthmus identified by pace mapping in all of these 10 patients.
Conclusions—
VT isthmuses can be identified and part of their course delineated by pace mapping during sinus rhythm. This method could help target isthmus sites for ablation during stable sinus rhythm.
Collapse
Affiliation(s)
- Corinna B Brunckhorst
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass, USA.
| | | | | | | | | | | |
Collapse
|
20
|
Soejima K, Stevenson WG, Sapp JL, Selwyn AP, Couper G, Epstein LM. Endocardial and epicardial radiofrequency ablation of ventricular tachycardia associated with dilated cardiomyopathy. J Am Coll Cardiol 2004; 43:1834-42. [PMID: 15145109 DOI: 10.1016/j.jacc.2004.01.029] [Citation(s) in RCA: 336] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2003] [Revised: 12/09/2003] [Accepted: 01/05/2004] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the occurrence, locations, and relationship of ventricular tachycardia (VT) to low-voltage areas in dilated cardiomyopathy (DCM). BACKGROUND The substrate causing monomorphic VT after infarction is characterized by regions of low-voltage (<1.5 mV) scar on electroanatomic maps. The substrate causing VT associated with DCM is less well defined. METHODS A total of 28 patients were studied with endocardial (26 patients) and epicardial (8 patients) electroanatomic mapping. The VT circuits were defined by entrainment or pace mapping. RESULTS Ventricular tachycardia was due to focal VT in 5, bundle-branch re-entry in 2, and myocardial re-entry in 22 patients (both focal and re-entry VTs in 1 patient). All patients with myocardial re-entry had endocardial (20 of 20 patients) and/or epicardial (7 of 7 patients mapped) scar. Most (63%) endocardial scars were adjacent to a valve annulus. Of the 19 VT circuit isthmuses identified, 12 were associated with an endocardial scar and 7 with an epicardial scar. All myocardial re-entrant VTs were abolished in 12 of 22 patients, and inducible VT was modified in 4 patients. During follow-up of 334 +/- 280 days, 54% of patients with myocardial re-entry were free of VT despite frequent episodes before ablation. CONCLUSIONS The VTs in DCM are most commonly the result of myocardial re-entry associated with scar. Scars are often adjacent to a valve annulus, deep in the endocardium, and can be greater in extent on the epicardium than on the endocardium. The use of epicardial mapping and radiofrequency is likely to improve success.
Collapse
Affiliation(s)
- Kyoko Soejima
- Department of Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | | | | | | | | | | |
Collapse
|
21
|
|
22
|
Brunckhorst CB, Stevenson WG, Soejima K, Maisel WH, Delacretaz E, Friedman PL, Ben-Haim SA. Relationship of slow conduction detected by pace-mapping to ventricular tachycardia re-entry circuit sites after infarction. J Am Coll Cardiol 2003; 41:802-9. [PMID: 12628726 DOI: 10.1016/s0735-1097(02)02932-7] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES This study sought to characterize the relationship of conduction delays detected by pace-mapping, evident as a stimulus to QRS interval (S-QRS) delay >or=40 ms, to ventricular tachycardia (VT) re-entry circuit isthmuses defined by entrainment and ablation. BACKGROUND Areas of slow conduction and block in old infarcts cause re-entrant VT. METHODS In 12 patients with VT after infarction, pace-mapping was performed at 890 sites. Stimulus to QRS intervals were measured and plotted in three-dimensional reconstructions of the left ventricle. Conduction delay was defined as >or=40 ms and marked delay as >80 ms. The locations of conduction delays were compared to the locations of 14 target areas, defined as the region within a radius of 2 cm of a re-entry circuit isthmus. RESULTS Pacing captured at 829 sites; 465 (56%) had no S-QRS delay, 364 (44%) had a delay >or=40 ms, and 127 (15%) had a delay >80 ms. Sites with delays were clustered in 14 discrete regions, 13 of which overlapped target regions. Only 1 of the 14 target regions was not related to an area of S-QRS delay. Sites with marked delays >80 ms were more often in the target (52%) than sites with delays 40 to 80 ms (29%) (p < 0.0001). CONCLUSIONS Identification of abnormal conduction during pace-mapping can be used to focus mapping during induced VT to a discrete region of the infarct. Further study is warranted to determine if targeting regions of conduction delay may allow ablation of VT during stable sinus rhythm without mapping during VT.
Collapse
|
23
|
Kautzner J, Cihák R, Peichl P, Vancura V, Bytesník J. Catheter ablation of ventricular tachycardia following myocardial infarction using three-dimensional electroanatomical mapping. Pacing Clin Electrophysiol 2003; 26:342-7. [PMID: 12687842 DOI: 10.1046/j.1460-9592.2003.00046.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
One challenge encountered during catheter ablation of postinfarction ventricular tachycardia (VT) is the inducibility of multiple VT morphologies associated with variable hemodynamic instability. The clinical usefulness and safety of a three-dimensional electroanatomical mapping in guiding radiofrequency (RF) catheter ablation of VT, used in parallel with a multichannel recording system, was studied in 28 men (mean age = 63.8 +/- 10.6 years, mean left ventricular ejection fraction = 28% +/- 9%). Three-dimensional voltage maps of the left ventricle were obtained in sinus rhythm with annotation of areas of fractionated or late potentials, zones of slow conduction and/or dense scar with no pacing capture at 10 mA. RF lesions were created either in sinus rhythm or during hemodynamically stable VT within reconstructed critical zones of the circuit. A total of 82 VTs were induced (mean = 2.9 +/- 1.0/patient). Hemodynamically unstable clinical VTs were induced in 5 patients, and clinical or nonclinical unstable VT in 14. Clinical VT was rendered noninducible in 24/28 (85.7%) patients, and monomorphic VT was eliminated in 16/28 (57.1%) patients. The mean procedural time was 258 +/- 82 minutes, and fluoroscopic exposure 13.5 +/- 8.8 minutes. During a mean follow-up period of 10.6 +/- 6.4 months, catheter ablation was repeated in 6 patients for VT recurrences. No significant complications occurred except for a transient cerebral ischemic attack in one patient. In conclusion, electroanatomical mapping assisted the successful and safe catheter ablation of both mappable and nonmappable VTs in a significant proportion of patients after myocardial infarction.
Collapse
Affiliation(s)
- Josef Kautzner
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Vídenská 1958/9, 140 21 Prague 4, Czech Republic.
| | | | | | | | | |
Collapse
|
24
|
Soejima K, Stevenson WG, Maisel WH, Sapp JL, Epstein LM. Electrically Unexcitable Scar Mapping Based on Pacing Threshold for Identification of the Reentry Circuit Isthmus. Circulation 2002; 106:1678-83. [PMID: 12270862 DOI: 10.1161/01.cir.0000030187.39852.a7] [Citation(s) in RCA: 278] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
We hypothesized that delineating electrically unexcitable scar (EUS) within low-voltage infarct regions will locate reentry circuit isthmuses by defining their borders. The pacing threshold and electrogram amplitude that best determines EUS is unknown.
Methods and Results—
The change in dimension of the virtual electrode was estimated in 11 patients and observed to increase by 4.4±2.5 mm as stimulus strength increases from threshold (2.9±1.8 mA) to 10 mA. EUS was defined as a threshold >10 mA. In 14 consecutive patients, mapping and ablation of ventricular tachycardia (VT) were performed using an electroanatomic mapping system. During sinus rhythm, unipolar pacing was performed at sites with bipolar electrogram amplitude <1.5 mV. EUS regions were marked on the maps. Reentry circuit isthmuses were identified by entrainment mapping or pace mapping, and ablation was performed. EUS was identified in the infarct in all 14 patients (11.8±13.9 cm
2
). All 20 VT circuit isthmuses identified were adjacent to EUS. Although electrogram amplitude correlated with pacing threshold (
r
=0.64,
P
<0.0001), many isthmuses had very low-amplitude electrograms, and EUS could not be identified from electrogram amplitude alone. RF ablation lines connecting selected EUS regions abolished all inducible VTs in 10 patients (71%); spontaneous VT was markedly reduced during follow-up (from 142±360 to 0.9±2.0 episodes per month,
P
=0.002).
Conclusions—
This new method of identifying EUS provides complimentary information to the electrogram amplitude in delineating potential reentry circuit paths, potentially facilitating ablation during sinus rhythm.
Collapse
Affiliation(s)
- Kyoko Soejima
- Cardiovascular Division, Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass, USA.
| | | | | | | | | |
Collapse
|
25
|
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.
Collapse
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
| | | | | |
Collapse
|
26
|
Soejima K, Suzuki M, Maisel WH, Brunckhorst CB, Delacretaz E, Blier L, Tung S, Khan H, Stevenson WG. Catheter ablation in patients with multiple and unstable ventricular tachycardias after myocardial infarction: short ablation lines guided by reentry circuit isthmuses and sinus rhythm mapping. Circulation 2001; 104:664-9. [PMID: 11489772 DOI: 10.1161/hc3101.093764] [Citation(s) in RCA: 294] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Extensive lines of radiofrequency (RF) lesions through infarct (MI) can ablate multiple and unstable ventricular tachycardias (VTs). Methods for guiding ablation that minimize unnecessary RF applications are needed. This study assesses the feasibility of guiding RF line placement by mapping to identify a reentry circuit isthmus. METHODS AND RESULTS Catheter mapping and ablation were performed in 40 patients (MI location: inferior, 28; anterior, 7; and both, 5) with an electroanatomic mapping system to measure the infarct region and ablation lines. The initial line was placed in the MI region either through a circuit isthmus identified from entrainment mapping or a target identified from pace mapping. A total of 143 VTs (42 stable, 101 unstable) were induced. An isthmus was identified in 25 patients (63%; 5 with only stable VTs, 5 with only unstable VTs, and 15 with both VTs). Inducible VTs were abolished or modified in 100% of patients when the RF line included an isthmus compared with 53% when RF had to be guided by pace mapping (P=0.0002); those with an isthmus identified received shorter ablation lines (4.9+/-2.4 versus 7.4+/-4.3 cm total length, P=0.02). During follow-up, spontaneous VT decreased markedly regardless of whether an isthmus was identified. VT stability and number of morphologies did not influence outcome. CONCLUSIONS A 4- to 5-cm line of RF lesions abolishes all inducible VTs in more than 50% of patients. Less ablation is required if a reentry circuit isthmus is identified even when multiple and unstable VTs are present.
Collapse
Affiliation(s)
- K Soejima
- Cardiovascular Division, Department of Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
27
|
Ciaccio EJ, Tosti AC, Scheinman MM. Relationship between sinus rhythm activation and the reentrant ventricular tachycardia isthmus. Circulation 2001; 104:613-9. [PMID: 11479262 DOI: 10.1161/hc3101.092202] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In canine hearts with inducible reentry, the isthmus tends to form along an axis from the area of last to first activity during sinus rhythm. It was hypothesized that this phenomenon could be quantified to predict reentry and the isthmus location. METHODS AND RESULTS An in situ canine model of reentrant ventricular tachycardia occurring in the epicardial border zone was used in 54 experiments (25 canine hearts in which primarily long monomorphic runs of figure-8 reentry were inducible, 11 with short monomorphic or polymorphic runs, and 18 lacking inducible reentry). From the sinus rhythm activation map for each experiment, the linear regression coefficient and slope were calculated for the activation times along each of 8 rays extending from the area of last activation. The slope of the regression line for the ray with greatest regression coefficient (called the primary axis) was used to predict whether or not reentry would be inducible (correct prediction in 48 of 54 experiments). For all 36 experiments with reentry, isthmus location and shape were then estimated on the basis of site-to-site differences in sinus rhythm electrogram duration. For long and short runs of reentry, estimated isthmus location and shape partially overlapped the actual isthmus (mean overlap of 71.3% and 43.6%, respectively). On average for all reentry experiments, a linear ablation lesion positioned across the estimated isthmus would have spanned 78.2% of the actual isthmus width. CONCLUSIONS Parameters of sinus rhythm activation provide key information for prediction of reentry inducibility and isthmus location and shape.
Collapse
Affiliation(s)
- E J Ciaccio
- Department of Pharmacology, College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA.
| | | | | |
Collapse
|
28
|
Affiliation(s)
- W G Stevenson
- Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
| | | |
Collapse
|
29
|
Abstract
Ventricular tachycardia (VT) due to reentry in and around regions of ventricular scar from an old myocardial infarction or cardiomyopathic process is often a difficult management problem. Radiofrequency catheter ablation is an option for controlling frequent VT episodes. Patient and VT characteristics determine the mapping and ablation approach and efficacy. In patients with a VT that is hemodynamically tolerated to allow mapping, prevention of recurrent VT is achieved in 54% to 66% of patients with a procedure related mortality of 1% to 2.7%. Multiple morphologies of monomorphic VT and circuits that are located deep to the endocardium are common problems that reduce efficacy. Mapping to identify target regions for ablation can be difficult if VT is rapid and not tolerated, or not inducible. Ablation of these "unmappable VTs" by designing ablation lines or areas based on the characteristics of the scar as assessed during sinus rhythm, and using approaches to assess global activation from a limited number of beats has been shown to be feasible. Ablation of multiple VTs, epicardial VTs, and poorly tolerated VTs are feasible. Future studies defining efficacy and risks are needed.
Collapse
Affiliation(s)
- W G Stevenson
- Cardiac Arrythmia Service, Cardiovascular Division, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.
| | | |
Collapse
|
30
|
Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 20-2000. A 61-year-old man with a wide-complex tachycardia. N Engl J Med 2000; 342:1979-87. [PMID: 10874066 DOI: 10.1056/nejm200006293422608] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|