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Tonko JB, Lambiase P. Exploring the Full Potential of Radiofrequency Technology: A Practical Guide to Advanced Radiofrequency Ablation for Complex Ventricular Arrhythmias. Curr Cardiol Rep 2024; 26:269-282. [PMID: 38700597 DOI: 10.1007/s11886-024-02048-z] [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] [Accepted: 03/19/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE OF REVIEW Percutaneous radiofrequency (RF) catheter ablation is an established strategy to prevent ventricular tachycardia (VT) recurrence and ICD shocks. Yet delivery of durable lesion sets by means of traditional unipolar radiofrequency ablation remains challenging, and left ventricular transmurality is rarely achieved. Failure to ablate and eliminate functionally relevant areas is particularly common in deep intramyocardial substrates, e.g. septal VT and cardiomyopathies. Here, we aim to give a practical-orientated overview of advanced and emerging RF ablation technologies to target these complex VT substrates. We summarize recent evidence in support of these technologies and share experiences from a tertiary VT centre to highlight important "hands-on" considerations for operators new to advanced RF ablation strategies. RECENT FINDINGS A number of innovative and modified radiofrequency ablation approaches have been proposed to increase energy delivery to the myocardium and maximize RF lesion dimensions and depth. These include measures of impedance modulation, combinations of simultaneous unipolar ablations or true bipolar ablation, intramyocardial RF delivery via wires or extendable RF needles and investigational linear or spherical catheter designs. Recent new clinical evidence for the efficacy and safety of these investigational technologies and strategies merits a re-evaluation of their role and clinic application for percutaneous VT ablations. Complexity of substrates targeted with percutaneous VT ablation is increasing and requires detailed preprocedural imaging to characterize the substrate to inform the procedural approach and selection of ablation technology. Depending on local experience, options for additional and/or complementary interventional treatments should be considered upfront in challenging substrates to improve the success rates of index procedures. Advanced RF technologies available for clinical VT ablations include impedance modulation via hypotonic irrigation or additional dispersive patches and simultaneous unipolar as well as true bipolar ablation. Promising investigational RF technologies involve an extendable needle RF catheter, intramyocardial RF delivery over intentionally perforated wires as well as a variety of innovative ablation catheter designs including multipolar linear, spherical and partially insulated ablation catheters.
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Affiliation(s)
- J B Tonko
- Institute of Cardiovascular Science, University College London, 62 Huntley St, London, WC1E 6DD, UK.
- Bartholomew s Hospital, W Smithfield, London, UK.
| | - P Lambiase
- Institute of Cardiovascular Science, University College London, 62 Huntley St, London, WC1E 6DD, UK
- Bartholomew s Hospital, W Smithfield, London, UK
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2
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Tedrow UB, Kurata M, Kawamura I, Batnyam U, Dukkipati S, Nakamura T, Tanigawa S, Fuji A, Richardson TD, Kanagasundram AN, Koruth JS, John RM, Hasegawa K, Abdelwahab A, Sapp J, Reddy VY, Stevenson WG. Worldwide Experience With an Irrigated Needle Catheter for Ablation of Refractory Ventricular Arrhythmias: Final Report. JACC Clin Electrophysiol 2023; 9:1475-1486. [PMID: 37278684 DOI: 10.1016/j.jacep.2023.05.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 05/11/2023] [Accepted: 05/11/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND We previously reported feasibility of irrigated needle ablation (INA) with a retractable 27-G end-hole needle catheter to treat nonendocardial ventricular arrhythmia substrate, an important cause of ablation failure. OBJECTIVES The purpose of this study was to report outcomes and complications in our entire INA-treated population. METHODS Patients with recurrent sustained monomorphic ventricular tachycardia (VT) or high-density premature ventricular contractions (PVCs) despite radiofrequency ablation were prospectively enrolled at 4 centers. Endpoints included a 70% decrease in VT frequency or PVC burden decrease to <5,000/24 h at 6 months. RESULTS INA was performed in 111 patients (median: 2 failed prior ablations, 71% nonischemic heart disease, and left ventricular ejection fraction 36% ± 14%). INA acutely abolished targeted PVCs in 33 of 37 patients (89%), and PVCs were reduced to <5,000/day in 29 patients (78%). During 6-month follow-up, freedom from hospitalization was observed in 50 of 72 patients with VT (69%), and improvement or abolition of VT occurred in 47%. All patients received multiple INA applications, with more in the VT group than in the PVC group (median: 12 [IQR: 7-19] vs 7 [5-15]; P < 0.01). After INA, additional endocardial standard radiofrequency ablation was required in 23% of patients. Adverse events included 4 pericardial effusions (3.5%), 3 cases of (anticipated) atrioventricular block (2.6%), and 3 heart failure exacerbations (2.6%). During 6-month follow-up, 5 deaths occurred; none were procedure-related. CONCLUSIONS INA achieves improved arrhythmia control in 78% of patients with PVCs and avoids hospitalization in 69% of patients with VT refractory to standard ablation at 6-month follow-up. Procedural risks are acceptable. (Intramural Needle Ablation for Ablation of Recurrent Ventricular Tachycardia, NCT01791543; Intramural Needle Ablation for the Treatment of Refractory Ventricular Arrhythmias, NCT03204981).
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Affiliation(s)
- Usha B Tedrow
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Masaaki Kurata
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Iwanari Kawamura
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Uyanga Batnyam
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Srinivas Dukkipati
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Shinichi Tanigawa
- Cardiovascular Division, Department of Medicine, Jikei University Katsushika Medical Center, Tokyo, Japan
| | - Akira Fuji
- Hoshinooka Cardiovascular Clinic, Ehime, Japan
| | - Travis D Richardson
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Arvindh N Kanagasundram
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jacob S Koruth
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Roy M John
- Cardiovascular Division, Stanford University Medical Center, Stanford, California, USA
| | - Kanae Hasegawa
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Amir Abdelwahab
- Heart Rhythm Service, Department of Medicine, Division of Cardiology, QEⅡ Health Sciences Center and Dalhousie University Halifax, Nova Scotia, Canada
| | - John Sapp
- Heart Rhythm Service, Department of Medicine, Division of Cardiology, QEⅡ Health Sciences Center and Dalhousie University Halifax, Nova Scotia, Canada
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William G Stevenson
- Cardiovascular Division, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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Ravi V, Winterfield J, Liang J, Larsen T, Dye C, Sanders D, Skeete J, Payne J, Trohman RG, Aksu T, Sharma PS, Huang HD. Solving the Reach Problem: A Review of Present and Future Approaches for Addressing Ventricular Arrhythmias Arising from Deep Substrate. Arrhythm Electrophysiol Rev 2023; 12:e04. [PMID: 37600155 PMCID: PMC10433105 DOI: 10.15420/aer.2022.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/26/2022] [Indexed: 08/22/2023] Open
Abstract
Ventricular tachycardia (VT) is a significant cause of morbidity and mortality in patients with ischaemic and non-ischaemic cardiomyopathies. In most patients, the primary strategy of VT catheter ablation is based on the identification of critical components of reentry circuits and modification of abnormal substrate which can initiate reentry. Despite technological advancements in catheter design and improved ability to localise abnormal substrates, putative circuits and site of origins of ventricular arrhythmias (VAs), current technologies remain inadequate and durable success may be elusive when the critical substrate is deep or near to critical structures that are at risk of collateral damage. In this article, we review the available and potential future non-surgical investigational approaches for treatment of VAs and discuss the viability of these modalities.
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Affiliation(s)
- Venkatesh Ravi
- Saint Francis Heart and Vascular Institute, Tulsa, OK, US
| | - Jeffrey Winterfield
- Department of Cardiology, Medical University of South Carolina, Charleston, SC, US
| | - Jackson Liang
- Department of Cardiology, University of Michigan, Ann Arbor, MI, US
| | - Timothy Larsen
- Department of Cardiology, Rush University Medical Center, Chicago, IL, US
| | - Cicely Dye
- Department of Cardiology, Rush University Medical Center, Chicago, IL, US
| | - David Sanders
- Department of Cardiology, Rush University Medical Center, Chicago, IL, US
| | - Jamario Skeete
- Department of Cardiology, Rush University Medical Center, Chicago, IL, US
| | - Josh Payne
- Department of Cardiology, University of Michigan, Ann Arbor, MI, US
| | - Richard G Trohman
- Department of Cardiology, Rush University Medical Center, Chicago, IL, US
| | - Tolga Aksu
- Department of Cardiology, Yeditepe University Hospital, Istanbul, Turkey
| | - Parikshit S Sharma
- Department of Cardiology, Rush University Medical Center, Chicago, IL, US
| | - Henry D Huang
- Department of Cardiology, Rush University Medical Center, Chicago, IL, US
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Nayyar S. Intracardiac Electrogram Targets for Ventricular Tachycardia Ablation. Card Electrophysiol Clin 2022; 14:559-570. [PMID: 36396178 DOI: 10.1016/j.ccep.2022.06.001] [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
The pathogenesis of ventricular tachycardia (VT) in most patients with a prior myocardial scarring is reentry involving compartmentalized muscle fibers protected within the scar. Often the 12-lead ECG morphology of the VT itself is not available when treated with a defibrillator. Consequently, VT ablation takes on an interesting challenge of finding critical targets in sinus rhythm. High-density recordings are essential to evaluate a substrate based on whole electrogram voltage and activation delay, supplemented with substrate perturbation through alternate site pacing or introducing an extra stimulation. In this article, we discuss contemporary intracardiac electrogram targets for VT ablation, with explanation on each of their specific fundamental physiology.
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Affiliation(s)
- Sachin Nayyar
- Townsville University Hospital, James Cook University, Townsville, Queensland, Australia.
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Sung E, Prakosa A, Zhou S, Berger RD, Chrispin J, Nazarian S, Trayanova NA. Fat infiltration in the infarcted heart as a paradigm for ventricular arrhythmias. NATURE CARDIOVASCULAR RESEARCH 2022; 1:933-945. [PMID: 36589896 PMCID: PMC9802586 DOI: 10.1038/s44161-022-00133-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Infiltrating adipose tissue (inFAT) has been recently found to co-localize with scar in infarcted hearts and may contribute to ventricular arrhythmias (VAs), a life-threatening heart rhythm disorder. However, the contribution of inFAT to VA has not been well-established. We investigated the role of inFAT versus scar in VA through a combined prospective clinical and mechanistic computational study. Using personalized computational heart models and comparing the results from simulations of VA dynamics with measured electrophysiological abnormalities during the clinical procedure, we demonstrate that inFAT, rather than scar, is a primary driver of arrhythmogenic propensity and is frequently present in critical regions of the VA circuit. We determined that, within the VA circuitry, inFAT, as opposed to scar, is primarily responsible for conduction slowing in critical sites, mechanistically promoting VA. Our findings implicate inFAT as a dominant player in infarct-related VA, challenging existing paradigms and opening the door for unexplored anti-arrhythmic strategies.
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Affiliation(s)
- Eric Sung
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA
| | - Adityo Prakosa
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA
| | - Shijie Zhou
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA
| | - Ronald D. Berger
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA.,Department of Medicine, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jonathan Chrispin
- Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA.,Department of Medicine, Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD, USA.,These authors jointly supervised this work: Jonathan Chrispin, Saman Nazarian, Natalia A. Trayanova
| | - Saman Nazarian
- Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,These authors jointly supervised this work: Jonathan Chrispin, Saman Nazarian, Natalia A. Trayanova
| | - Natalia A. Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA.,Alliance for Cardiovascular Diagnostic and Treatment Innovation, Johns Hopkins University, Baltimore, MD, USA.,These authors jointly supervised this work: Jonathan Chrispin, Saman Nazarian, Natalia A. Trayanova.,Correspondence and requests for materials should be addressed to Natalia A. Trayanova.
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Sapp JL. Needle Ablation for Ventricular Tachycardia: From Bench to Bedside. Can J Cardiol 2022; 38:1150-1152. [PMID: 35781012 DOI: 10.1016/j.cjca.2022.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 11/02/2022] Open
Affiliation(s)
- John L Sapp
- QEII Health Sciences Centre and Dalhousie University, Halifax, Nova Scotia, Canada.
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Boosting Bipolar Radiofrequency Energy Deployment to Target Deep Intramural Substrates. JACC Clin Electrophysiol 2022; 8:511-512. [PMID: 35450606 DOI: 10.1016/j.jacep.2022.02.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/09/2022] [Accepted: 02/09/2022] [Indexed: 11/20/2022]
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