1
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Liao YWB, Santangeli P. Strategies for Catheter Ablation of Premature Ventricular Contractions and Ventricular Tachycardia With Intramural Origins. Tex Heart Inst J 2024; 51:e248465. [PMID: 39257064 PMCID: PMC11387704 DOI: 10.14503/thij-24-8465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2024]
Affiliation(s)
- Yi-Wen Becky Liao
- Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Pasquale Santangeli
- Cardiac Electrophysiology and Pacing Section, Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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2
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Yamada T, Kay GN. Trends Favoring an Anatomical Approach to Radiofrequency Catheter Ablation of Idiopathic Ventricular Arrhythmias Originating From the Left Ventricular Summit. Circ Arrhythm Electrophysiol 2024; 17:e012548. [PMID: 38629301 DOI: 10.1161/circep.123.012548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 03/26/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Epicardial radiofrequency catheter ablation (RFCA) of idiopathic ventricular arrhythmias (VAs) originating from the left ventricular summit (LVS) is challenging because of the anatomic barriers. On the other hand, RFCA at the endocardial sites near the earliest epicardial activation site of LVS-VAs (anatomic approach) has proven successful. The evolving trends in the approaches and outcomes of RFCA of LVS-VAs at a single center were evaluated. METHODS We studied 88 consecutive patients with idiopathic LVS-VAs at our institute from 2009 to 2019. These patients were divided into 3 periods: 2009 to 2012 (early), 2013 to 2015 (middle), and 2016 to 2019 (recent). The data were compared among the 3 periods. RESULTS The RFCA success rate did not significantly change from the early to middle period but significantly increased from the middle to recent period (P=0.0315). The transpericardial approach usage significantly decreased over the 3 periods. The anatomic approach usage significantly increased over the 3 periods. The use of the transpericardial approach did not affect the RFCA outcomes over the 3 periods. The success rate of the anatomic RFCA tended to increase from the early to middle period and significantly increased from the middle to recent period (P=0.0412). The number of endocardial locations where RFCA was successful increased over the 3 periods. CONCLUSIONS Over the 10-year period, the transpericardial approach became decreasingly performed, whereas the anatomic approach became increasingly performed with a satisfactory improvement in the RFCA outcomes of LVS-VAs. The anatomic RFCA became more successful by identifying more and various endocardial locations as target sites.
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Affiliation(s)
- Takumi Yamada
- Cardiovascular Division, University of Minnesota, Minneapolis (T.Y.)
| | - George Neal Kay
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL (G.N.K.)
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3
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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.
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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
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4
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Hanson M, Futyma P, Bode W, Liang JJ, Tapia C, Adams C, Zarębski Ł, Wrzos A, Saenz L, Sadek M, Muser D, Baranchuk A, Marchlinski F, Santangeli P, Garcia F, Enriquez A. Catheter ablation of intramural outflow tract premature ventricular complexes: a multicentre study. Europace 2023; 25:euad100. [PMID: 37096979 PMCID: PMC10228610 DOI: 10.1093/europace/euad100] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 03/20/2023] [Indexed: 04/26/2023] Open
Abstract
AIMS Ablation of outflow tract ventricular arrhythmias may be limited by a deep intramural location of the arrhythmogenic source. This study evaluates the acute and long-term outcomes of patients undergoing ablation of intramural outflow tract premature ventricular complexes (PVCs). METHODS AND RESULTS This multicenter series included patients with structurally normal heart or nonischemic cardiomyopathy and intramural outflow tract PVCs defined by: (a) ≥ 2 of the following criteria: (1) earliest endocardial or epicardial activation < 20ms pre-QRS; (2) Similar activation in different chambers; (3) no/transient PVC suppression with ablation at earliest endocardial/epicardial site; or (b) earliest ventricular activation recorded in a septal coronary vein. Ninety-two patients were included, with a mean PVC burden of 21.5±10.9%. Twenty-six patients had had previous ablations. All PVCs had inferior axis, with LBBB pattern in 68%. In 29 patients (32%) direct mapping of the intramural septum was performed using an insulated wire or multielectrode catheter, and in 13 of these cases the earliest activation was recorded within a septal vein. Most patients required special ablation techniques (one or more), including sequential unipolar ablation in 73%, low-ionic irrigation in 26%, bipolar ablation in 15% and ethanol ablation in 1%. Acute PVC suppression was achieved in 75% of patients. Following the procedure, the PVC burden was reduced to 5.8±8.4%. The mean follow-up was 15±14 months and 16 patients underwent a repeat ablation. CONCLUSION Ablation of intramural PVCs is challenging; acute arrhythmia elimination is achieved in 3/4 patients, and non-conventional approaches are often necessary for success.
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Affiliation(s)
- Matthew Hanson
- Division of Cardiology, Queen’s University, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada
| | - Piotr Futyma
- University of Rzeszów and St. Joseph's Heart Rhythm Center, Rzeszów, Poland
| | - Weeranun Bode
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jackson J Liang
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Carlos Tapia
- Fundación Cardioinfantil, Instituto de Cardiología, Bogotá, Colombia
| | - Christian Adams
- Fundación Cardioinfantil, Instituto de Cardiología, Bogotá, Colombia
| | - Łukasz Zarębski
- University of Rzeszów and St. Joseph's Heart Rhythm Center, Rzeszów, Poland
| | - Aleksandra Wrzos
- University of Rzeszów and St. Joseph's Heart Rhythm Center, Rzeszów, Poland
| | - Luis Saenz
- Fundación Cardioinfantil, Instituto de Cardiología, Bogotá, Colombia
| | - Mouhannad Sadek
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Daniele Muser
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Adrian Baranchuk
- Division of Cardiology, Queen’s University, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada
| | - Francis Marchlinski
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pasquale Santangeli
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fermin Garcia
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andres Enriquez
- Division of Cardiology, Queen’s University, 76 Stuart Street, Kingston, Ontario K7L 2V7, Canada
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5
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Guandalini GS. Intramyocardial Mapping of Ventricular Arrhythmias via Septal Venous Perforators: Defining the Superior Intraseptal Space. Card Electrophysiol Clin 2023; 15:39-47. [PMID: 36774135 DOI: 10.1016/j.ccep.2022.10.004] [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: 06/18/2023]
Abstract
Left ventricular outflow tract arrhythmias that fail endocardial mapping and ablation have traditionally been labeled as originating from the epicardial left ventricular summit. Although these sometimes can be targeted from the epicardial surface of the left ventricular ostium, such approach poses significant technical challenges. A significant proportion of such arrhythmias, however, exhibit intramyocardial origin, demonstrated by mapping intraseptal branches of the anterior interventricular vein, and henceforth defined as the basal superior intraseptal space.
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Affiliation(s)
- Gustavo S Guandalini
- Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania - Pavilion, One Convention Avenue, Level 2 - City Side, Philadelphia, PA 19104, USA.
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6
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Yamada T. Predictors of Successful Endocardial Ablation of Epicardial Left Ventricular Summit Arrhythmias. Card Electrophysiol Clin 2023; 15:15-24. [PMID: 36774132 DOI: 10.1016/j.ccep.2022.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Endocardial catheter ablation of ventricular arrhythmias (VAs) originating from the left ventricular summit (LVS) at remote structures adjacent to the LVS may be an alternative (anatomic approach) but may not be so successful. This type of catheter ablation is successful most commonly in the left ventricular outflow tract followed by the aortic cusps and rarely in the right ventricular outflow tract. A right bundle branch block QRS morphology and anatomic distance between the earliest ventricular activation site in the coronary venous system and endocardial ablation site (<13 mm) could be predictors of a successful endocardial catheter ablation of LVS VAs.
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Affiliation(s)
- Takumi Yamada
- Cardiovascular Division, University of Minnesota, 420 Delaware Street Southeast, MMC 508, Minneapolis, MN 55455, USA.
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Romero J, Diaz JC, Gamero M, Alviz I, Lorente M, Gabr M, Toquica CC, Krishnan S, Velasco A, Lin A, Natale A, Zou F, Di Biase L. Fluoroless Catheter Ablation of Left Ventricular Summit Arrhythmias: A Step-by-Step Approach. Card Electrophysiol Clin 2023; 15:75-83. [PMID: 36774139 DOI: 10.1016/j.ccep.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Prolonged use of fluoroscopy during catheter ablation (CA) of arrhythmias is associated with a significant exposure to ionizing radiation and risk of orthopedic injuries given the need for heavy protective equipment. CA of ventricular arrhythmias (VAs) arising from the left ventricular (LV) summit is challenging, requiring a vast knowledge of the intricate cardiac anatomy of this area and careful imaging delineation of the different anatomical structures, which is frequently performed using fluoroscopic guidance. Certain techniques, including pericardial mapping and ablation, use of intracoronary wires, and mapping and ablation inside the coronary venous system have been proposed, further prolonging fluoroscopy time. Fluoroless CA procedures are feasible with currently available technology and appear to have similar safety and efficacy outcomes compared with conventional techniques. To successfully perform fluoroless CA of LV summit arrhythmias, it is important to be fully acquainted with intracardiac echocardiography (ICE) imaging and electroanatomic mapping (EAM). We will describe our approach to perform fluoroless CA in LV summit VAs.
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Affiliation(s)
- Jorge Romero
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Juan Carlos Diaz
- Arrhythmia and electrhophysiology service, Clinica Las Vegas, Grupo Quiron Salud; Universidad CES School of Medicine, Medellin, Colombia, USA
| | - Maria Gamero
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Isabella Alviz
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Marta Lorente
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mohamed Gabr
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Suraj Krishnan
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Alejandro Velasco
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Aung Lin
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Fengwei Zou
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Luigi Di Biase
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
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8
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Hanson MG, Enriquez A. Deductive Electrocardiographic Analysis of Left Ventricular Summit Arrhythmias. Card Electrophysiol Clin 2023; 15:9-14. [PMID: 36774141 DOI: 10.1016/j.ccep.2022.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The left ventricular summit is a source of idiopathic ventricular arrhythmias and presents distinct challenges for mapping and ablation. These arrhythmias are typically targeted from the distal coronary venous system or most often from endocardial vantage points such as the left coronary cusp, basal left ventricle or septal right ventricular outflow tract. In this article, we review the electrocardiographic patterns that suggest a possible origin from the left ventricular summit and the features that may help to predict the most likely site of successful ablation.
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Affiliation(s)
- Matthew G Hanson
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada
| | - Andres Enriquez
- Division of Cardiology, Queen's University, Kingston, Ontario, Canada.
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9
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Huang LH, Gao ZZ, Li WY, Zhang HC, Zheng JW, Liu XP. Stereotactic body radiation therapy for refractory premature ventricular contractions that originate from the left ventricular summit: A case report. Pacing Clin Electrophysiol 2023; 46:190-194. [PMID: 36069105 DOI: 10.1111/pace.14590] [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: 04/11/2022] [Revised: 07/20/2022] [Accepted: 08/20/2022] [Indexed: 11/29/2022]
Abstract
The case highlights an available method to minimize the target volume and reduce the radiation dose by using a temporary catheter, to reduce the long-term risk of radiotherapy for ventricular arrhythmias.
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Affiliation(s)
- Li-Hong Huang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhi-Zhang Gao
- Department of Radiation Oncology, Sunshine Union Hospital, Weifang, China
| | - Wei-Yong Li
- Department of Radiation Oncology, Sunshine Union Hospital, Weifang, China
| | - Hou-Cai Zhang
- Department of Radiation Oncology, Sunshine Union Hospital, Weifang, China
| | | | - Xing-Peng Liu
- Heart Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
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10
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Miyamoto S, Okubo Y, Uotani Y, Oguri N, Miyauchi S, Okamura S, Tokuyama T, Nakano Y. Initial experience of novel over the wire type decapolar catheter for ventricular arrhythmias originating from left ventricular summit. JOURNAL OF INTERVENTIONAL CARDIAC ELECTROPHYSIOLOGY : AN INTERNATIONAL JOURNAL OF ARRHYTHMIAS AND PACING 2023; 66:117-124. [PMID: 35960405 DOI: 10.1007/s10840-022-01340-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Previously, direct monitoring of local activation at the communicating vein (CV) has been reported to be useful for the ablation of ventricular arrhythmias (VAs) originating from the left ventricular (LV) summit. In this study, we evaluated the performance of the novel over-the-wire (OTW)-type decapolar catheter for VAs originating from the LV summit. METHODS Overall, 17 patients who underwent catheter ablation for idiopathic VAs originating from the LV summit were included in this study. Of these, seven patients underwent mapping of the epicardial LV outflow tract with the novel 2.7 Fr OTW-type decapolar catheter (EPstar FIX AIV), and ten underwent mapping with the standard 2.0 Fr octopolar catheter (EPstar FIX 2F) procedure (AIV group = EPstar FIX AIV and control group = EPstar FIX 2F). RESULTS No significant differences in the baseline characteristics were observed between the two groups. In the AIV group, all patients achieved successful catheter positioning in the target CV, whereas in the control group, two patients failed to achieve the same. The novel catheter not only advanced to the target vessels using a 0.014-in guidewire but it was also used for contrast injection from the catheter lumen, which enabled accurate and safe positioning. As a result, the earliest activation time preceding QRS onset during the VA, recorded at the CV, was significantly earlier when compared with the control group (44.66 ± 11.23 ms vs. 32.16 ± 4.26 ms, P = 0.007). CONCLUSIONS Compared with the conventional electrode catheter, this novel multipolar electrode catheter is more effective for mapping local activation at the CV.
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Affiliation(s)
- Shogo Miyamoto
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Yousaku Okubo
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan.
| | - Yukimi Uotani
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Naoto Oguri
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Shunsuke Miyauchi
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Sho Okamura
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Takehito Tokuyama
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Yukiko Nakano
- Department of Cardiovascular Medicine, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
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11
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Yamada T. Techniques for Catheter Ablation of Idiopathic Ventricular Arrhythmias Originating from the Outflow Tract and Left Ventricular Summit. Card Electrophysiol Clin 2022; 14:621-631. [PMID: 36396181 DOI: 10.1016/j.ccep.2022.07.008] [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: 06/16/2023]
Abstract
Idiopathic ventricular arrhythmias (VAs) most commonly originate from the ventricular outflow tracts. Because the anatomy of this region is complex and some of those VA origins are intramural and epicardial, it may sometimes be difficult to locate the site of the VA origin. Meticulous mapping in multiple different locations such as the right and left ventricular outflow tracts, endocardial and epicardial sites, and above and below the aortic and pulmonic valves may be required to achieve successful catheter ablation of those VAs. Special ablation techniques may be considered to improve the outcome of catheter ablation of intramural and epicardial VAs.
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Affiliation(s)
- Takumi Yamada
- Cardiovascular Division, University of Minnesota, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA.
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12
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Dukkipati SR, Nakamura T, Nakajima I, Oates C, Narui R, Tanigawa S, Sljapic T, Whang W, Koruth JS, Choudry S, Schaeffer B, Fujii A, Tedrow UB, Sapp JL, Stevenson WG, Reddy VY. Intramural Needle Ablation for Refractory Premature Ventricular Contractions. Circ Arrhythm Electrophysiol 2022; 15:e010020. [PMID: 35476455 DOI: 10.1161/circep.121.010020] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Frequent premature ventricular contractions (PVCs) are often amenable to catheter ablation. However, a deep intramural focus may lead to failure due to inability of standard ablation techniques to penetrate the focus. We sought to assess the efficacy and safety of infusion needle ablation (INA) for PVCs that are refractory to standard radiofrequency ablation. METHODS Under 2 Food and Drug Administration approved protocols, INA was evaluated in patients with frequent PVCs that were refractory to standard ablation. Initial targets for ablation were selected by standard mapping techniques. INA was performed with a deflectable catheter equipped with an extendable/retractable needle at the tip that can be extended up to 12 mm into the myocardium and is capable of pacing and recording. After contrast injection for location assessment, radiofrequency ablation was performed with the needle tip using a temperature-controlled mode (maximum temperature 60 °C) with saline infusion from the needle. The primary end point was a decrease in PVC burden to <5000/24 hours at 6 months. The primary safety end point was incidence of procedure- or device-related serious adverse events. RESULTS At 4 centers, 35 patients (age 55.3±16.9 years, 74.2% male) underwent INA. The baseline median PVC burden was 25.4% (interquartile range, 18.4%-33.9%) and mean left ventricular ejection fraction was 37.7±12.3%. Delivering 10.3±8.0 INA lesions/patient (91% had adjunctive standard radiofrequency ablation also) resulted in acute PVC elimination in 71.4%. After a mean follow-up of 156±109 days, the primary efficacy end point was met in 73.3%. The median PVC burden decreased to 0.8% (interquartile range, 0.1%-6.0%; P<0.001). The primary safety end point occurred in 14.3% consisting of 1 (2.9%) heart block, 1 (2.9%) femoral artery dissection, and 3 (8.6%) pericardial effusions (all treated percutaneously). CONCLUSIONS INA is effective for the elimination of frequent PVCs that are refractory to conventional ablation and is associated with an acceptable safety profile. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01791543 and NCT03204981.
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Affiliation(s)
- Srinivas R Dukkipati
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, NY (S.R.D., C.O., T.S., W.W., J.S.K., S.C., V.Y.R.)
| | - Tomofumi Nakamura
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (T.N., I.N., R.N., W.G.S.)
| | - Ikutaro Nakajima
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (T.N., I.N., R.N., W.G.S.)
| | - Connor Oates
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, NY (S.R.D., C.O., T.S., W.W., J.S.K., S.C., V.Y.R.)
| | - Ryohsuke Narui
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (T.N., I.N., R.N., W.G.S.)
| | - Shinichi Tanigawa
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (S.T., B.S., A.F., U.B.T.)
| | - Tatjana Sljapic
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, NY (S.R.D., C.O., T.S., W.W., J.S.K., S.C., V.Y.R.)
| | - William Whang
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, NY (S.R.D., C.O., T.S., W.W., J.S.K., S.C., V.Y.R.)
| | - Jacob S Koruth
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, NY (S.R.D., C.O., T.S., W.W., J.S.K., S.C., V.Y.R.)
| | - Subbarao Choudry
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, NY (S.R.D., C.O., T.S., W.W., J.S.K., S.C., V.Y.R.)
| | - Benjamin Schaeffer
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (S.T., B.S., A.F., U.B.T.)
| | - Akira Fujii
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (S.T., B.S., A.F., U.B.T.)
| | - Usha B Tedrow
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (S.T., B.S., A.F., U.B.T.)
| | - John L Sapp
- Heart Rhythm Service, Division of Cardiology, Department of Medicine, QEII Health Sciences Centre, Halifax, Nova Scotia, Canada (J.L.S.)
| | - William G Stevenson
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee (T.N., I.N., R.N., W.G.S.)
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Department of Cardiology, Icahn School of Medicine at Mount Sinai, NY (S.R.D., C.O., T.S., W.W., J.S.K., S.C., V.Y.R.)
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13
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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]
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14
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Jena A, Iqbal M, Baek YS, Lee KN, Rho SY, Shim JM, Choi JI, Kim YH. Unipolar and bipolar electrogram characteristics of recurrent cases of idiopathic ventricular arrhythmias undergoing repeat catheter ablation. Indian Pacing Electrophysiol J 2021; 22:12-16. [PMID: 34823016 PMCID: PMC8811281 DOI: 10.1016/j.ipej.2021.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 11/02/2021] [Accepted: 11/18/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction Activation mapping guided catheter ablation (CA) of ventricular arrhythmias (VAs) is limited in some cases when it is only relied on bipolar electrogram (EGM). We hypothesized that activation mapping with use of combined bipolar and unipolar EGM facilitates to identify the focal origin of VAs and results in reduction of recurrence rate of CA of VAs. Methods We analyzed the data of patients undergoing repeat ablations for idiopathic out-flow tract VAs. The EGM of the 1 st and 2 nd ablations were compared for earliest local activation time (LAT), presence of discrete potentials, and polarity reversal, unipolar potential morphology (QS or non-QS), potential amplitude and activation slope. Results Thirty-seven patients were included. The Local activation time was significantly earlier in the 2nd ablation as compared to the 1st procedure (36.90 msec vs 31.85 msec, P < 0.01). The incidence of discrete potentials and polarity reversal were similar in both procedures (51% vs 57%, P = 0.8 and 62% in both the occasions, respectively). The unipolar voltage was similar in both occasions (6.94 mV vs 7.22 mV in repeat ablations, P = 0.7). The recurrence rate (5.7%) was significantly lower with routine use of combined unipolar and bipolar EGMs, as compared to the use of bipolar EGM alone (16.7%) Conclusions Use of both bipolar and unipolar electrograms helps in better delineation of the sites of earliest activation for effective ablation of VAs. Use of unipolar electrograms in addition to bipolar electrograms is associated with lower long term recurrence rate. In patients undergoing redo ablations for idiopathic OTVAs, a slow-rapid initial QS morphology with its earlier timing prior to onset of QRS on unipolar EGM facilitate identification of early activation sites and improves success of CA. Bipolar EGM chracteristics like polarity reversal and presence of discrete potentials have no additive efficacy in redo CA cases. A slow-rapid initial QS morphology with its earlier timing to QRS onset may improve the success of CA in idiopathic OTVAs.
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Affiliation(s)
- Anupam Jena
- Kalinga Institute of Medical Sciences, Republic of Korea
| | - Mohammad Iqbal
- Korea University Medical Center, Seoul, Republic of Korea
| | - Yong-Soo Baek
- Korea University Medical Center, Seoul, Republic of Korea
| | - Kwang-No Lee
- Korea University Medical Center, Seoul, Republic of Korea
| | | | - Jae Min Shim
- Korea University Medical Center, Seoul, Republic of Korea
| | - Joing Il Choi
- Korea University Medical Center, Seoul, Republic of Korea
| | - Young-Hoon Kim
- Korea University Medical Center, Seoul, Republic of Korea.
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15
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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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16
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Affiliation(s)
- Koji Higuchi
- Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
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17
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Yamada T. What Can the Current Technology Tell Us About the Relationship Between Intramural Scar and PVCs? JACC Clin Electrophysiol 2021; 7:742-744. [PMID: 34167751 DOI: 10.1016/j.jacep.2020.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 12/18/2020] [Accepted: 12/19/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Takumi Yamada
- Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota, USA.
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18
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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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19
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Novel technique targeting left ventricular summit premature ventricular contractions using radiofrequency ablation through a guidewire. HeartRhythm Case Rep 2021; 7:134-138. [PMID: 33786305 PMCID: PMC7987911 DOI: 10.1016/j.hrcr.2020.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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20
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Pothineni NVK, Garcia FC, Santangeli P. Radiofrequency Ablation Strategies for Intramural Ventricular Arrhythmias. Methodist Debakey Cardiovasc J 2021; 17:8-12. [PMID: 34104314 DOI: 10.14797/peyf3776] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Catheter ablation is an established treatment strategy for ventricular arrhythmias. However, the presence of intramural substrate poses challenges with mapping and delivery of radiofrequency energy, limiting overall success of catheter ablation. Advances over the past decade have improved our understanding of intramural substrate and paved the way for innovative treatment approaches. Modifications in catheter ablation techniques and development of novel ablation technologies have led to improved clinical outcomes for patients with ventricular arrhythmias. In this review, we explore mapping techniques to identify intramural substrate and describe available radiofrequency energy delivery techniques that can improve overall success rates of catheter ablation.
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Affiliation(s)
| | - Fermin C Garcia
- Hospital of The University of Pennsylvania, Philadelphia, Pennsylvania
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21
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Kamioka M, Hijioka N, Nodera M, Yamada S, Kaneshiro T, Takeishi Y. Electrophysiological properties and involvement of anatomical factors for the prediction of intramural origin in patients with ventricular tachyarrhythmia arising from the left ventricular outflow tract. J Interv Card Electrophysiol 2021; 63:115-123. [PMID: 33564988 DOI: 10.1007/s10840-021-00959-3] [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: 10/22/2020] [Accepted: 02/04/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To elucidate the electrophysiological predictors of the intramural origins of left ventricular outflow tract-ventricular tachyarrhythmias (LVOT-VAs), and to clarify the involvement of anatomical factors. METHODS Twenty-nine successfully ablated LVOT-VAs patients with origins in the aortomitral continuity (AMC) (n = 8), aortic sinus of valsalva (ASV) (n = 9), great cardiac vein (GCV) (n = 5), and intramural myocardium (n = 7) were enrolled. Intramural origins were defined as when effective ablation from AMC and epicardium (ASV and/or GCV) was needed. The local activation time difference (LATD) was calculated as follows: (earliest AMC activation) - (earliest epicardial activation), and was presented as an absolute value. Electrophysiological parameters and anatomical factors predisposing the intramural origins were investigated. RESULTS LATD of intramural origins was significantly shorter than that of AMC and GCV (4.5 ± 2.6 vs. 12.1 ± 7.4 vs. 17.4 ± 4.7, P < 0.05), respectively. In multivariate logistic regression analysis, LATD was associated with intramural origins (odds ratio: 0.711, confidence interval: 0.514-0.985, P = 0.040). ROC analysis revealed LATD of 7 ms as cut-off value. In computed tomography analysis, some patients who had thick fat tissue below the GCV, and an unusual GCV running pattern might be misdiagnosed as intramural origins. CONCLUSION LATD ≤ 7 ms was associated with intramural origins, but with some anatomical limitations.
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Affiliation(s)
- Masashi Kamioka
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan.
| | - Naoko Hijioka
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Minoru Nodera
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Shinya Yamada
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
| | - Takashi Kaneshiro
- Department of Arrhythmia and Cardiac Pacing, Fukushima Medical University, Fukushima, Japan
| | - Yasuchika Takeishi
- Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan
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22
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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.
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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.
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23
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Ablation strategies for intramural ventricular arrhythmias. Heart Rhythm 2020; 17:1176-1184. [DOI: 10.1016/j.hrthm.2020.02.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/07/2020] [Indexed: 11/23/2022]
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24
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Shapira-Daniels A, Barkagan M, Rottmann M, Sroubek J, Tugal D, Carlozzi MA, McConville JW, Buxton AE, Anter E. Modulating the Baseline Impedance: An Adjunctive Technique for Maximizing Radiofrequency Lesion Dimensions in Deep and Intramural Ventricular Substrate: An Adjunctive Technique for Maximizing Radiofrequency Lesion Dimensions in Deep and Intramural Ventricular Substrate. Circ Arrhythm Electrophysiol 2020; 12:e007336. [PMID: 31113232 DOI: 10.1161/circep.119.007336] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Radiofrequency ablation of intramural ventricular substrate is often limited by insufficient tissue penetration despite high energy settings. As lesion dimensions have a direct and negative relationship to impedance, reducing the baseline impedance may increase the ablation effect on deep ventricular tissue. Methods This study included 16 patients with ventricular tachycardia or frequent ventricular premature complexes refractory to ablation with irrigated catheters. After a failed response to radiofrequency ablation, impedance was modulated by adding or repositioning return patches in an attempt to decrease the circuit impedance. Ablation was repeated at a similar location and power settings, and the effect on arrhythmia suppression and adverse effects were evaluated. Results Six patients with idiopathic ventricular premature complexes originating from the left ventricular summit (n=4) or papillary muscles (n=2), 6 patients with noninfarct related ventricular tachycardia and 4 patients with infarct-related ventricular tachycardia had unsuccessful response to radiofrequency ablation at critical sites (number of applications: 10.4±3.1, power: 42.3±2.9 W, duration: 55.3±25.5 seconds, impedance reduction: 14.6±3.5 Ω, low-ionic solution was used in 81.25%). Modulating the return patches resulted in reduced baseline impedance (111.7±8.2 versus 134.7±6.6 Ω, P<0.0001), increased current output (0.6±0.02 versus 0.56±0.02 Amp; P<0.0001) and greater impedance drop (16.8±3.0 Ω, P<0.001). Repeat ablation at similar locations had a successful effect in 12 out of 16 (75.0%) patients. During a follow-up duration of 13±5 months, 10 out of 12 (83.3%) patients remained free of arrhythmia recurrence. The frequency of steam pops was similar between the higher and lower baseline impedance settings (7.1 versus 8.2%; P=0.74). Conclusions In patients with deep ventricular substrate, reducing the baseline impedance is a simple, safe, and effective technique for increasing the effect of radiofrequency ablation. However, its combination with low-ionic solutions may increase the risk for steam pops and neurological events.
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Affiliation(s)
- Ayelet Shapira-Daniels
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Michael Barkagan
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Markus Rottmann
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jakub Sroubek
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Derin Tugal
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Michael A Carlozzi
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - James W McConville
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Alfred E Buxton
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Elad Anter
- Cardiovascular Division, Department of Medicine, Harvard-Thorndike Electrophysiology Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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25
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Mehra N, Asirvatham SJ. Expecting failure yet obtaining success. J Cardiovasc Electrophysiol 2019; 30:2995-2997. [PMID: 31642149 DOI: 10.1111/jce.14225] [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: 10/02/2019] [Accepted: 10/03/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Nandini Mehra
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Department of Medicine, Mayo Clinic, Rochester, Minnesota.,Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
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26
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Yamada T. Twelve-lead electrocardiographic localization of idiopathic premature ventricular contraction origins. J Cardiovasc Electrophysiol 2019; 30:2603-2617. [PMID: 31502322 DOI: 10.1111/jce.14152] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 08/16/2019] [Accepted: 08/29/2019] [Indexed: 11/29/2022]
Abstract
The major sites of origins of idiopathic ventricular arrhythmias have been elucidated. Idiopathic ventricular arrhythmias most often present as premature ventricular contractions (PVCs) with a focal mechanism, and commonly occur without structural heart disease. Idiopathic ventricular arrhythmias usually originate from specific anatomical structures, commonly endocardial but sometimes epicardial and exhibit characteristic electrocardiograms (ECGs) based on their anatomical background. There are general and specific ECG characteristics that can localize the site of idiopathic PVC origins. The general ECG characteristics include the bundle branch block pattern, axis, QRS polarity in lead V6, QRS duration, precordial transition, maximal deflection index, and so forth. They can roughly localize the site of idiopathic PVC origins. Several major sites of idiopathic PVC origins are located close to each other, and specific ECG characteristics are helpful for localizing the site of origins more accurately in those PVCs. Twelve-lead surface ECG algorithms usually can localize the site of idiopathic PVC origins with a high accuracy, but their accuracy can be limited by the patients' physique, heart rotation, specific conduction properties, presence of structural heart disease, and so forth. This review describes an overview of the approaches to the 12-lead surface ECG localization of idiopathic PVCs, and also discusses their caveats and limitations.
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Affiliation(s)
- Takumi Yamada
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
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27
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Yamada T. Special considerations in mapping and ablation of focal ventricular arrhythmias originating from the left ventricular outflow tract in patients with a transcatheter aortic valve replacement. J Cardiovasc Electrophysiol 2019; 30:2640-2647. [PMID: 31512333 DOI: 10.1111/jce.14175] [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: 06/24/2019] [Revised: 08/25/2019] [Accepted: 08/28/2019] [Indexed: 11/29/2022]
Abstract
Transcatheter aortic valve replacements (TAVRs) have been increasingly performed in high-risk patients with severe aortic stenosis. Focal ventricular arrhythmias (VAs) originating from the left ventricular outflow tract (LVOT) can occur after a TAVR, and radiofrequency catheter ablation (RFCA) should be considered as a treatment option when those VAs are drug-refractory. There are specific challenges in the RFCA of LVOT VAs after a TAVR because the tubular structure of the TAVR device sits in the LVOT. However, if the anatomical background of the TAVR and LVOT VAs are well understood and the anatomical relationship between the TAVR device and LVOT is sufficiently evaluated, RFCA of LVOT VAs in patients with a TAVR should be safe and highly successful.
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Affiliation(s)
- Takumi Yamada
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama
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28
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Motonaga KS, Hsia HH. Road to the Summit May Follow an Eccentric Path. Circ Arrhythm Electrophysiol 2019; 12:e007691. [PMID: 31401855 DOI: 10.1161/circep.119.007691] [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] [Indexed: 11/16/2022]
Affiliation(s)
- Kara S Motonaga
- Department of Pediatrics, Division of Pediatric Cardiology, Stanford University, Palo Alto, CA (K.S.M.)
| | - Henry H Hsia
- the Department of Medicine, Division of Cardiology, University of California San Francisco (H.H.H.)
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29
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Yamada T, Kumar V, Yoshida N, Doppalapudi H. Eccentric Activation Patterns in the Left Ventricular Outflow Tract during Idiopathic Ventricular Arrhythmias Originating From the Left Ventricular Summit. Circ Arrhythm Electrophysiol 2019; 12:e007419. [DOI: 10.1161/circep.119.007419] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Idiopathic ventricular arrhythmias (VAs) originating from the left ventricular summit (LVS) can be ablated from the great cardiac vein and remote endocardial sites. The ablation sites are determined by mapping in the great cardiac vein and left ventricular outflow tract. This study investigated whether that mapping could accurately predict the sites of LVS-VA origins.
Methods:
We studied 26 consecutive patients with idiopathic LVS-VA origins that were identified in the basal and apical LVS in 15 and 11 patients, respectively.
Results:
Radiofrequency catheter ablation of the apical LVS-VAs was successful in the great cardiac vein in 9 patients and in the apical LV outflow tract in 2. That of the basal LVS-VAs was successful in the aortomitral continuity in 9 patients, at the junction of the left and right coronary cusps in 4, and in the left coronary cusp in 2. Three apical LVS-VAs exhibited an eccentric endocardial activation pattern that was from the basal to apical LV outflow tract. In 11 basal LVS-VAs, the activation pattern was eccentric because the ventricular activation within the great cardiac vein in the apical LVS was earlier than that in the basal LV outflow tract. In 2 basal LVS-VAs, the activation pattern was eccentric because a relatively early ventricular activation was recorded at multiple sites away from the successful ablation site.
Conclusions:
Eccentric activation patterns often occurred during idiopathic LVS-VAs, which could mislead the catheter ablation of those VAs. Understanding such eccentric activation patterns was suggested to be able to improve the outcomes of the catheter ablation of those VAs by the anatomic approach.
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Affiliation(s)
- Takumi Yamada
- Division of Cardiovascular Disease, University of Alabama at Birmingham
| | - Vineet Kumar
- Division of Cardiovascular Disease, University of Alabama at Birmingham
| | - Naoki Yoshida
- Division of Cardiovascular Disease, University of Alabama at Birmingham
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30
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Baszko A, Kałmucki P, Siminiak T, Szyszka A. Telescopic coronary sinus cannulation for mapping and ethanol ablation of arrhythmia originating from left ventricular summit. Cardiol J 2019; 27:312-315. [PMID: 31257570 DOI: 10.5603/cj.a2019.0064] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 05/01/2019] [Accepted: 05/03/2019] [Indexed: 11/25/2022] Open
Affiliation(s)
- Artur Baszko
- Poznań University of Medical Sciences, ul. 28 Czerwca 1956r No 194, 61-485 Poznan, Poland.
| | - Piotr Kałmucki
- Poznań University of Medical Sciences, ul. 28 Czerwca 1956r No 194, 61-485 Poznan, Poland
| | - Tomasz Siminiak
- Poznań University of Medical Sciences, ul. 28 Czerwca 1956r No 194, 61-485 Poznan, Poland
| | - Andrzej Szyszka
- Poznań University of Medical Sciences, ul. 28 Czerwca 1956r No 194, 61-485 Poznan, Poland
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31
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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.
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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
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32
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Tzou WS. The answer lies somewhere in between: Important lessons in understanding and conquering midmyocardial ventricular arrhythmias arising from the outflow tract. J Cardiovasc Electrophysiol 2018; 29:1672-1674. [PMID: 30378712 DOI: 10.1111/jce.13755] [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: 09/22/2018] [Accepted: 09/24/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Wendy S Tzou
- Section of Cardiac Electrophysiology, University of Colorado, Aurora, Colorado
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33
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Candemir B, Ozyurek E, Vurgun K, Turan N, Duzen V, Goksuluk H, Ozyuncu N, Kurklu S, Altin T, Akyurek O, Erol C. Effect of radiofrequency on epicardial myocardium after ablation of ventricular arrhythmias from within coronary sinus. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2018; 41:1060-1068. [PMID: 29935047 DOI: 10.1111/pace.13429] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 03/16/2018] [Accepted: 03/27/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Radiofrequency (RF) ablation of idiopathic ventricular arrhythmias (IVA) from the coronary venous system (CVS) has been increasingly performed, but real effect of ablation lesions from CVS on epicardial myocardium has not been studied. OBJECTIVE To compare effects of RF delivered inside the distal CVS during ablation of IVAs originating from left ventricular summit (LVS) with IVAs ablated from right ventricular outflow tract (RVOT) using cardiac magnetic resonance imaging (CMRI). METHODS Twenty consecutive patients with IVAs who underwent acutely successful RF ablation at initial appropriate sites, i.e., distal CVS (Group 1, n = 10) or RVOT (Group 2; n = 10) were enrolled. Detailed contrast-enhanced CMRI of each patient was performed 3 months later. Presence and location of scars, distance of CVS to epicardial ventricular myocardium were measured and analyzed. RESULTS Group 1 consisted of 10 and Group 2 consisted of 10 patients. Three months after the ablation, only three patients in Group 1 had detectable late gadolinium enhancement (LGE) on CMRI while nine out of 10 patients in Group 2 had evident LGE on CMRI (P: 0.02). The mean distance of distal CVS to epicardial anterobasal myocardium was measured to be 8.8 ± 1.6 mm in Group 1. In three cases that had detectable scar on superior anterobasal LV epicardium, the mean distance was 7.4 ± 1.1 mm. CONCLUSIONS RF delivery inside the CVS is less likely to produce detectable LGE on CMRI compared to RVOT. This may partially explain less than ideal long-term results after ablation of LVS IVAs from within the great cardiac vein/anterior interventricular vein.
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Affiliation(s)
- Basar Candemir
- Cardiology Department, Ankara University, Ankara, Turkiye
| | - Elif Ozyurek
- Magnetic Resonance Imaging Division, Department of Radiology, Ankara University, Ankara, Turkiye
| | - Kutay Vurgun
- Cardiology Department, Ankara University, Ankara, Turkiye
| | - Nazli Turan
- Cardiology Department, Ankara University, Ankara, Turkiye
| | - Veysel Duzen
- Cardiology Department, Gaziantep Ersin Arslan Research Hospital, Ankara, Turkiye
| | | | - Nil Ozyuncu
- Cardiology Department, Ankara University, Ankara, Turkiye
| | - Seda Kurklu
- Cardiology Department, Ankara University, Ankara, Turkiye
| | - Timucin Altin
- Cardiology Department, Ankara University, Ankara, Turkiye
| | - Omer Akyurek
- Cardiology Department, Ankara University, Ankara, Turkiye
| | - Cetin Erol
- Cardiology Department, Ankara University, Ankara, Turkiye
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34
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Romero J, Diaz JC, Hayase J, Dave RH, Bradfield JS, Shivkumar K. Intramyocardial radiofrequency ablation of ventricular arrhythmias using intracoronary wire mapping and a coronary reentry system: Description of a novel technique. HeartRhythm Case Rep 2018; 4:285-292. [PMID: 30023273 PMCID: PMC6050428 DOI: 10.1016/j.hrcr.2018.03.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jorge Romero
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California.,Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Juan Carlos Diaz
- Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Justin Hayase
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Ravi H Dave
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jason S Bradfield
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California
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35
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Yamada T. Which ventricle should be mapped first in catheter ablation of ventricular arrhythmias originating from the ventricular outflow tract? J Cardiovasc Electrophysiol 2018; 29:600-602. [PMID: 29436088 DOI: 10.1111/jce.13461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 02/07/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Takumi Yamada
- Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL, USA
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36
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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
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37
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Komatsu Y, Nogami A, Shinoda Y, Masuda K, Machino T, Kuroki K, Yamasaki H, Sekiguchi Y, Aonuma K. Idiopathic Ventricular Arrhythmias Originating From the Vicinity of the Communicating Vein of Cardiac Venous Systems at the Left Ventricular Summit. Circ Arrhythm Electrophysiol 2018; 11:e005386. [DOI: 10.1161/circep.117.005386] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 11/28/2017] [Indexed: 11/16/2022]
Abstract
Background
The communicating vein (CV) between the great cardiac vein and small cardiac venous systems passes between the aortic and pulmonary annulus and is located in close association with the left ventricular summit (summit CV).
Methods and Results
Thirty-one patients with idiopathic ventricular arrhythmias (VAs) underwent mapping of the left ventricular summit by using a 2F microcatheter introduced into the summit CV with coronary sinus venographic guidance. Of these, 14 patients were found to have summit-CV VAs. The remaining 17 patients (control group) had VAs originating from the right ventricular outflow tract and the aortic cusps. In patients with summit-CV VAs, the earliest activation during VAs in the summit CV preceded QRS onset by 34.1±5.3 ms. The summit-CV VAs exhibited inferior axis, negative polarity in lead I, deeper QS wave in lead aVL than aVR, and nonspecific bundle branch block morphology with an R/S ratio in lead V
1
of 0.67±0.33, which could be distinguishable from VAs originating from the right ventricular outflow tract and the right coronary cusp. Because of the inaccessibility of the summit CV to ablation catheter, ablation of summit-CV VAs was attempted at adjacent structures where an excellent pacemap was rarely obtained. Overall ablation success was achieved in 10 (71%) patients with summit VAs and 15 (88%) patients in control group (
P
=0.24).
Conclusions
The myocardium near the summit CV can be the source of idiopathic VAs. Direct monitoring of the summit CV is helpful for identifying the site of origin and provides a landmark of the ablation target, which may facilitate ablation through adjacent structures.
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Affiliation(s)
- Yuki Komatsu
- From the Department of Cardiology, University of Tsukuba, Japan
| | - Akihiko Nogami
- From the Department of Cardiology, University of Tsukuba, Japan
| | | | - Keita Masuda
- From the Department of Cardiology, University of Tsukuba, Japan
| | - Takeshi Machino
- From the Department of Cardiology, University of Tsukuba, Japan
| | - Kenji Kuroki
- From the Department of Cardiology, University of Tsukuba, Japan
| | - Hiro Yamasaki
- From the Department of Cardiology, University of Tsukuba, Japan
| | - Yukio Sekiguchi
- From the Department of Cardiology, University of Tsukuba, Japan
| | - Kazutaka Aonuma
- From the Department of Cardiology, University of Tsukuba, Japan
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38
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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.
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Affiliation(s)
| | - Michael Fiek
- Medizinische Klinik I, HELIOS Klinikum München West, Munich, Germany
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39
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Zheng C, Li J, Li J, Zhou DP, Li XW, Wu SJ, Lin JF. Approach selection of radiofrequency catheter ablation for ventricular arrhythmias originating from the left ventricular summit: potential relevance of Pseudo Delta wave, Intrinsicoid deflection time, maximal deflection index. BMC Cardiovasc Disord 2017; 17:140. [PMID: 28558750 PMCID: PMC5450141 DOI: 10.1186/s12872-017-0575-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 05/22/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ventricular arrhythmias (VAs) originating from the left ventricular summit is a challenge for radiofrequency catheter ablation (RFCA). The present study aimed to investigate the appropriate RFCA strategy for VAs originating from the left ventricular summit. METHODS Forty-five consecutive patients with VAs arising from the left ventricular summit were successfully ablated at our cardiac electrophysiology center and reviewed in the study. RESULTS Thirty-two cases of VAs were eliminated in the left ventricular endocardium by retrograde transaortic (n = 22, 22/45, 48.9%) or antegrade transseptal (n = 10, 10/45, 22.2%) approaches, the other 13 cases were eliminated in the left ventricular epicardium by distal great cardiac vein (DGCV) approach (n = 13, 13/45, 28.9%). Though these VAs were similar in electrocardiographic (ECG) morphology, the pseudo delta waves (PDW), intrinsicoid deflection time (IDT), maximal deflection index (MDI) differed among them, PDW >53 ms, IDT > 74 ms, MDI > 0.45 strongly indicated that ablating left ventricular summit VAs by DGCV approach. During mean follow-up of 19.5 ± 13.2 (range, 3-60) months, 2 (4.4%) patients experienced VAs recurrence. CONCLUSION This retrospective study showed that VAs of left ventricular summit origin can be effectively cured with RFCA. For these VAs, prolonged PdW, IDT, MDI indicating RFCA by DGCV approach can be attempted firstly.
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Affiliation(s)
- Cheng Zheng
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, 109 Xueyuan Road, Wenzhou, Zhejiang, 325000, China
| | - Jin Li
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, 109 Xueyuan Road, Wenzhou, Zhejiang, 325000, China
| | - Jia Li
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, 109 Xueyuan Road, Wenzhou, Zhejiang, 325000, China
| | - De-Pu Zhou
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, 109 Xueyuan Road, Wenzhou, Zhejiang, 325000, China
| | - Xiao-Wei Li
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, 109 Xueyuan Road, Wenzhou, Zhejiang, 325000, China
| | - Shu-Jie Wu
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, 109 Xueyuan Road, Wenzhou, Zhejiang, 325000, China
| | - Jia-Feng Lin
- Department of Cardiology, Second Affiliated Hospital of Wenzhou Medical University, 109 Xueyuan Road, Wenzhou, Zhejiang, 325000, China.
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40
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Yamada T, Yoshida N, Doppalapudi H, Litovsky SH, McElderry HT, Kay GN. Efficacy of an Anatomical Approach in Radiofrequency Catheter Ablation of Idiopathic Ventricular Arrhythmias Originating From the Left Ventricular Outflow Tract. Circ Arrhythm Electrophysiol 2017; 10:e004959. [DOI: 10.1161/circep.116.004959] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 04/17/2017] [Indexed: 11/16/2022]
Abstract
Background—
When anatomic obstacles preclude radiofrequency catheter ablation of idiopathic ventricular arrhythmias (VAs) originating from the left ventricular outflow tract (LVOT), an alternative approach from the anatomically opposite side (endocardial versus epicardial or above versus below the aortic valve) may be considered (anatomic ablation). The purpose of this study was to investigate the efficacy of an anatomic ablation in idiopathic LVOT VAs.
Methods and Results—
We studied 229 consecutive patients with idiopathic LVOT VAs. Radiofrequency ablation from the first suitable site was successful in 190 patients, and in the remaining 39 patients, it was unsuccessful or had to be abandoned because of anatomic obstacles. In 22 of these 39 patients, an anatomic ablation was successful, and the VA origins were located in the intramural LVOT in 17 patients, basal left ventricular summit in 4, and LVOT septum near the His bundle in 1. The anatomic ablation was highly successful for idiopathic VAs originating from the intramural LVOT (>75%) and lateral LVOT, whereas it was unlikely to be successful for idiopathic VAs originating from the basal left ventricular summit (25%) and sepal LVOT.
Conclusions—
When a standard catheter ablation targeting the best electrophysiological measure of idiopathic LVOT VAs was unsuccessful or had to be abandoned because of anatomic obstacles, an anatomic ablation was moderately successful. These idiopathic LVOT VAs with a successful anatomic ablation commonly arose from the intramural LVOT among the left coronary cusp, aortomitral continuity, and epicardium, occasionally the basal left ventricular summit, and rarely the LVOT septum near the His bundle.
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Affiliation(s)
- Takumi Yamada
- From the Division of Cardiovascular Disease (T.Y., N.Y., H.D., H.T.M.E., G.N.K.), Department of Pathology (S.H.L.), University of Alabama at Birmingham
| | - Naoki Yoshida
- From the Division of Cardiovascular Disease (T.Y., N.Y., H.D., H.T.M.E., G.N.K.), Department of Pathology (S.H.L.), University of Alabama at Birmingham
| | - Harish Doppalapudi
- From the Division of Cardiovascular Disease (T.Y., N.Y., H.D., H.T.M.E., G.N.K.), Department of Pathology (S.H.L.), University of Alabama at Birmingham
| | - Silvio H. Litovsky
- From the Division of Cardiovascular Disease (T.Y., N.Y., H.D., H.T.M.E., G.N.K.), Department of Pathology (S.H.L.), University of Alabama at Birmingham
| | - H. Thomas McElderry
- From the Division of Cardiovascular Disease (T.Y., N.Y., H.D., H.T.M.E., G.N.K.), Department of Pathology (S.H.L.), University of Alabama at Birmingham
| | - G. Neal Kay
- From the Division of Cardiovascular Disease (T.Y., N.Y., H.D., H.T.M.E., G.N.K.), Department of Pathology (S.H.L.), University of Alabama at Birmingham
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41
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Santangeli P, Callans DJ. Idiopathic Outflow Tract Ventricular Arrhythmia Ablation. Circ Arrhythm Electrophysiol 2016; 9:CIRCEP.116.004537. [DOI: 10.1161/circep.116.004537] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Pasquale Santangeli
- From the Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
| | - David J. Callans
- From the Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia
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