1
|
Ross F, Everhart K, Latham G, Joffe D. Perioperative and Anesthetic Considerations in Pediatric Valvar and Subvalvar Aortic Stenosis. Semin Cardiothorac Vasc Anesth 2023; 27:292-304. [PMID: 37455142 DOI: 10.1177/10892532231189933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Aortic stenosis (AS) is a common form of left ventricular outflow tract obstruction (LVOTO) in children with congenital heart disease. This review specifically considers the perioperative features of valvar (VAS) and subvalvar AS (subAS) in the pediatric patient. Although VAS and subAS share some clinical features and diagnostic approaches, they are distinct clinical entities with separate therapeutic options, which range from transcatheter intervention to surgical repair. We detail the pathophysiology of AS and highlight the range of treatment strategies with a focus on anesthetic considerations for the care of these patients before, during, and after intervention.
Collapse
Affiliation(s)
- Faith Ross
- Department of Anesthesiology and Pain Medicine, Division of Pediatric Cardiac Anesthesiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Kelly Everhart
- Department of Anesthesiology and Pain Medicine, Division of Pediatric Cardiac Anesthesiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Greg Latham
- Department of Anesthesiology and Pain Medicine, Division of Pediatric Cardiac Anesthesiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Denise Joffe
- Department of Anesthesiology and Pain Medicine, Division of Pediatric Cardiac Anesthesiology, Seattle Children's Hospital, Seattle, WA, USA
| |
Collapse
|
2
|
Pugliese L, Ricci F, Luciano A, De Stasio V, Presicce M, Spiritigliozzi L, Di Tosto F, Di Donna C, D'Errico F, Benelli L, Pasqualetto M, Grimaldi F, Mecchia D, Sbordone P, Cesareni M, Cerimele C, Cerocchi M, Laudazi M, Leomanni P, Rellini C, Dell'Olio V, Patanè A, Romeo F, Barillà F, Garaci F, Floris R, Chiocchi M. Role of computed tomography in transcatheter replacement of 'other valves': a comprehensive review of preprocedural imaging. J Cardiovasc Med (Hagerstown) 2022; 23:575-588. [PMID: 35994705 DOI: 10.2459/jcm.0000000000001362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Transcatheter procedures for heart valve repair or replacement represent a valid alternative for treating patients who are inoperable or at a high risk for open-heart surgery. The transcatheter approach has become predominant over surgical intervention for aortic valve disease, but it is also increasingly utilized for diseases of the 'other valves', that is the mitral and, to a lesser extent, tricuspid and pulmonary valve. Preprocedural imaging is essential for planning the transcatheter intervention and computed tomography has become the main imaging modality by providing information that can guide the type of treatment and choice of device as well as predict outcome and prevent complications. In particular, preprocedural computed tomography is useful for providing anatomic details and simulating the effects of device implantation using 3D models. Transcatheter mitral valve replacement is indicated for the treatment of mitral regurgitation, either primary or secondary, and computed tomography is crucial for the success of the procedure. It allows evaluating the mitral valve apparatus, the surrounding structures and the left heart chambers, identifying the best access route and the landing zone and myocardial shelf, and predicting obstruction of the left ventricular outflow tract, which is the most frequent postprocedural complication. Tricuspid valve regurgitation with or without stenosis and pulmonary valve stenosis and regurgitation can also be treated using a transcatheter approach. Computer tomography provides information on the tricuspid and pulmonary valve apparatus, the structures that are spatially related to it and may be affected by the procedure, the right heart chambers and the right ventricular outflow tract.
Collapse
Affiliation(s)
- Luca Pugliese
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Francesca Ricci
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Alessandra Luciano
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Vincenzo De Stasio
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Matteo Presicce
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Luigi Spiritigliozzi
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Federica Di Tosto
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Carlo Di Donna
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Francesca D'Errico
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Leonardo Benelli
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Monia Pasqualetto
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Francesco Grimaldi
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Daniele Mecchia
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Paolo Sbordone
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Matteo Cesareni
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Cecilia Cerimele
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Martina Cerocchi
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Mario Laudazi
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Paola Leomanni
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Carlotta Rellini
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Vito Dell'Olio
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Alberto Patanè
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Francesco Romeo
- Department of System Medicine, University of Rome Tor Vergata and Unit of Cardiology and Interventional Cardiology, Policlinico Tor Vergata, Rome, Italy
| | - Francesco Barillà
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Francesco Garaci
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Roberto Floris
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| | - Marcello Chiocchi
- Department of Biomedicine and Prevention, Division of Diagnostic Imaging, University of Rome Tor Vergata and Unit of Diagnostic Imaging
| |
Collapse
|
3
|
Huh H, Lee J, Kinno M, Markl M, Thomas JD, Barker AJ. Two wrongs sometimes do make a right: errors in aortic valve stenosis assessment by same-day Doppler echocardiography and 4D flow MRI. Int J Cardiovasc Imaging 2022; 38:1815-1823. [PMID: 35190940 PMCID: PMC9392814 DOI: 10.1007/s10554-022-02553-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 02/04/2022] [Indexed: 11/28/2022]
Abstract
This study aims to systematically verify if the simplified geometry and flow profile of the left ventricular outflow tract (LVOT) assumed in 2D echocardiography is appropriate while examining the utility of 4D flow MRI to assess valvular disease. This prospective study obtained same-day Doppler echocardiography and 4D flow MRI in 37 healthy volunteers (age: 51.9 ± 18.2, 20 females) and 7 aortic stenosis (AS) patients (age: 64.2 ± 9.6, 1 female). Two critical assumptions made in echocardiography for aortic valve area assessment were examined, i.e. the assumption of (1) a circular LVOT shape and (2) a flat velocity profile through the LVOT. 3D velocity and shape information obtained with 4D flow MRI was used as comparison. It was found that the LVOT area was lower (by 26.5% and 24.5%) and the velocity time integral (VTI) was higher (by 28.5% and 30.2%) with echo in the healthy and AS group, respectively. These competing errors largely cancelled out when examining individual and cohort averaged LVOT stroke volume. The LVOT area, VTI and stroke volume measured by echo and 4D flow MRI were 3.6 ± 0.7 vs. 4.9 ± 1.0 cm2 (p < 0.001), 21.2 ± 3.0 vs 15.2 ± 2.8 cm (p < 0.001), and 75.6 ± 15.6 vs 72.8 ± 14.1 ml (p = 0.3376), respectively. In the ensemble average of LVOT area and VTI, under- and over-estimation seem to compensate each other to result in a 'realistic' stroke volume. However, it is important to understand that this compensation may fail. 4D flow MRI provides a unique insight into this phenomenon.
Collapse
Affiliation(s)
- Hyungkyu Huh
- Medical Device Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu, South Korea
| | - Jeesoo Lee
- Department of Radiology, Northwestern University, Feinberg School of Medicine, 737 N. Michigan Avenue, Suite 1600, Chicago, IL, 60611, USA
| | - Menhel Kinno
- Division of Cardiology, Loyola University Chicago, Stritch School of Medicine, Chicago, IL, USA
| | - Michael Markl
- Department of Radiology, Northwestern University, Feinberg School of Medicine, 737 N. Michigan Avenue, Suite 1600, Chicago, IL, 60611, USA
- Department of Biomedical Engineering, Northwestern University, McCormick School of Engineering, Evanston, IL, USA
| | - James D Thomas
- Division of Cardiology, Department of Medicine, Bluhm Cardiovascular Institute, Northwestern University, Feinberg School of Medicine, 676 N. St. Claire Street, Suite 600, Chicago, IL, 60611, USA
| | - Alex J Barker
- Department of Radiology and Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
- Pediatric Radiology, Children's Hospital Colorado, Aurora, USA.
| |
Collapse
|
4
|
Sinha M, Pandey NN, Sharma A, Parashar N, Kumar S, Sharma G. Aneurysmal and obstructive lesions of the left ventricular outflow: evaluation on multidetector computed tomography angiography. Pol J Radiol 2021; 86:e195-e203. [PMID: 34093915 PMCID: PMC8147719 DOI: 10.5114/pjr.2021.105588] [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: 05/23/2020] [Accepted: 08/06/2020] [Indexed: 11/30/2022] Open
Abstract
The left ventricular outflow is an anatomically complex region situated between the anterior leaflet of the mitral valve and the left ventricular aspect of the muscular and membranous interventricular septum. It gives rise to the aorta, provides support to the aortic valvular cusps, and houses important components of the conduction system. The left ventricular outflow handles high pressures and pressure variations and is subsequently affected by a variety of aetio-pathological conditions. Diseases involving the left ventricular outflow can be intraluminal, mural, or extramural, and the consequent complications of the lesions can be local, loco-regional, or even systemic. Appropriate evaluation requires comprehensive multimodality imaging with each modality contributing to assessment of different aspects of diagnosis, lesion characterization, local extension, prognostication for systemic complications and mortality, and the decision for the approach and type of intervention and aggressive follow-up in case non-interventional management is decided. In this review, we briefly describe the relevant anatomy and the gamut of structural abnormalities pertaining to the left ventricular outflow on multidetector computed tomography angiography.
Collapse
Affiliation(s)
| | | | - Arun Sharma
- Correspondence address: Dr. Arun Sharma, 148, The Foothills, New Chandigarh (Pb), India, e-mail:
| | | | | | | |
Collapse
|
5
|
De Almeida MC, Mori S, Anderson RH. Three-dimensional visualization of the bovine cardiac conduction system and surrounding structures compared to the arrangements in the human heart. J Anat 2021; 238:1359-1370. [PMID: 33491213 DOI: 10.1111/joa.13397] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 12/10/2020] [Accepted: 01/05/2021] [Indexed: 12/14/2022] Open
Abstract
In the human heart, the atrioventricular node is located toward the apex of the triangle of Koch, which is also at the apex of the inferior pyramidal space. It is adjacent to the atrioventricular portion of the membranous septum, through which it penetrates to become the atrioventricular bundle. Subsequent to its penetration, the conduction axis is located on the crest of the ventricular septum, sandwiched between the muscular septum and ventricular component of the membranous septum, where it gives rise to the ramifications of the left bundle branch. In contrast, the bovine conduction axis has a long non-branching component, which penetrates into a thick muscular atrioventricular septum having skirted the main cardiac bone and the rightward half of the non-coronary sinus of the aortic root. It commonly gives rise to both right and left bundle branches within the muscular ventricular septum. Unlike the situation in man, the left bundle branch is long and thin before it branches into its fascicles. These differences from the human heart, however, have yet to be shown in three-dimensions relative to the surrounding structures. We have now achieved this goal by injecting contrast material into the insulating sheaths that surround the conduction network, evaluating the results by subsequent computed tomography. The fibrous atrioventricular membranous septum of the human heart is replaced in the ox by the main cardiac bone and the muscular atrioventricular septum. The apex of the inferior pyramidal space, which in the bovine, as in the human, is related to the atrioventricular node, is placed inferiorly relative to the left ventricular outflow tract. The bovine atrioventricular conduction axis, therefore, originates from a node itself located inferiorly compared to the human arrangement. The axis must then skirt the non-coronary sinus of the aortic root prior to penetrating the thicker muscular ventricular septum, thus accounting for its long non-branching course. We envisage that our findings will further enhance comparative anatomical research.
Collapse
Affiliation(s)
- Marcos C De Almeida
- Department of Genetics and Morphology, Brasilia's University, Brasilia, Brazil
| | - Shumpei Mori
- UCLA Cardiac Arrhythmia Center, UCLA Health System, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Robert H Anderson
- Biosciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| |
Collapse
|
6
|
Zaky A, Meers JB, Townsley MM. Appraising the Left Ventricular Outflow Tract: An Ongoing Challenge. J Cardiothorac Vasc Anesth 2020; 35:796-798. [PMID: 33309495 DOI: 10.1053/j.jvca.2020.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Ahmed Zaky
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - J Brad Meers
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Matthew M Townsley
- Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, AL
| |
Collapse
|
7
|
Transcatheter Mitral Valve Planning and the Neo-LVOT: Utilization of Virtual Simulation Models and 3D Printing. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2018; 20:99. [PMID: 30367270 DOI: 10.1007/s11936-018-0694-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW Transcatheter mitral valve replacement (TMVR) is an emerging alternative for patients with severe mitral valve regurgitation who are considered at high risk for conventional surgical options. The early clinical experience with TMVR has shown that pre-procedural planning with computed tomography (CT) is needed to mitigate the risk of potentially lethal procedural complications such as left ventricular outflow tract (LVOT) obstruction. The goal of this review is to provide an overview of key concepts relating to TMVR pre-procedural planning, with particular emphasis on imaging-based methods for predicting TMVR-related LVOT obstruction. RECENT FINDINGS Risk of LVOT obstruction can be assessed with CT-based pre-procedural planning by using virtual device simulations to estimate the residual 'neo-LVOT' cross-sectional area which remains after device implantation. A neo-LVOT area of less than 2 cm2 is currently thought to increase the risk of obstruction; however, additional studies are needed to further validate this cutoff value. Three-dimensional printing and personalized computational simulations are also emerging as valuable tools which may offer insights not readily confered by conventional two-dimensional image analysis. The simulated neo-LVOT should be routinely assessed on pre-procedural CT when evaluating anatomical suitability for TMVR.
Collapse
|
8
|
Wang DD, Eng MH, Greenbaum AB, Myers E, Forbes M, Karabon P, Pantelic M, Song T, Nadig J, Guerrero M, O'Neill WW. Validating a prediction modeling tool for left ventricular outflow tract (LVOT) obstruction after transcatheter mitral valve replacement (TMVR). Catheter Cardiovasc Interv 2017; 92:379-387. [DOI: 10.1002/ccd.27447] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 10/27/2017] [Accepted: 11/16/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Dee Dee Wang
- Center for Structural Heart Disease, Division of Cardiology; Henry Ford Health System; Detroit Michigan
| | - Marvin H. Eng
- Center for Structural Heart Disease, Division of Cardiology; Henry Ford Health System; Detroit Michigan
| | - Adam B. Greenbaum
- Center for Structural Heart Disease, Division of Cardiology; Henry Ford Health System; Detroit Michigan
| | - Eric Myers
- Center for Structural Heart Disease, Division of Cardiology; Henry Ford Health System; Detroit Michigan
| | - Michael Forbes
- Center for Structural Heart Disease, Division of Cardiology; Henry Ford Health System; Detroit Michigan
| | - Patrick Karabon
- Center for Structural Heart Disease, Division of Cardiology; Henry Ford Health System; Detroit Michigan
| | - Milan Pantelic
- Department of Radiology; Henry Ford Health System; Detroit Michigan
| | - Thomas Song
- Department of Radiology; Henry Ford Health System; Detroit Michigan
| | - Jeff Nadig
- Department of Radiology; Henry Ford Health System; Detroit Michigan
| | - Mayra Guerrero
- Division of Cardiology; Evanston Hospital, North Shore University Health System; Chicago Illinois
| | - William W. O'Neill
- Center for Structural Heart Disease, Division of Cardiology; Henry Ford Health System; Detroit Michigan
| |
Collapse
|
9
|
Murphy DJ, Ge Y, Don CW, Keraliya A, Aghayev A, Morgan R, Galper B, Bhatt DL, Kaneko T, Di Carli M, Shah P, Steigner M, Blankstein R. Use of Cardiac Computerized Tomography to Predict Neo-Left Ventricular Outflow Tract Obstruction Before Transcatheter Mitral Valve Replacement. J Am Heart Assoc 2017; 6:e007353. [PMID: 29102981 PMCID: PMC5721795 DOI: 10.1161/jaha.117.007353] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- David J Murphy
- Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Yin Ge
- Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Abhishek Keraliya
- Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ayaz Aghayev
- Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Roisin Morgan
- Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Deepak L Bhatt
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | - Tsuyoshi Kaneko
- Cardiac Surgery Division, Brigham and Women's Hospital, Boston, MA
| | - Marcelo Di Carli
- Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Pinak Shah
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | - Michael Steigner
- Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
10
|
Lin CY, Chung FP, Lin YJ, Chang SL, Lo LW, Hu YF, Liao JN, Tuan TC, Chao TF, Chang YT, Chen YY, Te ALD, Yamada S, Kuo L, Vicera JJB, Chang TY, Minh HQ, Salim S, Huang TC, Chen SA. Novel electrophysiological criteria for septal ventricular outflow tract tachycardias requiring a sequential bilateral ablation. J Cardiovasc Electrophysiol 2017; 29:298-307. [PMID: 29071756 DOI: 10.1111/jce.13376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/17/2017] [Accepted: 10/20/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Septal ventricular outflow tract ventricular arrhythmias (OT-VAs) are defined as septal origin VAs from the right ventricular or left ventricular OT. Patients with septal OT-VAs may require a sequential bilateral OT ablation. This study aimed to evaluate the electrophysiological characteristics and ablation outcome in patients with septal OT-VAs. METHODS We retrospectively analyzed the electrocardiography and electrophysiological parameters in 96 patients (mean age 49 ± 15 years, 49 male) undergoing bilateral activation mapping before catheter ablation of idiopathic septal OT-VAs. The patients were categorized into three groups based on the successful ablation sites, including the right ventricular outflow tract (RVOT), RVOT/left ventricular outflow tract (LVOT), and LVOT. RESULTS Mapping in the three groups demonstrated a gradually decreasing and increasing trend in the earliest activation time obtained from the RVOT and LVOT, respectively. The absolute earliest activation time discrepancy (AEAD) of ≤18 milliseconds could predict the requirement for a sequential bilateral ablation with a sensitivity and specificity of 100.0% and 93.7%, respectively. The small AEAD (≤21 milliseconds) was associated with a higher recurrence rate in patients receiving a successful unilateral ablation, while patients with a longer distance between the bilateral OT earliest activation sites (DEA > 26 mm) increased future recurrences after an initially successful sequential bilateral ablation. CONCLUSIONS The application of bilateral OT-VA activation mapping and the measurement of the AEAD and DEA provided not only pivotal information for the ablation strategy, but also prognostic implications for recurrences in patients with septal OT-VAs.
Collapse
Affiliation(s)
- Chin-Yu Lin
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Department of Medicine, Taipei Veterans General Hospital, YuanShan Branch, Yi-Lan, Taiwan
| | - Fa-Po Chung
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Lin Chang
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Li-Wei Lo
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yu-Feng Hu
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jo-Nan Liao
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ta-Chuan Tuan
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Tze-Fan Chao
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yao-Ting Chang
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yun-Yu Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,Institute of Epidemiology and Preventive Medicine College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Abigail Louise D Te
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shinya Yamada
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ling Kuo
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jennifer Jeanne B Vicera
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ting-Yung Chang
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hoang Quang Minh
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Simon Salim
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ting-Chung Huang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shih-Ann Chen
- Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan.,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| |
Collapse
|
11
|
Padmanabhan D, Sugrue A, Gaba P, Asirvatham SJ. Outflow tract ventricular arrhythmias : Electrocardiographic features in relation to mapping and ablation. Herzschrittmacherther Elektrophysiol 2017; 28:177-186. [PMID: 28534205 DOI: 10.1007/s00399-017-0507-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 04/13/2017] [Indexed: 10/19/2022]
Abstract
Ventricular arrhythmia arising from the outflow tracts can manifest itself as frequent premature ventricular complexes (PVCs), salvos of ventricular tachycardia (VT), and/or sustained VT. It is amenable to management with medication and catheter ablation without need for an intracardiac defibrillator. The electrocardiogram (ECG) is a crucial tool in the management of these patients as it is can help localize the site of origin, thereby helping guide the electrophysiologist. An appreciation of the unique anatomy of the outflow tracts as well as their relationships with the surrounding structures is essential in interpreting the ECG. In this review, we examine the ECG features of the various outflow tract arrhythmia morphologies with a focus on anatomy and provide an approach to the ablation of these abnormal rhythms.
Collapse
Affiliation(s)
- Deepak Padmanabhan
- Department of Cardiovascular Sciences, Mayo Clinic, 55901, Rochester, MN, USA
| | - Alan Sugrue
- Department of Cardiovascular Sciences, Mayo Clinic, 55901, Rochester, MN, USA
| | - Prakriti Gaba
- Department of Cardiovascular Sciences, Mayo Clinic, 55901, Rochester, MN, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Sciences, Mayo Clinic, 55901, Rochester, MN, USA.
| |
Collapse
|
12
|
Anatomy and Function of the Normal and Diseased Mitral Apparatus: Implications for Transcatheter Therapy. Interv Cardiol Clin 2016; 5:1-16. [PMID: 27852475 DOI: 10.1016/j.iccl.2015.08.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Transcatheter mitral valve therapy requires an in-depth understanding of the mitral valve apparatus (annulus, leaflets, chordae tendinae, and papillary muscles) and the impact of various disease states. Adjacent structures (left atrium, left ventricular outflow tract, aortic valve, coronary sinus, and circumflex artery) must also be respected. This article reviews the anatomy and function of the normal and diseased mitral valve apparatus and the implications for catheter-based intervention.
Collapse
|
13
|
|
14
|
Mehrotra P, Flynn AW, Jansen K, Tan TC, Mak G, Julien HM, Zeng X, Picard MH, Passeri JJ, Hung J. Differential Left Ventricular Outflow Tract Remodeling and Dynamics in Aortic Stenosis. J Am Soc Echocardiogr 2015; 28:1259-66. [DOI: 10.1016/j.echo.2015.07.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Indexed: 10/23/2022]
|
15
|
Acosta J, Penela D, Herczku C, Macías Y, Andreu D, Fernández-Armenta J, Cipolletta L, Díaz A, Korshunov V, Brugada J, Mont L, Cabrera JA, Sánchez-Quintana D, Berruezo A. Impact of earliest activation site location in the septal right ventricular outflow tract for identification of left vs right outflow tract origin of idiopathic ventricular arrhythmias. Heart Rhythm 2015; 12:726-34. [DOI: 10.1016/j.hrthm.2014.12.029] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Indexed: 11/24/2022]
|
16
|
Khan S, Ripley D, de Belder M, Goodwin A, Barham N, Wright R. Left ventricular outflow tract obstruction following an uncomplicated primary percutaneous coronary intervention: a recognized but rare cause of cardiogenic shock. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2013; 2:68-71. [PMID: 24062935 DOI: 10.1177/2048872612471204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 11/25/2012] [Indexed: 11/16/2022]
Abstract
Dynamic left ventricular outflow tract obstruction is a rare but important complication of myocardial infarction. It occurs acutely and may mimic the presentation of papillary muscle rupture or acquired ventricular septal defect. Unlike these mechanical complications, it does not require circulatory support or cardiac surgical intervention. Recognition is critical because it typically responds to volume loading and beta blockade. We report a case who displayed many classical features of this condition.
Collapse
Affiliation(s)
- S Khan
- The James Cook University Hospital, Middlesbrough, UK
| | | | | | | | | | | |
Collapse
|
17
|
Bhakta MD, Sorajja D, Scott LRP, Srivathsan K. Linear segmental isolation of the left coronary cusp to eliminate ventricular arrhythmia originating in close proximity to left main coronary artery. J Interv Card Electrophysiol 2011; 32:53-7. [PMID: 21643777 DOI: 10.1007/s10840-011-9581-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Accepted: 04/14/2011] [Indexed: 10/18/2022]
Affiliation(s)
- Mayurkumar D Bhakta
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Scottsdale, AZ, USA
| | | | | | | |
Collapse
|
18
|
|
19
|
Ho SY. Structure and anatomy of the aortic root. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2009; 10:i3-10. [DOI: 10.1093/ejechocard/jen243] [Citation(s) in RCA: 189] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
20
|
|
21
|
Srivathsan KS, Bunch TJ, Asirvatham SJ, Edwards WD, Friedman PA, Munger TM, Hammill SC, Cha YM, Brady PA, Jahangir A, Bradley DJ, Rea RF, Packer DL, Shen WK. Mechanisms and Utility of Discrete Great Arterial Potentials in the Ablation of Outflow Tract Ventricular Arrhythmias. Circ Arrhythm Electrophysiol 2008; 1:30-8. [DOI: 10.1161/circep.107.750315] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Komandoor S. Srivathsan
- From the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Scottsdale, Ariz (K.S.S.), and Rochester, Minn (T.J.B., S.J.A., P.A.F., T.M.M., S.C.H., Y.-M.C., P.A.B., A.J., D.J.B., R.F.R., D.L.P., W.-K.S.), and the Division of Anatomic Pathology, Mayo Clinic, Rochester, Minn (W.D.E.)
| | - T. Jared Bunch
- From the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Scottsdale, Ariz (K.S.S.), and Rochester, Minn (T.J.B., S.J.A., P.A.F., T.M.M., S.C.H., Y.-M.C., P.A.B., A.J., D.J.B., R.F.R., D.L.P., W.-K.S.), and the Division of Anatomic Pathology, Mayo Clinic, Rochester, Minn (W.D.E.)
| | - Samuel J. Asirvatham
- From the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Scottsdale, Ariz (K.S.S.), and Rochester, Minn (T.J.B., S.J.A., P.A.F., T.M.M., S.C.H., Y.-M.C., P.A.B., A.J., D.J.B., R.F.R., D.L.P., W.-K.S.), and the Division of Anatomic Pathology, Mayo Clinic, Rochester, Minn (W.D.E.)
| | - William D. Edwards
- From the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Scottsdale, Ariz (K.S.S.), and Rochester, Minn (T.J.B., S.J.A., P.A.F., T.M.M., S.C.H., Y.-M.C., P.A.B., A.J., D.J.B., R.F.R., D.L.P., W.-K.S.), and the Division of Anatomic Pathology, Mayo Clinic, Rochester, Minn (W.D.E.)
| | - Paul A. Friedman
- From the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Scottsdale, Ariz (K.S.S.), and Rochester, Minn (T.J.B., S.J.A., P.A.F., T.M.M., S.C.H., Y.-M.C., P.A.B., A.J., D.J.B., R.F.R., D.L.P., W.-K.S.), and the Division of Anatomic Pathology, Mayo Clinic, Rochester, Minn (W.D.E.)
| | - Thomas M. Munger
- From the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Scottsdale, Ariz (K.S.S.), and Rochester, Minn (T.J.B., S.J.A., P.A.F., T.M.M., S.C.H., Y.-M.C., P.A.B., A.J., D.J.B., R.F.R., D.L.P., W.-K.S.), and the Division of Anatomic Pathology, Mayo Clinic, Rochester, Minn (W.D.E.)
| | - Stephen C. Hammill
- From the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Scottsdale, Ariz (K.S.S.), and Rochester, Minn (T.J.B., S.J.A., P.A.F., T.M.M., S.C.H., Y.-M.C., P.A.B., A.J., D.J.B., R.F.R., D.L.P., W.-K.S.), and the Division of Anatomic Pathology, Mayo Clinic, Rochester, Minn (W.D.E.)
| | - Yong-Mei Cha
- From the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Scottsdale, Ariz (K.S.S.), and Rochester, Minn (T.J.B., S.J.A., P.A.F., T.M.M., S.C.H., Y.-M.C., P.A.B., A.J., D.J.B., R.F.R., D.L.P., W.-K.S.), and the Division of Anatomic Pathology, Mayo Clinic, Rochester, Minn (W.D.E.)
| | - Peter A. Brady
- From the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Scottsdale, Ariz (K.S.S.), and Rochester, Minn (T.J.B., S.J.A., P.A.F., T.M.M., S.C.H., Y.-M.C., P.A.B., A.J., D.J.B., R.F.R., D.L.P., W.-K.S.), and the Division of Anatomic Pathology, Mayo Clinic, Rochester, Minn (W.D.E.)
| | - Arshad Jahangir
- From the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Scottsdale, Ariz (K.S.S.), and Rochester, Minn (T.J.B., S.J.A., P.A.F., T.M.M., S.C.H., Y.-M.C., P.A.B., A.J., D.J.B., R.F.R., D.L.P., W.-K.S.), and the Division of Anatomic Pathology, Mayo Clinic, Rochester, Minn (W.D.E.)
| | - David J. Bradley
- From the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Scottsdale, Ariz (K.S.S.), and Rochester, Minn (T.J.B., S.J.A., P.A.F., T.M.M., S.C.H., Y.-M.C., P.A.B., A.J., D.J.B., R.F.R., D.L.P., W.-K.S.), and the Division of Anatomic Pathology, Mayo Clinic, Rochester, Minn (W.D.E.)
| | - Robert F. Rea
- From the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Scottsdale, Ariz (K.S.S.), and Rochester, Minn (T.J.B., S.J.A., P.A.F., T.M.M., S.C.H., Y.-M.C., P.A.B., A.J., D.J.B., R.F.R., D.L.P., W.-K.S.), and the Division of Anatomic Pathology, Mayo Clinic, Rochester, Minn (W.D.E.)
| | - Douglas L. Packer
- From the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Scottsdale, Ariz (K.S.S.), and Rochester, Minn (T.J.B., S.J.A., P.A.F., T.M.M., S.C.H., Y.-M.C., P.A.B., A.J., D.J.B., R.F.R., D.L.P., W.-K.S.), and the Division of Anatomic Pathology, Mayo Clinic, Rochester, Minn (W.D.E.)
| | - Win-Kuang Shen
- From the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Scottsdale, Ariz (K.S.S.), and Rochester, Minn (T.J.B., S.J.A., P.A.F., T.M.M., S.C.H., Y.-M.C., P.A.B., A.J., D.J.B., R.F.R., D.L.P., W.-K.S.), and the Division of Anatomic Pathology, Mayo Clinic, Rochester, Minn (W.D.E.)
| |
Collapse
|
22
|
|