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Bisht DS, Kishor K. The Janus Heads of ventricular Tachycardia: Single-circuit with dual exits. Indian Pacing Electrophysiol J 2024:S0972-6292(24)00115-3. [PMID: 39218353 DOI: 10.1016/j.ipej.2024.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 08/02/2024] [Accepted: 08/30/2024] [Indexed: 09/04/2024] Open
Abstract
In the setting of ischemic heart disease (IHD), ventricular tachycardia (VT) commonly originates from areas of incomplete scar tissue. High-density electroanatomic mapping has enhanced our understanding of VT circuits, predominantly characterised by dense scar and surviving myocyte bundles. We present a case of a 58-year-old male with IHD and sustained monomorphic VT, successfully treated with radiofrequency ablation following high-density mapping and entrainment techniques. Two inducible VT phenotypes were identified, with ablation at one site effectively terminating both VT morphologies. This case illustrates the importance of precise circuit localisation and targeted ablation in managing post-infarction VT, leading to a satisfactory patient outcome.
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Affiliation(s)
| | - Kamal Kishor
- Mukat Hospital & Heart Institute, Chandigarh, India.
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2
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Santangeli P, Higuchi K, Sroubek J. Ventricular Tachycardia Ablation Endpoints: Moving Beyond Noninducibility. JACC Clin Electrophysiol 2024; 10:981-999. [PMID: 38385913 DOI: 10.1016/j.jacep.2023.12.009] [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] [Received: 08/15/2023] [Revised: 12/08/2023] [Accepted: 12/30/2023] [Indexed: 02/23/2024]
Abstract
In patients with structural heart disease and ventricular tachycardia (VT) undergoing catheter ablation, the response to programmed electrical stimulation (PES) at the end of the procedure has been traditionally used to evaluate the acute success and predict long-term outcomes. Although noninducibility at PES has been extensively investigated and validated in clinical trials and large multicenter registries, its performance in predicting long-term freedom from VT is suboptimal. In addition, PES has inherent limitations related to the influence of background antiarrhythmic drug therapy, periprocedural use of anesthesia, and the heterogeneity in PES protocols. The increased utilization of substrate-based ablation approaches that focus on ablation of abnormal electrograms identified with mapping in sinus or paced rhythm has been paralleled by a need for additional procedural endpoints beyond VT noninducibility at PES. This article critically appraises the relative merits and limitations of different procedural endpoints according to different ablation techniques for catheter ablation of scar-related VT.
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Affiliation(s)
- Pasquale Santangeli
- Section of Cardiac Pacing and Electrophysiology, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA.
| | - Koji Higuchi
- Section of Cardiac Pacing and Electrophysiology, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jakub Sroubek
- Section of Cardiac Pacing and Electrophysiology, Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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3
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Saitoh O, Kasai T, Fuse K, Oikawa A, Furushima H, Chinushi M. Impedance-decline-guide power control long application time bipolar radiofrequency catheter ablation. J Cardiovasc Electrophysiol 2022; 33:2538-2545. [PMID: 36135613 DOI: 10.1111/jce.15684] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 09/15/2022] [Accepted: 09/17/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Bipolar (BIP) radiofrequency (RF) ablation creates deep myocardial lesions but ideal energy application modes to treat ventricular arrhythmias originating from deep inside the thick myocardium have not been well established. An experimental study was performed to clarify whether high power and long application time BIP ablation were performable by impedance-decline-guide power control (PC) and whether it could create transmural lesions in the thick ventricle with a minimum risk of steam-pop. METHODS AND RESULTS Perfused porcine ventricle (18.4 ± 2.3 mm) was placed in an experimental bath and BIP ablation (50 W) for 120 s was attempted with catheter contact of 30-g using two protocols; fixed power (FP) and impedance-decline-guide PC. In the latter protocol, BIP ablation was started from 50 W, while the energy was decreased to 40-20 W according to the impedance decline during RF ablation. FP ablation was attempted in 30 applications and the transmural lesion was created in all 30, although steam-pop occurred in 16/30 applications (53%). Low minimum impedance, large total impedance decline (TID), and %-TID were associated with the steam-pop occurrence. PC ablation was attempted in another 21 applications, and the transmural lesion was created in all 21 without steam-pop. PC ablation was superior to FP ablation (21/21 vs. 14/30, p < .001) in the creation of a transmural lesion without resulting in steam-pop. CONCLUSIONS High power and long application time BIP ablation seems to be feasible according to the impedance-decline-guide approach, which could create transmural lesions in thick porcine ventricles with minimal risk of steam-pop.
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Affiliation(s)
- Osamu Saitoh
- Cardiovascular Research of Graduate School of Health Sciences, Niigata University School of Medicine, Niigata, Japan
| | - Takumi Kasai
- Cardiovascular Research of Graduate School of Health Sciences, Niigata University School of Medicine, Niigata, Japan
| | - Kyogo Fuse
- Cardiovascular Research of Graduate School of Health Sciences, Niigata University School of Medicine, Niigata, Japan
| | - Ayaka Oikawa
- Cardiovascular Research of Graduate School of Health Sciences, Niigata University School of Medicine, Niigata, Japan
| | - Hiroshi Furushima
- Cardiovascular Research of Graduate School of Health Sciences, Niigata University School of Medicine, Niigata, Japan
| | - Masaomi Chinushi
- Cardiovascular Research of Graduate School of Health Sciences, Niigata University School of Medicine, Niigata, Japan
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4
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Wiles BM, Li AC, Waight MC, Saba MM. Contemporary Management of Complex Ventricular Arrhythmias. Arrhythm Electrophysiol Rev 2022; 11:e04. [PMID: 35734144 PMCID: PMC9194914 DOI: 10.15420/aer.2021.66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/06/2022] [Indexed: 12/02/2022] Open
Abstract
Percutaneous catheter ablation is an effective and safe therapy that can eliminate ventricular tachycardia, reducing the risks of both recurrent arrhythmia and shock therapies from a defibrillator. Successful ablation requires accurate identification of arrhythmic substrate and the effective delivery of energy to the targeted tissue. A thorough pre-procedural assessment is needed before considered 3D electroanatomical mapping can be performed. In contemporary practice, this must combine traditional electrophysiological techniques, such as activation and entrainment mapping, with more novel physiological mapping techniques for which there is an ever-increasing evidence base. Novel techniques to maximise energy delivery to the tissue must also be considered and balanced against their associated risks of complication. This review provides a comprehensive appraisal of contemporary practice and the evidence base that supports recent developments in mapping and ablation, while also considering potential future developments in the field.
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Affiliation(s)
- Benedict M Wiles
- Advanced Ventricular Arrhythmia Training and Research (AVATAR) Program, St George's University Hospitals NHS Foundation Trust, London, UK
- Cardiology Clinical Academic Group, St George's University of London, London, UK
| | - Anthony C Li
- Advanced Ventricular Arrhythmia Training and Research (AVATAR) Program, St George's University Hospitals NHS Foundation Trust, London, UK
- Cardiology Clinical Academic Group, St George's University of London, London, UK
| | - Michael C Waight
- Advanced Ventricular Arrhythmia Training and Research (AVATAR) Program, St George's University Hospitals NHS Foundation Trust, London, UK
- Cardiology Clinical Academic Group, St George's University of London, London, UK
| | - Magdi M Saba
- Advanced Ventricular Arrhythmia Training and Research (AVATAR) Program, St George's University Hospitals NHS Foundation Trust, London, UK
- Cardiology Clinical Academic Group, St George's University of London, London, UK
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5
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto S, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 guideline on non-pharmacotherapy of cardiac arrhythmias. J Arrhythm 2021; 37:709-870. [PMID: 34386109 PMCID: PMC8339126 DOI: 10.1002/joa3.12491] [Citation(s) in RCA: 94] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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6
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Srinivasan NT, Garcia J, Schilling RJ, Ahsan S, Hunter RJ, Lowe M, Chow AW, Lambiase PD. Dynamic spatial dispersion of repolarization is present in regions critical for ischemic ventricular tachycardia ablation. Heart Rhythm O2 2021; 2:280-289. [PMID: 34337579 PMCID: PMC8322930 DOI: 10.1016/j.hroo.2021.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The presence of dynamic substrate changes may facilitate functional block and reentry in ventricular tachycardia (VT). OBJECTIVE We aimed to study dynamic ventricular repolarization changes in critical regions of the VT circuit during sensed single extrastimulus pacing known as the Sense Protocol (SP). METHODS Twenty patients (aged 67 ± 9 years, 17 male) underwent VT ablation. A bipolar voltage map was obtained during sinus rhythm (SR) and right ventricular SP pacing at 20 ms above ventricular effective refractory period. Ventricular repolarization maps were constructed. Ventricular repolarization time (RT) was calculated from unipolar electrogram T waves, using the Wyatt method, as the dV/dtmax of the unipolar T wave. Entrainment or pace mapping confirmed critical sites for ablation. RESULTS The median global repolarization range (max-min RT per patient) was 166 ms (interquartile range [IQR] 143-181 ms) during SR mapping vs 208 ms (IQR 182-234) during SP mapping (P = .0003 vs intrinsic rhythm). Regions of late potentials (LP) had a longer RT during SP mapping compared to regions without LP (mean 394 ± 40 ms vs 342 ± 25 ms, P < .001). In paired regions of normal myocardium there was no significant spatial dispersion of repolarization (SDR)/10 mm2 during SP mapping vs SR mapping (SDR 11 ± 6 ms vs 10 ± 6 ms, P = .54). SDR/10 mm2 was greater in critical areas of the VT circuit during SP mapping 63 ± 29 ms vs SR mapping 16 ± 9 ms (P < .001). CONCLUSION Ventricular repolarization is prolonged in regions of LP and increases dynamically, resulting in dynamic SDR in critical areas of the VT circuit. These dynamic substrate changes may be an important factor that facilitates VT circuits.
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Affiliation(s)
- Neil T. Srinivasan
- Department of Cardiac Electrophysiology, The Essex Cardiothoracic Centre, Basildon, Essex, United Kingdom
- Department of Cardiac Electrophysiology, The Barts Heart Center, St Bartholomew’s Hospital, London, United Kingdom
- Institute of Cardiovascular Science, University College London, London, United Kingdom
- Circulatory Health Research Group, Medical Technology Research Centre, School of Medicine, Anglia Ruskin University, Essex, United Kingdom
| | - Jason Garcia
- Department of Cardiac Electrophysiology, The Barts Heart Center, St Bartholomew’s Hospital, London, United Kingdom
| | - Richard J. Schilling
- Department of Cardiac Electrophysiology, The Barts Heart Center, St Bartholomew’s Hospital, London, United Kingdom
| | - Syed Ahsan
- Department of Cardiac Electrophysiology, The Barts Heart Center, St Bartholomew’s Hospital, London, United Kingdom
| | - Ross J. Hunter
- Department of Cardiac Electrophysiology, The Barts Heart Center, St Bartholomew’s Hospital, London, United Kingdom
| | - Martin Lowe
- Department of Cardiac Electrophysiology, The Barts Heart Center, St Bartholomew’s Hospital, London, United Kingdom
| | - Anthony W. Chow
- Department of Cardiac Electrophysiology, The Barts Heart Center, St Bartholomew’s Hospital, London, United Kingdom
| | - Pier D. Lambiase
- Department of Cardiac Electrophysiology, The Barts Heart Center, St Bartholomew’s Hospital, London, United Kingdom
- Institute of Cardiovascular Science, University College London, London, United Kingdom
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7
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto SI, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 Guideline on Non-Pharmacotherapy of Cardiac Arrhythmias. Circ J 2021; 85:1104-1244. [PMID: 34078838 DOI: 10.1253/circj.cj-20-0637] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Haruhiko Abe
- Department of Heart Rhythm Management, University of Occupational and Environmental Health, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital
| | - Toshiyuki Ishikawa
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University
| | - Katsuhiko Imai
- Department of Cardiovascular Surgery, Kure Medical Center and Chugoku Cancer Center
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kaoru Okishige
- Department of Cardiology, Yokohama City Minato Red Cross Hospital
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Morio Shoda
- Department of Cardiology, Tokyo Women's Medical University
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Yoshihiro Seo
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui
| | | | - Yuji Nakazato
- Department of Cardiovascular Medicine, Juntendo University Urayasu Hospital
| | - Takashi Nishimura
- Department of Cardiac Surgery, Tokyo Metropolitan Geriatric Hospital
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | | | - Yuji Murakawa
- Fourth Department of Internal Medicine, Teikyo University Hospital Mizonokuchi
| | - Teiichi Yamane
- Department of Cardiology, Jikei University School of Medicine
| | - Takeshi Aiba
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Koichi Inoue
- Division of Arrhythmia, Cardiovascular Center, Sakurabashi Watanabe Hospital
| | - Yuki Iwasaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kikuya Uno
- Arrhythmia Center, Chiba Nishi General Hospital
| | - Michio Ogano
- Department of Cardiovascular Medicine, Shizuoka Medical Center
| | - Masaomi Kimura
- Advanced Management of Cardiac Arrhythmias, Hirosaki University Graduate School of Medicine
| | | | - Shingo Sasaki
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine
| | | | - Tsuyoshi Shiga
- Department of Cardiology, Tokyo Women's Medical University
| | - Tsugutoshi Suzuki
- Departments of Pediatric Electrophysiology, Osaka City General Hospital
| | - Yukio Sekiguchi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Kyoko Soejima
- Arrhythmia Center, Second Department of Internal Medicine, Kyorin University Hospital
| | - Masahiko Takagi
- Division of Cardiac Arrhythmia, Department of Internal Medicine II, Kansai Medical University
| | - Masaomi Chinushi
- School of Health Sciences, Faculty of Medicine, Niigata University
| | - Nobuhiro Nishi
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hitoshi Hachiya
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | | | | | - Yasushi Miyauchi
- Department of Cardiovascular Medicine, Nippon Medical School Chiba-Hokusoh Hospital
| | - Aya Miyazaki
- Department of Pediatric Cardiology, Congenital Heart Disease Center, Tenri Hospital
| | - Tomoshige Morimoto
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Hiro Yamasaki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | | | - Takeshi Kimura
- Department of Cardiology, Graduate School of Medicine and Faculty of Medicine, Kyoto University
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Sáenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Europace 2020; 21:1143-1144. [PMID: 31075787 DOI: 10.1093/europace/euz132] [Citation(s) in RCA: 222] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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9
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Bella PD, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. J Interv Card Electrophysiol 2020; 59:145-298. [PMID: 31984466 PMCID: PMC7223859 DOI: 10.1007/s10840-019-00663-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, IN, USA
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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10
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Rottmann M, Kleber AG, Barkagan M, Sroubek J, Leshem E, Shapira-Daniels A, Buxton AE, Anter E. Activation During Sinus Rhythm in Ventricles With Healed Infarction: Differentiation Between Arrhythmogenic and Nonarrhythmogenic Scar. Circ Arrhythm Electrophysiol 2019; 12:e007879. [PMID: 31597477 DOI: 10.1161/circep.119.007879] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In infarct-related ventricular tachycardia (VT), the circuit often corresponds to a location characterized by activation slowing during sinus rhythm (SR). However, the relationship between activation slowing during SR and vulnerability for reentry and correlation to components of the VT circuit are unknown. This study examined the relationship between activation slowing during SR and vulnerability for reentry and correlated these areas with components of the circuit. METHODS In a porcine model of healed infarction, the spatial distribution of endocardial activation velocity was compared between SR and VT. Isthmus sites were defined using activation and entrainment mapping as areas exhibiting diastolic activity within the circuit while bystanders were defined as areas displaying diastolic activity outside the circuit. RESULTS Of 15 swine, 9 had inducible VT (5.2±3.0 per animal) while in 6 swine VT could not be induced despite stimulation from 4 RV and LV sites at 2 drive trains with 6 extra-stimuli down to refractoriness. Infarcts with VT had a greater magnitude of activation slowing during SR. A minimal endocardial activation velocity cutoff ≤0.1 m/s differentiated inducible from noninducible infarctions (P=0.015). Regions of maximal endocardial slowing during SR corresponded to the VT isthmus (area under curve=0.84 95% CI, 0.78-0.90) while bystander sites exhibited near-normal activation during SR. VT circuits were complex with 41.7% exhibiting discontinuous propagation with intramural bridges of slow conduction and delayed quasi-simultaneous endocardial activation. Regions forming the VT isthmus borders had faster activation during SR while regions forming the inner isthmus were activated faster during VT. CONCLUSIONS Endocardial activation slowing during SR may differentiate infarctions vulnerable for VT from those less vulnerable for VT. Sites of slow activation during SR correspond to sites forming the VT isthmus but not to bystander sites.
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Affiliation(s)
- Markus Rottmann
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Andre G Kleber
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Michael Barkagan
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jakub Sroubek
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Eran Leshem
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Ayelet Shapira-Daniels
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Alfred E Buxton
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Elad Anter
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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11
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Heart Rhythm 2019; 17:e2-e154. [PMID: 31085023 PMCID: PMC8453449 DOI: 10.1016/j.hrthm.2019.03.002] [Citation(s) in RCA: 186] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Indexed: 01/10/2023]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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12
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Kitamura T, Martin CA, Vlachos K, Martin R, Frontera A, Takigawa M, Thompson N, Cheniti G, Massouille G, Lam A, Bourier F, Duchateau J, Pambrun T, Denis A, Derval N, Hocini M, HaÏssaguerre M, Cochet H, JaÏs P, Sacher F. Substrate Mapping and Ablation for Ventricular Tachycardia in Patients with Structural Heart Disease: How to Identify Ventricular Tachycardia Substrate. J Innov Card Rhythm Manag 2019; 10:3565-3580. [PMID: 32477720 PMCID: PMC7252795 DOI: 10.19102/icrm.2019.100302] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 08/20/2018] [Indexed: 01/02/2023] Open
Abstract
Catheter ablation for ventricular tachycardia (VT) has been increasingly used over the past two decades in patients with structural heart disease (SHD). In these individuals, a substrate mapping strategy is being more commonly applied to identify targets for VT ablation, which has been shown to be more effective versus targeting mappable VTs alone. There are a number of substrate mapping methods in existence that aim to explore potential VT isthmuses, although their success rates vary. Most of the reported electrogram-based mapping studies have been performed with ablation catheters; meanwhile, the use of multipolar mapping catheters with smaller electrodes and closer interelectrode spacing has emerged, which allows for an assessment of detailed near-field abnormal electrograms at a higher resolution. Another recent advancement has occurred in the use of imaging techniques in VT ablation, particularly in refining the substrate. The goal of this paper is to review the key developments and limitations of current mapping strategies of substrate-based VT ablation and their outcomes. In addition, we briefly summarize the role of cardiac imaging in delineating VT substrate.
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Affiliation(s)
- Takeshi Kitamura
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France.,Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Claire A Martin
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France.,Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Konstantinos Vlachos
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Ruairidh Martin
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France.,Newcastle University, Newcastle-upon-Tyne, UK
| | - Antonio Frontera
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France.,San Raffaele Hospital, Milan, Italy
| | - Masateru Takigawa
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Nathaniel Thompson
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Ghassen Cheniti
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Gregoire Massouille
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Anna Lam
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Felix Bourier
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Josselin Duchateau
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Thomas Pambrun
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Arnaud Denis
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Nicolas Derval
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Meleze Hocini
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Michel HaÏssaguerre
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Hubert Cochet
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Pierre JaÏs
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Frédéric Sacher
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
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13
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Preoperative imaging in search of ventricular tachycardia circuit. Heart Rhythm 2018; 16:595-596. [PMID: 30445169 DOI: 10.1016/j.hrthm.2018.11.012] [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: 11/06/2018] [Indexed: 11/24/2022]
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14
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Shimada H, Nishizaki M, Yamawake N, Suzuki M, Sakurada H, Hiraoka M. A case of scar-related ventricular tachycardia demonstrating termination with nonglobal capture at the site of concealed entrainment with dual slow conduction pathways. HeartRhythm Case Rep 2018; 4:459-463. [PMID: 30364584 PMCID: PMC6197363 DOI: 10.1016/j.hrcr.2018.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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15
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Jacobson JT, Iwai S, Aronow WS. Treatment of Ventricular Arrhythmias and Use of Implantable Cardioverter-Defibrillators to Improve Survival in Older Adult Patients with Cardiac Disease. Heart Fail Clin 2017; 13:589-605. [PMID: 28602374 DOI: 10.1016/j.hfc.2017.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Ventricular arrhythmia (VA) and sudden cardiac death (SCD) are well-recognized problems in the overall heart failure population, but treatment decisions can be more complex and nuanced in older patients. Sustained VA does not always lead to SCD, but identifies a higher risk population and may cause significant symptoms. Antiarrhythmic drugs (AAD) and catheter ablation are the mainstays for prevention of VA, but have not been shown to improve mortality. The value of implantable cardiac defibrillators (ICDs) may be influenced by patient age. This article discusses long-term treatment of VA and the use of ICDs in the elderly.
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Affiliation(s)
- Jason T Jacobson
- Division of Cardiology, Department of Medicine, Westchester Medical Center, New York Medical College, Macy Pavilion, 100 Woods Road, Valhalla, NY 10595, USA
| | - Sei Iwai
- Division of Cardiology, Department of Medicine, Westchester Medical Center, New York Medical College, Macy Pavilion, 100 Woods Road, Valhalla, NY 10595, USA
| | - Wilbert S Aronow
- Division of Cardiology, Department of Medicine, Westchester Medical Center, New York Medical College, Macy Pavilion, 100 Woods Road, Valhalla, NY 10595, USA.
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16
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Wasmer K, Eckardt L. [3-D mapping and ablation of recurrent ventricular tachycardia in patients with ischemic cardiomyopathy]. Herzschrittmacherther Elektrophysiol 2017; 28:199-205. [PMID: 28534206 DOI: 10.1007/s00399-017-0506-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 04/18/2017] [Indexed: 10/19/2022]
Abstract
Catheter ablation of ventricular tachycardia (VT) is an established therapy for patients with ischemic cardiomyopathy to reduce implantable cardioverter-defibrillator (ICD) interventions and is a class I recommendation in international guidelines. Numerous publications confirm its value. Use of three-dimensional mapping systems with or without image integration is standard for ablation of complex arrhythmias. In patients with history of myocardial infarction they help to understand activation of reentrant circuits and are prerequisite for substrate mapping. While a combination of activation and substrate mapping is performed in many patients based on clinical presentation, substrate-based ablation appears to be superior to clinical VT ablation alone.
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Affiliation(s)
- Kristina Wasmer
- Abteilung für Rhythmologie, Department für Kardiologie und Angiologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland.
| | - Lars Eckardt
- Abteilung für Rhythmologie, Department für Kardiologie und Angiologie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
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17
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Miller JM. Mark E Josephson: Clinical Investigator. Arrhythm Electrophysiol Rev 2017; 6:9-12. [PMID: 28507738 DOI: 10.15420/aer.2017.6.1:ed3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Mark E Josephson entered the world of clinical cardiac electrophysiology (EP) almost at its inception (1972); with so much to learn and so many directions one could take, he dived into the field with unbridled enthusiasm and an uncommon - perhaps almost unique - aptitude for asking questions and finding ways to answer them. Few aspects of EP escaped his indelible influence. In this short paper, I will attempt to touch on some of the high points of his astounding career as a clinical investigator.
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Affiliation(s)
- John M Miller
- Indiana University School of Medicine; Indiana University Health, Indianapolis, USA
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18
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Kinjo T, Sasaki S, Kimura M, Owada S, Horiuchi D, Sasaki K, Itoh T, Ishida Y, Shoji Y, Nishizaki K, Tsushima Y, Tomita H, Okumura K. Long Postpacing Interval After Entrainment of Tachycardia Including a Slow Conduction Zone Within the Circuit. J Cardiovasc Electrophysiol 2016; 27:923-9. [PMID: 27196507 DOI: 10.1111/jce.13014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 05/08/2016] [Accepted: 05/11/2016] [Indexed: 11/27/2022]
Abstract
BACKGROUNDS Postpacing interval (PPI) measured after entrainment pacing describes the distance between pacing site and reentrant circuit. However, the influential features to PPI remain to be elucidated. METHODS AND RESULTS This study included 22 cases with slow/fast atrioventricular (AV) nodal reentrant tachycardia (AVNRT), 14 orthodromic AV reciprocating tachycardia (AVRT) using an accessary pathway, 22 typical atrial flutter (AFL), and 18 other macroreentrant atrial tachycardia (atypical AFL). Rapid pacing at a pacing cycle length (PCL) 5% shorter than tachycardia cycle length (TCL) was done from a site on or close to the reentry circuit. Pacing sites included the coronary sinus ostium in AVNRT, earliest atrial activation site in AVRT, and cavotricuspid isthmus in typical AFL. In atypical AFL, tachycardia circuit was determined on the basis of CARTO mapping, and then the pacing site was. TCL was significantly longer in AVNRT and AVRT than in typical AFL and atypical AFL (both P < 0.05). PCL minus TCL value was similar among the 4 groups. PPI minus TCL value (milliseconds) was significantly longer in AVNRT (median, 40 [IQR, 29-60.8]) and AVRT (34 [20-47]) than in typical AFL (0 [0-4]) and atypical AFL (3.5 [0-8]) (both P < 0.05). Furthermore, PPI minus TCL was prolonged with shortening of PCL in AVNRT and AVRT (both P < 0.05), whereas it was unchanged in typical AFL (P = 0.50). CONCLUSION PPI after concealed entrainment is prolonged compared with TCL when the reentry circuit involves a slow conduction zone with a decremental conduction property such as the AV node.
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Affiliation(s)
- Takahiko Kinjo
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shingo Sasaki
- Department of Advanced Management of Cardiac Arrhythmias, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Masaomi Kimura
- Department of Hypertension and Stroke Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shingen Owada
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Daisuke Horiuchi
- Department of Advanced Management of Cardiac Arrhythmias, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kenichi Sasaki
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Taihei Itoh
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuji Ishida
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yoshihiro Shoji
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kimitaka Nishizaki
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yuichi Tsushima
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hirofumi Tomita
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.,Department of Hypertension and Stroke Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Ken Okumura
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.,Department of Advanced Management of Cardiac Arrhythmias, Hirosaki University Graduate School of Medicine, Hirosaki, Japan.,Department of Hypertension and Stroke Medicine, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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19
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Usefulness of combined CARTO electroanatomical mapping and manifest entrainment in ablating adenosine triphosphate-sensitive atrial tachycardia originating from the atrioventricular node vicinity. J Arrhythm 2016; 32:133-40. [PMID: 27092195 PMCID: PMC4823578 DOI: 10.1016/j.joa.2015.11.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 11/04/2015] [Accepted: 11/12/2015] [Indexed: 11/23/2022] Open
Abstract
Background By using a noncontact mapping system, adenosine triphosphate (ATP)-sensitive atrial tachycardia (ATP-AT) originating from the atrioventricular (AV) node vicinity was successfully ablated at the entrance to the slow conduction zone indicated by the manifest entrainment technique. We aimed to prospectively validate the efficacy of the combination of CARTO electroanatomical mapping and manifest entrainment in ablating this ATP-AT. Methods Of the 27 AT patients from January 2013 to March 2014, 6 patients with sustained ATP-AT were studied (age, 67±13 years; tachycardia cycle length, 350±95 ms). We first created the CARTO map during AT, and performed rapid pacing from the anterior right atrial wall (ARAW) and cavotricuspid isthmus (CTI) approximately 30 mm remote from the earliest activation site (EAS). We identified the site where manifest entrainment, defined as the orthodromic capture of the EAS with a long conduction time, was observed, and ablated the site approximately 20 mm remote from the EAS, between the pacing site and the EAS. Results Manifest entrainment was demonstrated in all patients paced from the ARAW (four patients) and from the CTI (two patients). Ablation at the prespecified site terminated AT in 6±3 s, and AT became no longer inducible in all patients. At the successful ablation sites, discrete atrial electrograms were recorded; however, low-amplitude, fractionated electrograms suggestive of slow conduction were not observed in all patients. The atrio-His interval during sinus rhythm remained unchanged (from 96±12 to 89±7 ms, p=NS). During 11±6 months, no patients showed AT recurrence and AV conduction abnormality. Conclusion CARTO mapping- and manifest entrainment-guided ablation strategy is effective and safe in the treatment of ATP-AT.
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20
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TOKUDA MICHIFUMI, KOJODJOJO PIPIN, TUNG STANLEY, INADA KEIICHI, MATSUO SEIICHIRO, YAMANE TEIICHI, YOSHIMURA MICHIHIRO, TEDROW USHAB, STEVENSON WILLIAMG. Characteristics of Clinical and Induced Ventricular Tachycardia Throughout Multiple Ablation Procedures. J Cardiovasc Electrophysiol 2015; 27:88-94. [DOI: 10.1111/jce.12873] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 09/10/2015] [Accepted: 09/17/2015] [Indexed: 11/27/2022]
Affiliation(s)
- MICHIFUMI TOKUDA
- Cardiovascular Division, Brigham and Women's Hospital; Harvard Medical School; Boston Massachusetts USA
| | - PIPIN KOJODJOJO
- Cardiovascular Division, Brigham and Women's Hospital; Harvard Medical School; Boston Massachusetts USA
| | - STANLEY TUNG
- Cardiovascular Division, Brigham and Women's Hospital; Harvard Medical School; Boston Massachusetts USA
| | - KEIICHI INADA
- Cardiovascular Division, Brigham and Women's Hospital; Harvard Medical School; Boston Massachusetts USA
| | - SEIICHIRO MATSUO
- Division of Cardiology; The Jikei University School of Medicine; Tokyo Japan
| | - TEIICHI YAMANE
- Division of Cardiology; The Jikei University School of Medicine; Tokyo Japan
| | - MICHIHIRO YOSHIMURA
- Division of Cardiology; The Jikei University School of Medicine; Tokyo Japan
| | - USHA B. TEDROW
- Cardiovascular Division, Brigham and Women's Hospital; Harvard Medical School; Boston Massachusetts USA
| | - WILLIAM G. STEVENSON
- Cardiovascular Division, Brigham and Women's Hospital; Harvard Medical School; Boston Massachusetts USA
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21
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Liang JJ, Santangeli P, Callans DJ. Long-term Outcomes of Ventricular Tachycardia Ablation in Different Types of Structural Heart Disease. Arrhythm Electrophysiol Rev 2015; 4:177-83. [PMID: 26835122 DOI: 10.15420/aer.2015.4.3.177] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 10/19/2015] [Indexed: 12/29/2022] Open
Abstract
Ventricular tachycardia (VT) often occurs in the setting of structural heart disease and can affect patients with ischaemic or nonischaemic cardiomyopathies. Implantable cardioverter-defibrillators (ICDs) provide mortality benefit and are therefore indicated for secondary prevention in patients with sustained VT, but they do not reduce arrhythmia burden. ICD shocks are associated with increased morbidity and mortality, and antiarrhythmic medications are often used to prevent recurrent episodes. Catheter ablation is an effective treatment option for patients with VT in the setting of structural heart disease and, when successful, can reduce the number of ICD shocks. However, whether VT ablation results in a mortality benefit remains unclear. We aim to review the long-term outcomes in patients with different types of structural heart disease treated with VT ablation.
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Affiliation(s)
- Jackson J Liang
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, US
| | - Pasquale Santangeli
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, US
| | - David J Callans
- Electrophysiology Section, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, US
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22
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Anter E, Li J, Tschabrunn CM, Nezafat R, Josephson ME. Mapping of a Post-Infarction Left Ventricular Aneurysm-Dependent Macroreentrant Ventricular Tachycardia. HeartRhythm Case Rep 2015; 1:472-476. [PMID: 26664826 PMCID: PMC4671300 DOI: 10.1016/j.hrcr.2015.07.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Elad Anter
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jianqing Li
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Cory M Tschabrunn
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Reza Nezafat
- Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mark E Josephson
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Josephson ME, Anter E. Substrate Mapping for Ventricular Tachycardia: Assumptions and Misconceptions. JACC Clin Electrophysiol 2015; 1:341-352. [PMID: 29759461 DOI: 10.1016/j.jacep.2015.09.001] [Citation(s) in RCA: 125] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 08/31/2015] [Accepted: 09/04/2015] [Indexed: 11/30/2022]
Abstract
Substrate mapping was developed to treat poorly tolerated infarct-related ventricular tachycardias (VTs). This concept was based on 30-year-old data derived from surgical and percutaneous mapping during sinus rhythm and VT that demonstrated specific electrograms (EGMs) that characterized the "arrhythmogenic substrate" of VT. Electrogram characteristics of the arrhythmogenic VT substrate during sinus rhythm included low-voltage, fractionation, long duration, split signals, and isolated late potentials as well as EGMs demonstrating adjacent early and late activation. Introduction of electroanatomical mapping (EAM) systems during the mid-1990s has allowed investigators to record electrograms in 3 dimensions and to identify sites assumed to represent the central common pathway ("isthmus") during re-entrant VTs. However, several important assumptions and misconceptions make currently used "substrate mapping" techniques inaccurate. These include: 1) re-entrant circuits are produced by fixed barriers of immutable "inexcitable" scar; 2) low voltage amplitude (≤0.5 mV) implies dense "inexcitable" scar; 3) isthmuses identified in patients with tolerated VTs using entrainment mapping are both valid and provide an accurate depiction of isthmuses in less hemodynamically tolerated VTs; and 4) current mapping tools and methods can delineate specific electrophysiologic features that will determine the barriers forming channels during re-entrant VTs. None of these assumptions has been validated and recent experimental and human data using higher resolution mapping with very small electrodes cast doubt on their validity. These data call for re-evaluation of substrate-mapping techniques to characterize the arrhythmogenic substrate of post-infarction VT. Standardization of recording techniques including electrode size, interelectrode spacing, tissue contact, catheter orientation, and wavefront activation must be taken into consideration.
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Affiliation(s)
- Mark E Josephson
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
| | - Elad Anter
- Harvard-Thorndike Electrophysiology Institute, Cardiovascular Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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Tanawuttiwat T, Nazarian S, Calkins H. The role of catheter ablation in the management of ventricular tachycardia. Eur Heart J 2015; 37:594-609. [DOI: 10.1093/eurheartj/ehv421] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 08/07/2015] [Indexed: 12/11/2022] Open
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Finding the optimal ablation site in ventricular tachycardia through a single electrogram: Is it too good to be true? Heart Rhythm 2015; 12:1745-6. [DOI: 10.1016/j.hrthm.2015.05.033] [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: 05/20/2015] [Indexed: 11/21/2022]
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Jacobson JT, Iwai S, Aronow W. Management of ventricular arrhythmias in structural heart disease. Postgrad Med 2015; 127:549-59. [PMID: 25971427 DOI: 10.1080/00325481.2015.1045816] [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: 10/22/2022]
Abstract
Ventricular arrhythmias (VA) are a source of significant morbidity and mortality in patients with structural heart disease (SHD). The advent of the implantable cardiac defibrillator (ICD) has had a positive effect on mortality, but the associated morbidity remains a significant problem. Modern treatment of VA has advanced far beyond medical therapy and includes strategies as simple as intelligent ICD programming and as complex as catheter ablation (CA). In these pages, the spectrum of management strategies will be discussed; from anti-arrhythmic drugs and ICD implantation and programming to CA and autonomic modulation. The focus of this review will be on strategies for secondary prevention of VA in patients with SHD, supported by clinical evidence for their utilization.
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Affiliation(s)
- Jason T Jacobson
- Division of Cardiology, Department of Medicine, Westchester Medical Center, New York Medical College , Valhalla, New York , USA
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Josephson ME, Almendral J, Callans DJ. Resetting and entrainment of reentrant ventricular tachycardia associated with myocardial infarction. Heart Rhythm 2014; 11:1239-49. [DOI: 10.1016/j.hrthm.2014.03.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Indexed: 10/25/2022]
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29
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WO HUNGTA, WEN MINGSHIEN, CHANG POCHENG, CHOU CHUNGCHUAN, WANG CHUNCHIEH, YEH SANJOU, WU DELON. Successful Treatment of Macroreentrant Atrial Tachycardia by Radiofrequency Ablation Targeting Channels with Continuous Activation. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2014; 37:927-37. [DOI: 10.1111/pace.12408] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2013] [Accepted: 02/14/2014] [Indexed: 11/30/2022]
Affiliation(s)
- HUNG-TA WO
- Second Section of Cardiology, Chang Gung Memorial Hospital; Linko, and Chang Gung University College of Medicine; Taoyuan Taiwan
| | - MING-SHIEN WEN
- Second Section of Cardiology, Chang Gung Memorial Hospital; Linko, and Chang Gung University College of Medicine; Taoyuan Taiwan
| | - PO-CHENG CHANG
- Second Section of Cardiology, Chang Gung Memorial Hospital; Linko, and Chang Gung University College of Medicine; Taoyuan Taiwan
| | - CHUNG-CHUAN CHOU
- Second Section of Cardiology, Chang Gung Memorial Hospital; Linko, and Chang Gung University College of Medicine; Taoyuan Taiwan
| | - CHUN-CHIEH WANG
- Second Section of Cardiology, Chang Gung Memorial Hospital; Linko, and Chang Gung University College of Medicine; Taoyuan Taiwan
| | - SAN-JOU YEH
- Second Section of Cardiology, Chang Gung Memorial Hospital; Linko, and Chang Gung University College of Medicine; Taoyuan Taiwan
| | - DELON WU
- Second Section of Cardiology, Chang Gung Memorial Hospital; Linko, and Chang Gung University College of Medicine; Taoyuan Taiwan
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Tung R, Shivkumar K. Unusual response to entrainment of ventricular tachycardia: In or out? Heart Rhythm 2014; 11:725-7. [DOI: 10.1016/j.hrthm.2013.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Indexed: 11/25/2022]
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Schleifer JW, Mookadam F, Srivathsan K. Recent developments in the ablation of ventricular arrhythmias. Future Cardiol 2013; 9:799-808. [PMID: 24180538 DOI: 10.2217/fca.13.79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Catheter ablation for the management of recurrent ventricular arrhythmias (VAs) is an emerging technology, with good efficacy in selected patients. It is an effective treatment for recurrent VA and can terminate VA during electrical storm. Recent innovations enhance the accuracy of ventricular mapping, allowing for substrate modification while the patient remains in sinus rhythm, thus facilitating the treatment of different types of VA. Epicardial ablation is now a feasible option for treating VA and increases the likelihood of success in certain types of VA. Percutaneous hemodynamic support facilitates successful ablation during poorly tolerated VA. This article reviews recent advances in catheter ablation techniques for VA and approaches to the management of specific types of VA, with a view toward future developments.
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Affiliation(s)
- John William Schleifer
- Mayo Clinic Arizona, Division of Cardiovascular Diseases, Mayo Clinic Hospital, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
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ALMENDRAL JESÚS. Resetting and Entrainment of Reentrant Arrhythmias: Part II: Informative Content and Practical Use of These Responses. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2013; 36:641-61. [DOI: 10.1111/pace.12075] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Accepted: 11/24/2012] [Indexed: 11/27/2022]
Affiliation(s)
- JESÚS ALMENDRAL
- From the Cardiac Arrhythmia Unit; Grupo Hospital de Madrid; Universidad CEU-San Pablo; Madrid; Spain
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Estner HL, Zviman MM, Herzka D, Miller F, Castro V, Nazarian S, Ashikaga H, Dori Y, Berger RD, Calkins H, Lardo AC, Halperin HR. The critical isthmus sites of ischemic ventricular tachycardia are in zones of tissue heterogeneity, visualized by magnetic resonance imaging. Heart Rhythm 2011; 8:1942-9. [PMID: 21798226 DOI: 10.1016/j.hrthm.2011.07.027] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Accepted: 07/19/2011] [Indexed: 12/12/2022]
Abstract
BACKGROUND A need exists to develop alternative approaches to VT ablation that provide an improved delineation of the arrhythmogenic substrate. OBJECTIVE The aim of this study was to evaluate the hypotheses that: (1) the heterogeneous zone (HZ, a mixture of normal-appearing tissue and scar) in magnetic resonance imaging (MRI) contains the critical isthmus(es) for ventricular tachycardia (VT), (2) successful ablation of VT would include ablation in the HZ, and (3) inadequate ablation of HZ allows for VT recurrence. METHODS MRI and an electrophysiology study (EP) were performed in a model of chronic myocardial infarction in 17 pigs. In animals that were inducible for VT, ablations were done guided by standard EP criteria and blinded to the MRI. After ablation, electroanatomic mapping results were co-registered with MRI. RESULTS In 8 animals, 22 sustained monomorphic VTs were generated. The HZ was substantially larger in inducible (n = 8) compared with noninducible animals (n = 9) [25% ± 10% vs 13% ± 5% of total scar, respectively, P = .007]. Acutely, all targeted VTs were successfully ablated, and postprocedure analysis showed that at least 1 ablation was in the HZ in each animal. In 5 animals, a second EP and MRI were performed 1 week after ablation. Three animals had inducible VTs, and MRI showed that the HZ had not been completely ablated. In contrast, the 2 animals without inducible VT revealed no remaining HZ. CONCLUSION These findings show that MRI can define an HZ and determine the location of ablated lesions. The HZ may be a promising ablation target to cure ischemic VTs. Remnants of HZ after ablation may be the substrate for clinical relapses.
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Affiliation(s)
- Heidi L Estner
- Department of Medicine, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland 20215, USA.
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Arruda M, Fahmy T, Armaganijan L, Di Biase L, Patel D, Natale A. Endocardial and epicardial mapping and catheter ablation of post myocardial infarction ventricular tachycardia: A substrate modification approach. J Interv Card Electrophysiol 2010; 28:137-45. [PMID: 20396939 DOI: 10.1007/s10840-010-9469-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2008] [Accepted: 01/03/2010] [Indexed: 11/28/2022]
Abstract
Ventricular tachycardia associated with prior myocardial infarction account for significant morbidity, mortality, and health care costs despite the favorable outcomes shown by ICD clinical trials. Catheter ablation has been increasingly used as an adjunctive therapy in the management of scar-related ventricular tachycardia. Novel technologies have facilitated the outcomes of current ablation strategies. Three-dimensional mapping systems have allowed identification of the scar substrate, its critical sites in the tachycardia circuit, and selection of ablation sites based on fairly precise electroanatomic substrate.
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Affiliation(s)
- Mauricio Arruda
- University Hospitals, Harrington-McLaughlin Heart and Vascular Institute, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Lakeside 5038, Cleveland, OH 44106, USA.
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35
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Tedrow U, Stevenson WG. Epicardial Ablation of Ischemic Ventricular Tachycardia. Card Electrophysiol Clin 2010; 2:69-79. [PMID: 28770737 DOI: 10.1016/j.ccep.2009.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Endocardial catheter ablation for ventricular arrhythmias in patients with ischemic cardiomyopathy decreases ventricular tachycardia (VT) episodes, and painful implantable defibrillator shocks and can be lifesaving in the context of VT storm. Unfortunately, up to approximately one-third of postinfarction VTs are not accessible for ablation from the endocardium. Percutaneous access to the epicardial space has allowed ablation of a portion of these circuits, although anatomic barriers, such as the phrenic nerve, coronary arteries, and intramural circuits, still limit success in some cases. Adhesions, most often due to prior cardiac surgery, frequently necessitate a surgical approach to the pericardial space.
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Affiliation(s)
- Usha Tedrow
- The Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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36
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Natale A, Raviele A, Al-Ahmad A, Alfieri O, Aliot E, Almendral J, Breithardt G, Brugada J, Calkins H, Callans D, Cappato R, Camm JA, Della Bella P, Guiraudon GM, Haïssaguerre M, Hindricks G, Ho SY, Kuck KH, Marchlinski F, Packer DL, Prystowsky EN, Reddy VY, Ruskin JN, Scanavacca M, Shivkumar K, Soejima K, Stevenson WJ, Themistoclakis S, Verma A, Wilber D. Venice Chart International Consensus document on ventricular tachycardia/ventricular fibrillation ablation. J Cardiovasc Electrophysiol 2010; 21:339-79. [PMID: 20082650 DOI: 10.1111/j.1540-8167.2009.01686.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
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37
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Miyamoto K, Tsuchiya T, Narita S, Nagamoto Y, Yamaguchi T, Ando SI, Hayashida K, Tanioka Y, Takahashi N. Radiofrequency Catheter Ablation of Ventricular Tachyarrhythmia Under Navigation Using EnSite Array. Circ J 2010; 74:1322-31. [DOI: 10.1253/circj.cj-09-1008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | | | | | | | | | | | - Yoshito Tanioka
- Division of Cardiology, Omura Municipal Hospital Cardiovascular Center
| | - Naohiko Takahashi
- Department of Internal Medicine 1, Faculty of Medical Oita University
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Barrett CD, Di Biase L, Vacca M, Saenz LC, Burkhardt JD, Ruskin JN, Natale A. Ventricular Tachycardia Ablation-For Whom, When, and How? Card Electrophysiol Clin 2009; 1:201-211. [PMID: 28770785 DOI: 10.1016/j.ccep.2009.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
This article discusses how ventricular tachycardia ablation should be used, discusses which patients may derive benefit from this treatment, and highlights the best means of implementing it.
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Affiliation(s)
- Conor D Barrett
- Cardiac Arrhythmia Service, Massachusetts General Hospital and Harvard Medical School Boston, USA
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute at St David's Medical Center, 1015 East 32nd Street, Suite 506, Austin, TX 78705, USA; Department of Cardiology, University of Foggia, Foggia, Italy; Department of Biomedical Engineering, University of Texas, Austin, TX, USA
| | | | | | - J David Burkhardt
- Texas Cardiac Arrhythmia Institute at St David's Medical Center, 1015 East 32nd Street, Suite 506, Austin, TX 78705, USA
| | - Jeremy N Ruskin
- Cardiac Arrhythmia Service, Massachusetts General Hospital and Harvard Medical School Boston, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St David's Medical Center, 1015 East 32nd Street, Suite 506, Austin, TX 78705, USA; Division of Cardiology, Stanford University, Palo Alto, CA, USA; Case Western Reserve University, Cleveland, OH, USA; EP Services, California Pacific Medical Center, San Francisco, CA, USA; Department of Biomedical Engineering, University of Texas, Austin, TX, USA
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Catheter ablation of ventricular tachycardia. From indication to three-dimensional mapping technology. Herz 2009; 34:187-96. [PMID: 19444402 DOI: 10.1007/s00059-009-3247-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The majority of ventricular tachycardias (VTs) occurs in patients with structural heart disease, predominantly coronary heart disease. Implantable cardioverter defibrillators (ICDs) are first-line therapy in patients with VT and structural heart disease. In patients who receive an ICD after a spontaneous sustained VT, recurrent VT episodes or an electrical storm are major problems. In addition, in patients with an ICD implanted for primary prevention of sudden cardiac death, 20% will experience at least one VT episode within 3-5 years after ICD implantation. Catheter ablation has a high acute success rate in eliminating clinical VT. However, several factors make catheter ablation of VT more difficult than ablation of supraventricular tachyarrhythmias. (1) The infarct region is often large. (2) The induced VT can be unstable or hemodynamically only poorly tolerated and therefore "unmappable". (3) Though most commonly located in the subendocardium, the critical VT zone can occasionally be epicardial or intramural in location. (4) In many cases, several reentrant circuits may coexist making ablation of a single form of VT a palliative procedure which does not obviate the risk of sudden death. Thus, catheter ablation of sustained VT in the setting of structural heart disease can only be considered an adjunctive therapy which, in general, will require ICD therapy. Numerous "modern" mapping technologies have been developed, which have increased success rates of catheter ablation of VT in patients with and without structural heart disease. The aim of the present article is to review current three-dimensional mapping systems in comparison to conventional mapping and to describe a reasonable, tailored approach for the individual patient with VT.
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Aliot EM, Stevenson WG, Almendral-Garrote JM, Bogun F, Calkins CH, Delacretaz E, Bella PD, Hindricks G, Jais P, Josephson ME, Kautzner J, Kay GN, Kuck KH, Lerman BB, Marchlinski F, Reddy V, Schalij MJ, Schilling R, Soejima K, Wilber D. EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias: Developed in a partnership with the European Heart Rhythm Association (EHRA), a Registered Branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA). Europace 2009; 11:771-817. [DOI: 10.1093/europace/eup098] [Citation(s) in RCA: 283] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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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]
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43
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Miyamoto K, Tsuchiya T, Yasuoka C, Tanioka Y. A Case of Radiofrequency Catheter Ablation of Ventricular Tachycardia Associated with an Old Myocardial Infarction Guided by a Noncontact Mapping System. J Arrhythm 2009. [DOI: 10.1016/s1880-4276(09)80032-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Bogun F. Mapping of post-infarction VT: is sinus rhythm enough? Heart Rhythm 2008; 5:992-3. [PMID: 18598953 DOI: 10.1016/j.hrthm.2008.04.022] [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: 04/29/2008] [Indexed: 10/22/2022]
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45
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Catheter ablation of scar-related ventricular tachycardia: another piece of the puzzle. Heart Rhythm 2008; 5:375-7. [PMID: 18313594 DOI: 10.1016/j.hrthm.2007.12.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2007] [Indexed: 11/27/2022]
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46
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ZEPPENFELD KATJA, STEVENSON WILLIAMG. Ablation of Ventricular Tachycardia in Patients with Structural Heart Disease. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2008; 31:358-74. [DOI: 10.1111/j.1540-8159.2008.00999.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Abstract
Ventricular tachyarrhythmias (VTA), a major cause of sudden cardiac death, require meticulous management in order to prevent recurrent episodes. Recently, non-pharmacological interventions, including radiofrequency catheter ablation and implantable cardioverter defibrillators (ICD), have become important treatments of VTA. Catheter ablation is curative in a relatively high percentage of patients presenting with idiopathic monomorphic ventricular tachycardia (VT). For VT associated with structural heart disease, however, the efficacy of catheter ablation remains limited, and ICD is the first-line therapy. In a subset of patients presenting with recurrent episodes of ventricular fibrillation (VF), catheter ablation is a therapeutic option when the VF is triggered by specific premature ventricular complexes. In Japan, unlike in the United States and Europe, ICD have not yet been accepted as first-line prevention of sudden cardiac death caused by VTA. The efficacy of ICD is occasionally limited by intolerable complications, such as electrical storm, inappropriate shock delivery and infection. Catheter ablation and ICD therapy might need to be combined for problematic cases.
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Affiliation(s)
- Masaomi Chinushi
- School of Health Science, Niigata University School of Medicine, Niigata, Japan.
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48
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Callans DJ, Jacobson JT. Nonpharmacologic Treatment of Tachyarrhythmias. Cardiovasc Ther 2007. [DOI: 10.1016/b978-1-4160-3358-5.50026-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Smith SC, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol 2006; 48:e247-346. [PMID: 16949478 DOI: 10.1016/j.jacc.2006.07.010] [Citation(s) in RCA: 867] [Impact Index Per Article: 48.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Bogun F, Kim HM, Han J, Tamirissa K, Tschopp D, Reich S, Elmouchi D, Igic P, Lemola K, Good E, Oral H, Chugh A, Pelosi F, Morady F. Comparison of mapping criteria for hemodynamically tolerated, postinfarction ventricular tachycardia. Heart Rhythm 2006; 3:20-6. [PMID: 16399047 DOI: 10.1016/j.hrthm.2005.09.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2005] [Accepted: 09/15/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Mapping criteria for hemodynamically tolerated, postinfarction ventricular tachycardia (VT) have been evaluated in only small series of patients. OBJECTIVES The purpose of this study was to evaluate the utility of various mapping criteria for identifying a critical VT circuit isthmus in a post hoc analysis. METHODS Ninety VTs (cycle length 491 +/- 84 ms) were mapped in 48 patients with a prior myocardial infarction. The mapping catheter was positioned within a protected area of the reentrant circuit of the targeted VTs at 176 sites. All sites showed concealed entrainment. The predictive values of the following mapping criteria for a successful ablation site were compared: discrete isolated potential during VT, inability to dissociate the isolated potential from the VT, endocardial activation time >70 ms, matching electrogram-QRS and stimulus-QRS intervals, VT termination without global capture during pacing, stimulus-QRS/VT cycle length ratio <or=0.7, and postpacing interval. For each criterion, the receiver operating characteristic curve was constructed, and the area under the curve was calculated to assess the discriminatory value of the criterion. RESULTS Seventy-eight of 90 VTs (87%) were successfully ablated. The area under the receiver operating characteristic curve was largest (0.89) for matching stimulus-QRS and electrogram-QRS intervals. In combination with an isolated potential that could not be dissociated from the VT, the area under the receiver operating characteristic curve increased to 0.93. CONCLUSION At sites with concealed entrainment, matching stimulus-QRS and electrogram-QRS intervals were superior to other criteria in differentiating a critical isthmus from bystander or noncritical sites in postinfarction VT.
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Affiliation(s)
- Frank Bogun
- University of Michigan Medical Center, Ann Arbor, Michigan 48109-0366, USA.
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