1
|
Aguilera J, Cabrera J, Saenz LC, Santangeli P. Catheter Ablation of Idiopathic Epicardial Outflow Tract Premature Ventricular Contractions: A Case Report and Review of the Literature. Card Electrophysiol Clin 2024; 16:187-193. [PMID: 38749640 DOI: 10.1016/j.ccep.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
The epicardial outflow tract can be a site of origin of idiopathic ventricular arrhythmias. These arrhythmias are most commonly perivalvular and can be targeted from within the coronary venous system or from other adjacent structures, such as the right ventricular and left ventricular outflow tracts or the coronary cusp region. The authors report a case of an epicardial idiopathic outflow tract premature ventricular contraction originating from the midseptal epicardial left ventricle. In this case, direct epicardial access was crucial to identify early local activation and achieve successful catheter ablation.
Collapse
Affiliation(s)
- Jose Aguilera
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Juan Cabrera
- Section of Electrophysiology, Fundación Cardioinfantil, Bogotá, Colombia
| | - Luis Carlos Saenz
- Section of Electrophysiology, Fundación Cardioinfantil, Bogotá, Colombia
| | - Pasquale Santangeli
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.
| |
Collapse
|
2
|
Zhou ZX, Zheng C, Hu YD, Lin JF. Mapping and ablation of ventricular arrhythmias arising from the left ventricular summit. Pacing Clin Electrophysiol 2024; 47:242-252. [PMID: 38291856 DOI: 10.1111/pace.14932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 12/28/2023] [Accepted: 01/09/2024] [Indexed: 02/01/2024]
Abstract
The left ventricular summit (LVS) refers to the highest portion of the left ventricular outflow tract (LVOT). It is an epicardially delimited triangular area by the left coronary arteries and the coronary venous circulation. Its deep myocardium correlates closely with the left coronary cusp, aortic-mitral continuity, and right ventricular outflow tract (RVOT), complicating the anatomical relationship. Ventricular arrhythmias (VAs) originating from this area are common, accounting for 14.5% of all VAs origin from left ventricle. Specific electrocardiogram (ECG) characteristics may assist in locating LVS-VAs pre-procedure and facilitate procedure planning. However, catheter ablation of LVS-VAs remains challenging because of anatomical constraints. This paper reviews the recent understanding of LVS anatomy, concludes ECG characteristics, and summarizes current mapping and ablation methods for LVS-VAs.
Collapse
Affiliation(s)
- Zhi-Xiang Zhou
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Cheng Zheng
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - You-Dong Hu
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Jia Feng Lin
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| |
Collapse
|
3
|
Dilling-Boer D, Nof E, Beinaert R, Wakili R, Heidbuchel H, Koopman P, Schurmans J, Phlips T, Didenko M, Vijgen J. Damage to the left descending coronary artery due to radiofrequency ablation in the right ventricular outflow tract: Clinical case series and anatomical considerations. J Cardiovasc Electrophysiol 2023; 34:468-477. [PMID: 36651349 DOI: 10.1111/jce.15816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 12/27/2022] [Accepted: 01/04/2023] [Indexed: 01/19/2023]
Abstract
The purpose of this paper was to highlight the importance of the anatomy of the right ventricular outflow tract (RVOT) and the proximity of the mid segment of the left anterior descending coronary artery (LAD) to the RVOT in the setting of ablation of ventricular arrhythmias in the RVOT. During the period from 2014 till 2017, five patients with injury to the LAD during ablation within RVOT were identified in three centers, in Belgium, Germany and Israel. The clinical characteristics, procedural data and follow up data, where available, are reported. The literature review over coronary artery damage during radiofrequency ablation procedures is provided and the anatomy of the RVOT and the neighboring vascular structures is discussed. We present five patients who underwent radiofrequency ablation of ventricular arrhythmias mapped to the inferior and anterior part of the RVOT, at the insertion of the right ventricular wall to the septum, whereby ablation resulted in occlusion in four and severe stenosis in one, of the mid segment of the LAD coronary artery. All patients underwent percutaneous coronary intervention and stenting, four of them immediately during the same procedure and one 3 days later because of lack of signs and symptoms of acute coronary occlusion. In conclusion, the mid segment of the LAD at the level of the second septal perforator/second diagonal branch runs in very close proximity to the endocardial aspect of the lower part of the RVOT and care should be taken during ablation of ventricular arrhythmias in this region. Additional imaging such as intracardiac echocardiography and coronary angiography may be helpful in avoiding complications.
Collapse
Affiliation(s)
| | - Eyal Nof
- Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel.,Sacler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Roy Beinaert
- Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel.,Sacler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Reza Wakili
- Arrhythmia Service and Electrophysiology Section West German Heart and Vascular Center, University Hospital Essen, Essen, Germany
| | - Hein Heidbuchel
- Department of Cardiology, Antwerp University Hospital, Antwerp University, Antwerp, Belgium.,Faculty of Medicine, Hasselt University, Hasselt, Belgium
| | - Pieter Koopman
- Department of Cardiology, Hartcentrum Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Joris Schurmans
- Department of Cardiology, Hartcentrum Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Thomas Phlips
- Department of Cardiology, Hartcentrum Hasselt, Jessa Hospital, Hasselt, Belgium
| | - Maxim Didenko
- Kupriyanov Cardiovascular Surgery Clinic, Military Medical Academy, St. Petersburg, Russia
| | - Johan Vijgen
- Department of Cardiology, Hartcentrum Hasselt, Jessa Hospital, Hasselt, Belgium
| |
Collapse
|
4
|
Sridharan A, Hutchinson MD. Coronary arterial injury during right ventricular outflow tract ablation: Know your neighbors. J Cardiovasc Electrophysiol 2023; 34:1310-1311. [PMID: 36709466 DOI: 10.1111/jce.15835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 01/30/2023]
Affiliation(s)
- Aadhavi Sridharan
- Banner University Medical Center-Tucson and University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
| | - Mathew D Hutchinson
- Banner University Medical Center-Tucson and University of Arizona College of Medicine Tucson, Tucson, Arizona, USA
| |
Collapse
|
5
|
Guandalini GS, Santangeli P, Schaller R, Pothineni NVK, Briceño DF, Enriquez A, Razminia P, Tung R, Marchlinski FE, Garcia FC. Intramyocardial mapping of ventricular premature depolarizations via septal venous perforators: Differentiating the superior intraseptal region from left ventricular summit origins. Heart Rhythm 2022; 19:1475-1483. [DOI: 10.1016/j.hrthm.2022.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 02/25/2022] [Accepted: 03/04/2022] [Indexed: 11/04/2022]
|
6
|
Look left, look right, look left again. Heart Rhythm 2021; 18:2158-2159. [PMID: 34509636 DOI: 10.1016/j.hrthm.2021.09.005] [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: 09/05/2021] [Accepted: 09/07/2021] [Indexed: 11/20/2022]
|
7
|
Left Ventricular Summit-Concept, Anatomical Structure and Clinical Significance. Diagnostics (Basel) 2021; 11:diagnostics11081423. [PMID: 34441357 PMCID: PMC8393416 DOI: 10.3390/diagnostics11081423] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 08/02/2021] [Accepted: 08/04/2021] [Indexed: 01/18/2023] Open
Abstract
The left ventricular summit (LVS) is a triangular area located at the most superior portion of the left epicardial ventricular region, surrounded by the two branches of the left coronary artery: the left anterior interventricular artery and the left circumflex artery. The triangle is bounded by the apex, septal and mitral margins and base. This review aims to provide a systematic and comprehensive anatomical description and proper terminology in the LVS region that may facilitate exchanging information among anatomists and electrophysiologists, increasing knowledge of this cardiac region. We postulate that the most dominant septal perforator (not the first septal perforator) should characterize the LVS definition. Abundant epicardial adipose tissue overlying the LVS myocardium may affect arrhythmogenic processes and electrophysiological procedures within the LVS region. The LVS is divided into two clinically significant regions: accessible and inaccessible areas. Rich arterial and venous coronary vasculature and a relatively dense network of cardiac autonomic nerve fibers are present within the LVS boundaries. Although the approach to the LVS may be challenging, it can be executed indirectly using the surrounding structures. Delivery of the proper radiofrequency energy to the arrhythmia source, avoiding coronary artery damage at the same time, may be a challenge. Therefore, coronary angiography or cardiac computed tomography imaging is strongly recommended before any procedure within the LVS region. Further research on LVS morphology and physiology should increase the safety and effectiveness of invasive electrophysiological procedures performed within this region of the human heart.
Collapse
|
8
|
Muser D, Santangeli P. Epicardial Ablation of Idiopathic Ventricular Tachycardia. Card Electrophysiol Clin 2020; 12:295-312. [PMID: 32771184 DOI: 10.1016/j.ccep.2020.04.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Ventricular arrhythmias (VAs) occurring in the absence of structural heart disease or ion channelopathies are referred to as idiopathic. They can clinically present with frequent monomorphic premature ventricular contractions, nonsustained ventricular tachycardia (VT), or sustained VT, and generally share a benign prognosis. Approximately 4% to 10% of idiopathic VAs have an epicardial site of origin, represented in most cases by the left ventricular summit and, less frequently, by the cardiac crux. Epicardial foci can be addressed by catheter ablation via the coronary venous system tributaries. In rarer instances, a direct epicardial access from a subxiphoid approach is needed.
Collapse
Affiliation(s)
- Daniele Muser
- Electrophysiology Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Pasquale Santangeli
- Electrophysiology Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| |
Collapse
|
9
|
Kodali S, Santangeli P, Garcia FC. Mapping and Ablation of Arrhythmias from Uncommon Sites (Aortic Cusp, Pulmonary Artery, and Left Ventricular Summit). Card Electrophysiol Clin 2019; 11:665-674. [PMID: 31706473 DOI: 10.1016/j.ccep.2019.08.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite advances in our understanding of the relevant anatomy and mapping and catheter ablation techniques of idiopathic outflow tract ventricular arrhythmias, challenging sites for catheter ablation remain the aortic cusps, pulmonary artery, and notably the left ventricular summit. A systematic approach should be used to direct mapping efforts efficiently between endocardial, coronary venous, and epicardial sites. Foci at the left ventricular summit, particularly intraseptal and at the inaccessible epicardial region, remain difficult to reach and when percutaneous techniques fail, surgical ablation remains an option but with risk of late coronary artery stenosis.
Collapse
Affiliation(s)
- Santhisri Kodali
- Cardiac Electrophysiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, 9 Founders Pavilion, Philadelphia, PA 19104, USA
| | - Pasquale Santangeli
- Cardiac Electrophysiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, 9 Founders Pavilion, Philadelphia, PA 19104, USA
| | - Fermin C Garcia
- Cardiac Electrophysiology, Hospital of the University of Pennsylvania, 3400 Spruce Street, 9 Founders Pavilion, Philadelphia, PA 19104, USA.
| |
Collapse
|
10
|
Electrocardiographic features, mapping and ablation of idiopathic outflow tract ventricular arrhythmias. J Interv Card Electrophysiol 2019; 57:207-218. [PMID: 31650457 DOI: 10.1007/s10840-019-00617-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 08/27/2019] [Indexed: 01/01/2023]
Abstract
PURPOSE Idiopathic outflow tract ventricular arrhythmias are ventricular tachycardias or premature ventricular contractions presumably not related to myocardial scar or disorders of ion channels. These arrhythmias have focal origin and display characteristic electrocardiographic features. The purpose of this article is to review the state of the art of diagnosis and treatment of idiopathic outflow tract ventricular arrhythmias. METHODS We systematically reviewed scientific literature about idiopathic outflow tract ventricular arrhythmias selecting the most relevant papers on this topic. RESULTS The right ventricle outflow tract is the most common site of origin for outflow tract ventricular arrhythmias, but also left ventricle outflow tract can harbour these arrhythmias. Outflow tract ventricular arrhythmias are generally benign and may require treatment if they are symptomatic, incessant or give rise to cardiomyopathy. Radiofrequency catheter ablation is an effective and safe therapeutic strategy. A successful procedure requires a thorough preoperative analysis of the 12-lead electrocardiogram of the spontaneous arrhythmia combined with a detailed electroanatomical mapping and intracardiac echocardiography. CONCLUSIONS Idiopathic outflow tract arrhythmias are frequent in daily clinical practice and can be successfully eliminated through discrete radiofrequency catheter ablation with low rates of complications.
Collapse
|
11
|
Reithmann C, Kling T, Herkommer B, Fiek M, Ulbrich M. Magnetic resonance imaging abnormalities in the basal interventricular septum of patients with left ventricular outflow tract arrhythmias. J Cardiovasc Electrophysiol 2019; 30:1042-1052. [PMID: 30983055 DOI: 10.1111/jce.13951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 03/21/2019] [Accepted: 03/28/2019] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Concealed structural abnormalities were detected by delayed enhancement - magnetic resonance imaging (DE-MRI) in patients with apparently idiopathic tachycardia of left ventricular (LV) origin. Basal septal fibrosis was evaluated as a potential arrhythmia substrate in patients with left ventricular outflow tract (LVOT) arrhythmias. METHODS AND RESULTS A total of 22 patients with LVOT arrhythmias, including frequent monomorphic premature ventricular complexes (PVCs) in 15 patients and ventricular tachycardia (VT) in 7 patients, underwent catheter ablation and DE-MRI. A total of 19 patients with frequent PVCs and 17 patients with idiopathic VT of other origin served as a control group. Basal septal intramural fibrosis as thin strip-shaped intramyocardial DE or as marked intramyocardial DE involving >25% of wall thickness was detected more frequently in patients with LVOT arrhythmias (41% and 32%) than in patients with non LVOT arrhythmias (14% and 3%). After successful ablation, 4/16 patients with basal septal intramural fibrosis and LVOT PVCs (n = 3) or LVOT VT (n = 1) compared with no patient without basal septal fibrosis experienced episodes of sustained VT with similar or different QRS morphology resulting in ICD therapy in three patients. Follow-up DE-MRI after PVC ablation (17 ± 7 months) revealed an increase in LV ejection fraction from 49 ± 5% to 56 ± 5% (n = 9) but the amount of septal DE remained unchanged. CONCLUSIONS Basal septal intramural fibrosis may serve as the arrhythmia substrate in a substantial part of patients with premature ventricular complexes (PVCs) and VT originating from the LVOT and identifies patients with continued risk for VT recurrence after initially successful ablation of LVOT arrhythmias.
Collapse
Affiliation(s)
- Christopher Reithmann
- Medizinische Klinik 1, HELIOS Klinikum München-West, Akademisches Lehrkrankenhaus der Universität München, München, Germany
| | - Theresia Kling
- Medizinische Klinik 1, HELIOS Klinikum München-West, Akademisches Lehrkrankenhaus der Universität München, München, Germany
| | - Bernhard Herkommer
- Medizinische Klinik 1, HELIOS Klinikum München-West, Akademisches Lehrkrankenhaus der Universität München, München, Germany
| | - Michael Fiek
- Medizinische Klinik 1, HELIOS Klinikum München-West, Akademisches Lehrkrankenhaus der Universität München, München, Germany
| | - Michael Ulbrich
- Medizinische Klinik 1, HELIOS Klinikum München-West, Akademisches Lehrkrankenhaus der Universität München, München, Germany
| |
Collapse
|
12
|
Candemir B, Baskovski E, Duzen V, Coskun F, Vurgun K, Goksuluk H, Ozyuncu N, Kurklu ST, Altin T, Akyurek O, Erol C. Late elimination of challenging idiopathic ventricular arrhythmias originating from left ventricular summit by anatomical ablation. Indian Pacing Electrophysiol J 2019; 19:114-118. [PMID: 30822513 PMCID: PMC6531642 DOI: 10.1016/j.ipej.2019.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/10/2019] [Accepted: 02/14/2019] [Indexed: 12/02/2022] Open
Abstract
Ablation of premature ventricular complexes (PVCs) originating from left ventricular outflow tract (LVOT)/left ventricular summit (LVS) is challenging with considerable rate of failure. Recently, in a novel approach to ablation of these arrythmias, application of radiofrequency energy to anatomically opposite sites of presumed origin of arrythmia, has been associated with moderate procedure success. Although late elimination of PVCs that are persistent following an ablation procedure has been previously reported, this observation has not been studied sufficiently. In this report, firstly, we present three cases of lately eliminated LVS PVCs, then, we discuss possible mechanism of this observation and conclude that after an initial failed attempt of anatomic ablation, operators may choose a period of watchful waiting before attempting a redo procedure.
Collapse
Affiliation(s)
- Basar Candemir
- Ankara University, Cardiology Department, Ankara, Turkiye
| | - Emir Baskovski
- Ankara University, Cardiology Department, Ankara, Turkiye.
| | - Veysel Duzen
- Gaziantep Ersin Arslan Research Hospital, Cardiology Department, Gaziantep, Turkiye
| | - Firat Coskun
- Ankara University, Cardiology Department, Ankara, Turkiye
| | - Kutay Vurgun
- Ankara University, Cardiology Department, Ankara, Turkiye
| | | | - Nil Ozyuncu
- Ankara University, Cardiology Department, Ankara, Turkiye
| | | | - Timucin Altin
- Ankara University, Cardiology Department, Ankara, Turkiye
| | - Omer Akyurek
- Ankara University, Cardiology Department, Ankara, Turkiye
| | - Cetin Erol
- Ankara University, Cardiology Department, Ankara, Turkiye
| |
Collapse
|
13
|
Cheung JW, Anderson RH, Markowitz SM, Lerman BB. Catheter Ablation of Arrhythmias Originating From the Left Ventricular Outflow Tract. JACC Clin Electrophysiol 2019; 5:1-12. [DOI: 10.1016/j.jacep.2018.11.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 11/13/2018] [Accepted: 11/21/2018] [Indexed: 12/12/2022]
|
14
|
Xie S, Kubala M, Liang JJ, Hayashi T, Park J, Padros IL, Garcia FC, Santangeli P, Supple GE, Frankel DS, Zado ES, Lin D, Schaller RD, Dixit S, Callans DJ, Nazarian S, Marchlinski FE. Lead I R‐wave amplitude to differentiate idiopathic ventricular arrhythmias with left bundle branch block right inferior axis originating from the left versus right ventricular outflow tract. J Cardiovasc Electrophysiol 2018; 29:1515-1522. [DOI: 10.1111/jce.13747] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 07/08/2018] [Accepted: 08/03/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Shuanglun Xie
- Cardiac Electrophysiology Program, Cardiovascular DivisionHospital of the University of PennsylvaniaPhiladelphia Pennsylvania
| | - Maciej Kubala
- Cardiac Electrophysiology Program, Cardiovascular DivisionHospital of the University of PennsylvaniaPhiladelphia Pennsylvania
| | - Jackson J. Liang
- Cardiac Electrophysiology Program, Cardiovascular DivisionHospital of the University of PennsylvaniaPhiladelphia Pennsylvania
| | - Tatsuya Hayashi
- Cardiac Electrophysiology Program, Cardiovascular DivisionHospital of the University of PennsylvaniaPhiladelphia Pennsylvania
| | - Jaeseok Park
- Cardiac Electrophysiology Program, Cardiovascular DivisionHospital of the University of PennsylvaniaPhiladelphia Pennsylvania
| | - Irene Lucena Padros
- Cardiac Electrophysiology Program, Cardiovascular DivisionHospital of the University of PennsylvaniaPhiladelphia Pennsylvania
| | - Fermin C. Garcia
- Cardiac Electrophysiology Program, Cardiovascular DivisionHospital of the University of PennsylvaniaPhiladelphia Pennsylvania
| | - Pasquale Santangeli
- Cardiac Electrophysiology Program, Cardiovascular DivisionHospital of the University of PennsylvaniaPhiladelphia Pennsylvania
| | - Gregory E. Supple
- Cardiac Electrophysiology Program, Cardiovascular DivisionHospital of the University of PennsylvaniaPhiladelphia Pennsylvania
| | - David S. Frankel
- Cardiac Electrophysiology Program, Cardiovascular DivisionHospital of the University of PennsylvaniaPhiladelphia Pennsylvania
| | - Erica S. Zado
- Cardiac Electrophysiology Program, Cardiovascular DivisionHospital of the University of PennsylvaniaPhiladelphia Pennsylvania
| | - David Lin
- Cardiac Electrophysiology Program, Cardiovascular DivisionHospital of the University of PennsylvaniaPhiladelphia Pennsylvania
| | - Robert D. Schaller
- Cardiac Electrophysiology Program, Cardiovascular DivisionHospital of the University of PennsylvaniaPhiladelphia Pennsylvania
| | - Sanjay Dixit
- Cardiac Electrophysiology Program, Cardiovascular DivisionHospital of the University of PennsylvaniaPhiladelphia Pennsylvania
| | - David J. Callans
- Cardiac Electrophysiology Program, Cardiovascular DivisionHospital of the University of PennsylvaniaPhiladelphia Pennsylvania
| | - Saman Nazarian
- Cardiac Electrophysiology Program, Cardiovascular DivisionHospital of the University of PennsylvaniaPhiladelphia Pennsylvania
| | - Francis E. Marchlinski
- Cardiac Electrophysiology Program, Cardiovascular DivisionHospital of the University of PennsylvaniaPhiladelphia Pennsylvania
| |
Collapse
|
15
|
De Simone A, La Rocca V, Panella A, Bianchi V, Maddaluno F, Stabile G, Garcia Bolao I. High-density mapping to guide ablation of a right bundle branch morphology premature ventricular contraction from the right outflow tract. Clin Case Rep 2018; 6:1060-1065. [PMID: 29881564 PMCID: PMC5986006 DOI: 10.1002/ccr3.1370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 12/06/2017] [Accepted: 12/10/2017] [Indexed: 11/07/2022] Open
Abstract
The Rhythmia ultrahigh-density mapping system with a specific algorithm seems to be helpful in identifying the target area to successfully treat multiple morphologies by catheter ablation in the right ventricular outflow tract RVOT. Interestingly, the acquisition process seemed to be extremely faster than a standard manual point-by-point premature ventricular contraction (PVC) mapping.
Collapse
|
16
|
Muser D, Santangeli P. Ventricular Arrhythmias Linked to the Left Ventricular Summit Communicating Veins. Circ Arrhythm Electrophysiol 2018; 11:e006105. [DOI: 10.1161/circep.117.006105] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Daniele Muser
- From the Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - Pasquale Santangeli
- From the Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| |
Collapse
|
17
|
Reithmann C, Fiek M. Left ventricular outflow tract arrhythmias with divergent QRS morphology: mapping of different exits and ablation strategy. J Interv Card Electrophysiol 2017; 51:61-69. [PMID: 29280039 DOI: 10.1007/s10840-017-0307-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 12/15/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Ventricular arrhythmias (VAs) from the left ventricular outflow tract (LVOT) can have multiple exits exhibiting divergent ECG features. METHODS In a series of 131 patients with VAs with LVOT origin, 10 patients presented with divergent QRS morphologies. Multisite endo- and epicardial mapping of different exit sites was performed. RESULTS The earliest ventricular activity of 23 LVOT VAs in 10 patients was detected in the endocardium of the LV in 7 patients, the aortic sinuses of Valsalva (SoV) in 3 patients, the distal coronary sinus in 6 patients, the anterior interventricular vein in 3 patients, and the posterior right ventricular outflow tract (RVOT) in 4 patients. Simultaneous elimination of two divergent QRS morphologies of LVOT VAs by ablation from a single site was achieved in 5 patients (aorto-mitral continuity in 3 patients, SoV and RVOT in each 1 patient) using a mean maximum ablation energy of 46 ± 5 W. Sequential ablation from two or three different sites, including trans-pericardial and distal coronary sinus ablation in each 2 patients, led to elimination of the divergent VA QRS morphologies in the other 5 patients. During the follow-up of 28 ± 29 months, 4 of the 10 patients had recurrence of at least one LVOT VA. A 43-year-old patient with muscular dystrophy Curschmann-Steinert had recurrence of sustained LVOT VTs and died of sudden cardiac death. CONCLUSIONS Multisite mapping of different exit sites of LVOT VAs can guide ablation of intramural foci but the recurrence rate after initially successful ablation was high.
Collapse
Affiliation(s)
| | - Michael Fiek
- Medizinische Klinik I, HELIOS Klinikum München West, Munich, Germany
| |
Collapse
|
18
|
|
19
|
John RM, Stevenson WG. Outflow Tract Premature Ventricular Contractions and Ventricular Tachycardia: The Typical and the Challenging. Card Electrophysiol Clin 2016; 8:545-554. [PMID: 27521088 DOI: 10.1016/j.ccep.2016.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The ventricular outflow tracts are the most common sites of origin for ventricular arrhythmias that occur in the absence of structural heart disease. Drug therapy with β-blockers and calcium blockers has limited efficacy for control. In the presence of marked symptoms or frequent arrhythmia causing left ventricular (LV) dysfunction, catheter ablation is a consideration. The right ventricular outflow tract, aortic root, LV outflow endocardium, and epicardium are potential sites for ablation for these arrhythmias. In intractable cases of highly symptomatic ventricular arrhythmias originating from the LV summit, surgical ablation is an option.
Collapse
Affiliation(s)
- Roy M John
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| | - William G Stevenson
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
20
|
|
21
|
Supple GE. Outflow tract ventricular arrhythmias: When and how to treat? Trends Cardiovasc Med 2015; 25:559-60. [PMID: 25801789 DOI: 10.1016/j.tcm.2015.02.003] [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: 02/08/2015] [Accepted: 02/09/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Gregory E Supple
- Division of Cardiac Electrophysiology, University of Pennsylvania, Philadelphia, PA.
| |
Collapse
|
22
|
|