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Haberl C, Crean AM, Zelt JGE, Redpath CJ, deKemp RA. Role of Nuclear Imaging in Cardiac Stereotactic Body Radiotherapy for Ablation of Ventricular Tachycardia. Semin Nucl Med 2024; 54:427-437. [PMID: 38658301 DOI: 10.1053/j.semnuclmed.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 04/26/2024]
Abstract
Ventricular tachycardia (VT) is a life-threatening arrhythmia common in patients with structural heart disease or nonischemic cardiomyopathy. Many VTs originate from regions of fibrotic scar tissue, where delayed electrical signals exit scar and re-enter viable myocardium. Cardiac stereotactic body radiotherapy (SBRT) has emerged as a completely noninvasive alternative to catheter ablation for the treatment of recurrent or refractory ventricular tachycardia. While there is no common consensus on the ideal imaging workflow, therapy planning for cardiac SBRT often combines information from a plurality of imaging modalities including MRI, CT, electroanatomic mapping and nuclear imaging. MRI and CT provide detailed anatomic information, and late enhancement contrast imaging can indicate regions of fibrosis. Electroanatomic maps indicate regions of heterogenous conduction voltage or early activation which are indicative of arrhythmogenic tissue. Some early clinical adopters performing cardiac SBRT report the use of myocardial perfusion and viability nuclear imaging to identify regions of scar. Nuclear imaging of hibernating myocardium, inflammation and sympathetic innervation have been studied for ventricular arrhythmia prognosis and in research relating to catheter ablation of VT but have yet to be studied in their potential applications for cardiac SBRT. The integration of information from these many imaging modalities to identify a target for ablation can be challenging. Multimodality image registration and dedicated therapy planning tools may enable higher target accuracy, accelerate therapy planning workflows and improve patient outcomes. Understanding the pathophysiology of ventricular arrhythmias, and localizing the arrhythmogenic tissues, is vital for successful ablation with cardiac SBRT. Nuclear imaging provides an arsenal of imaging strategies to identify regional scar, hibernation, inflammation, and sympathetic denervation with some advantages over alternative imaging strategies.
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Affiliation(s)
- Connor Haberl
- University of Ottawa Heart Institute, Ottawa, ON; Carleton University, Ottawa, ON
| | - Andrew M Crean
- University of Ottawa Heart Institute, Ottawa, ON; North West Heart Center, University of Manchester Foundation NHS Trust, Manchester, UK
| | - Jason G E Zelt
- The Ottawa Hospital, Ottawa, ON; Department of Medicine, University of Ottawa, Ottawa, ON
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2
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Rosu-Bubulac M, Trankle CR, Mankad P, Grizzard JD, Ellenbogen KA, Jordan JH, Weiss E. Institutional experience report on the target contouring workflow in the radiotherapy department for stereotactic arrhythmia radioablation delivered on conventional linear accelerators. Strahlenther Onkol 2024; 200:83-96. [PMID: 37872398 DOI: 10.1007/s00066-023-02159-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 09/17/2023] [Indexed: 10/25/2023]
Abstract
PURPOSE In stereotactic arrhythmia radioablation (STAR), the target is defined using multiple imaging studies and a multidisciplinary team consisting of electrophysiologist, cardiologist, cardiac radiologist, and radiation oncologist collaborate to identify the target and delineate it on the imaging studies of interest. This report describes the workflow employed in our radiotherapy department to transfer the target identified based on electrophysiology and cardiology imaging to the treatment planning image set. METHODS The radiotherapy team was presented with an initial target in cardiac axes orientation, contoured on a wideband late gadolinium-enhanced (WB-LGE) cardiac magnetic resonance (CMR) study, which was subsequently transferred to the computed tomography (CT) scan used for treatment planning-i.e., the average intensity projection (AIP) image set derived from a 4D CT-via an axial CMR image set, using rigid image registration focused on the target area. The cardiac and the respiratory motion of the target were resolved using ciné-CMR and 4D CT imaging studies, respectively. RESULTS The workflow was carried out for 6 patients and resulted in an internal target defined in standard anatomical orientation that encompassed the cardiac and the respiratory motion of the initial target. CONCLUSION An image registration-based workflow was implemented to render the STAR target on the planning image set in a consistent manner, using commercial software traditionally available for radiation therapy.
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Affiliation(s)
- Mihaela Rosu-Bubulac
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA.
| | - Cory R Trankle
- Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, VA, USA
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Pranav Mankad
- Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, VA, USA
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - John D Grizzard
- Department of Radiology, Virginia Commonwealth University, Richmond, VA, USA
| | - Kenneth A Ellenbogen
- Department of Internal Medicine, Division of Cardiology, Virginia Commonwealth University, Richmond, VA, USA
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Jennifer H Jordan
- Department of Biomedical Engineering, Virginia Commonwealth University, Richmond, VA, USA
- Pauley Heart Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Elisabeth Weiss
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA, USA
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3
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Amino M, Kabuki S, Kunieda E, Hashimoto J, Sugawara A, Sakai T, Sakama S, Ayabe K, Ohno Y, Yagishita A, Kobayashi Y, Ikari Y, Yoshioka K. Interim Report of a Japanese Phase II Trial for Cardiac Stereotactic Body Radiotherapy in Refractory Ventricular Tachycardia - Focus on Target Determination. Circ Rep 2023; 5:69-79. [PMID: 36909137 PMCID: PMC9992511 DOI: 10.1253/circrep.cr-23-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 01/11/2023] [Indexed: 02/10/2023] Open
Abstract
Background: Cardiac radiotherapy using stereotactic body radiation therapy (SBRT) has attracted attention as a minimally invasive treatment for refractory ventricular tachycardia. However, a standardized protocol and software program for determining the irradiation target have not been established. Here, we report the first preclinical stereotactic radioregulation antiarrhythmic therapy trial in Japan, focused on the target-setting process. Methods and Results: From 2019 onwards, 3 patients (age range 60-91 years) presenting with ischemic or non-ischemic cardiomyopathy were enrolled. Two patients were extremely serious and urgent, and were followed up for 6 and 30 months. To determine the irradiation targets, we aggregated electrophysiological, structural, and functional data and reflected them in an American Heart Association 17-segment model, as per the current recommendations. However, in all 3 patients, invasive electrophysiological study, phase-contrast computed tomography, and magnetic resonance imaging could not be performed; therefore, electrophysiological and structural information was limited. As alternatives, high-resolution ambulatory electrocardiography and nuclear medicine studies were useful in assessing arrhythmic substrates; however, concerns regarding test weighting and multiple scoring remain. Risks to surrounding organs were fully taken into account. Conclusions: In patients requiring cardiac SBRT, the information needed for target planning is sometimes limited to minimally invasive tests. Although there are issues to be resolved, this is a promising option for the life-saving treatment of patients in critical situations.
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Affiliation(s)
- Mari Amino
- Department of Cardiology, Tokai University Isehara Japan.,National Institute for Quantum and Radiological Science and Technology Chiba Japan
| | - Shigeto Kabuki
- Department of Radiation Oncology, Tokai University Isehara Japan
| | - Etsuo Kunieda
- Department of Radiation Oncology, Tokai University Isehara Japan
| | - Jun Hashimoto
- Department of Diagnostic Radiology, Tokai University Isehara Japan
| | - Akitomo Sugawara
- Department of Radiation Oncology, Tokai University Isehara Japan
| | - Tetsuri Sakai
- Department of Cardiology, Tokai University Isehara Japan
| | - Susumu Sakama
- Department of Cardiology, Tokai University Isehara Japan
| | - Kengo Ayabe
- Department of Cardiology, Tokai University Isehara Japan
| | - Yohei Ohno
- Department of Cardiology, Tokai University Isehara Japan
| | | | | | - Yuji Ikari
- Department of Cardiology, Tokai University Isehara Japan
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4
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Kochav SM, Garan H, Gorenstein LA, Wan EY, Yarmohammadi H. Cardiac Sympathetic Denervation for the Management of Ventricular Arrhythmias. J Interv Card Electrophysiol 2022; 65:813-26. [PMID: 35397706 DOI: 10.1007/s10840-022-01211-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/29/2022] [Indexed: 01/01/2023]
Abstract
BACKGROUND The autonomic nervous system contributes to the pathogenesis of ventricular arrhythmias (VA). Though anti-arrhythmic drug therapy and catheter ablation are the mainstay of management of VAs, success may be limited in patients with more refractory arrhythmias. Sympathetic modulation is increasingly recognized as a valuable adjunct tool for managing VAs in patients with structural heart disease and inherited arrhythmias. RESULTS In this review, we explore the role of the sympathetic nervous system and rationale for cardiac sympathetic denervation (CSD) in VAs and provide a disease-focused review of the utility of CSD for patients both with and without structural heart disease. CONCLUSIONS We conclude that CSD is a reasonable therapeutic option for patients with VA, both with and without structural heart disease. Though not curative, many studies have demonstrated a significant reduction in the burden of VAs for the majority of patients undergoing the procedure. However, in patients with unilateral CSD and subsequent VA recurrence, complete bilateral CSD may provide long-lasting reprieve from VA.
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Ghannam M, Bogun F. Improving Outcomes in Ventricular Tachycardia Ablation Using Imaging to Identify Arrhythmic Substrates. Card Electrophysiol Clin 2022; 14:609-620. [PMID: 36396180 DOI: 10.1016/j.ccep.2022.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Ventricular tachycardia (VT) ablation is limited by modest acute and long-term success rates, in part due to the challenges in accurately identifying the arrhythmogenic substrate. The combination of multimodality imaging along with information from electroanatomic mapping allows for a more comprehensive assessment of the arrhythmogenic substrate which facilitates VT ablation, and the use of preprocedural imaging has been shown to improve long-term ablation outcomes. Beyond regional recognition of the arrhythmogenic substrate, advanced imaging techniques can be used to create tailored ablation strategies preprocedurally. This review will focus on how imaging can be used to guide ablation planning and execution with a focus on clinical applications aimed at improving the outcome of VT ablation procedures.
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Affiliation(s)
- Michael Ghannam
- Division of Cardiovascular Medicine, University of Michigan, 1500 E. Medical Center Dr., SPC5853, Ann Arbor, Michigan 48109-5853, USA.
| | - Frank Bogun
- Division of Cardiovascular Medicine, University of Michigan, 1500 E. Medical Center Dr., SPC5853, Ann Arbor, Michigan 48109-5853, USA
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Schindler TH, Valenta I, Dilsizian V. Disturbances in Brain-Heart Neuronal-Metabolic Axis Are Associated With Major Arrhythmic Events in Heart Failure. J Am Coll Cardiol 2022; 80:1897-1899. [DOI: 10.1016/j.jacc.2022.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 09/16/2022] [Indexed: 11/09/2022]
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7
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Chen HS, Jungen C, Kimura Y, Dibbets-Schneider P, Piers SR, Androulakis AFA, van der Geest RJ, de Geus-Oei LF, Scholte AJHA, Lamb HJ, Jongbloed MRM, Zeppenfeld K. Ventricular Arrhythmia Substrate Distribution and Its Relation to Sympathetic Innervation in Nonischemic Cardiomyopathy Patients. JACC Clin Electrophysiol 2022; 8:1234-1245. [PMID: 36265999 DOI: 10.1016/j.jacep.2022.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 06/14/2022] [Accepted: 07/09/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Nonischemic cardiomyopathy patients referred for catheter ablation of ventricular arrhythmias (VAs) typically have either inferolateral (ILS) or anteroseptal (ASS) VA substrate locations, with poorer outcomes for ASS. Sympathetic denervation is an important determinant of arrhythmogenicity. Its relation to nonischemic fibrosis in general and to the different VA substrates is unknown. OBJECTIVES This study sought to evaluate the association between VA substrates, myocardial fibrosis, and sympathetic denervation. METHODS Thirty-five patients from the Leiden Nonischemic Cardiomyopathy Study, who underwent electroanatomic voltage mapping and iodine-123 metaiodobenzylguanidine imaging between 2011 and 2018 were included. Late gadolinium-enhanced cardiac magnetic resonance data were collected when available. The relation between global cardiac sympathetic innervation and area-weighted unipolar voltage (UV) as a surrogate for diffuse fibrosis was evaluated. For regional analysis, patients were categorized as ASS or ILS. The distribution of low UV, sympathetic denervation, and late gadolinium enhancement (LGE) scar were compared using the 17-segment model. RESULTS Median area-weighted UV was 12.3 mV in patients with normal sympathetic innervation and 8.7 mV in patients with sympathetic denervation. Global sympathetic denervation correlated with diffuse myocardial fibrosis (R = 0.53; P = 0.02). ILS (n = 13) matched with low UV, sympathetic denervation, and LGE scar in all patients, whereas ASS (n = 11) matched with low UV in all patients, with LGE scar in 63% (P = 0.20), but with sympathetic denervation in only 27% of patients (P = 0.0002). CONCLUSIONS Global cardiac sympathetic denervation is related to fibrosis in nonischemic cardiomyopathy patients with VA. The mismatch between regional fibrosis and preserved innervation for ASS may contribute to a VA substrate difficult to control by catheter ablation.
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Affiliation(s)
- H Sophia Chen
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands; Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, the Netherlands
| | - Christiane Jungen
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands; Department of Cardiology, University Heart and Vascular Center Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | - Yoshitaka Kimura
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Sebastiaan R Piers
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands
| | - Alexander F A Androulakis
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands
| | - Rob J van der Geest
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Lioe-Fee de Geus-Oei
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Arthur J H A Scholte
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands
| | - Hildo J Lamb
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Monique R M Jongbloed
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands; Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, the Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology, Willem Einthoven Center for Cardiac Arrhythmia Research and Management, Leiden University Medical Center, Leiden, the Netherlands.
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8
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Travin MI. Importance of individual patient characteristics when assessing the ability of cardiac adrenergic imaging to guide ICD use. J Nucl Cardiol 2022; 29:692-697. [PMID: 33083985 DOI: 10.1007/s12350-020-02387-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 09/15/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Mark I Travin
- Division of Nuclear Medicine, Department of Radiology, Montefiore Medical Center and the Albert Einstein College of Medicine, 111 E. 210th Street, Bronx, NY, 10467-2490, USA.
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Thackeray JT. Fantastic voyage: Catheter-based quantification of tracer distribution on a miniature scale. J Nucl Cardiol 2022; 29:677-679. [PMID: 33025474 PMCID: PMC8993770 DOI: 10.1007/s12350-020-02379-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 09/08/2020] [Indexed: 11/01/2022]
Affiliation(s)
- James T Thackeray
- Department of Nuclear Medicine, Hannover Medical School, Carl Neuberg Str 1, Hannover, 30625, Germany.
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10
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Abstract
PURPOSE OF REVIEW This review presents the current state of imaging approaches that enable real-time molecular imaging in the interventional suite and discusses the potential future use of integrated nuclear imaging and fluoroscopy for intraprocedural guidance in the evaluation and treatment of both cardiovascular and oncological diseases. RECENT FINDINGS Although there are no commercially available real-time hybrid nuclear imaging devices that are approved for use in the interventional suite, prototype open gantry hybrid nuclear imaging and x-ray c-arm imaging systems and theranostic catheter for location radiotracer detection are currently undergoing development and testing by multiple groups. The integration of physiological and molecular targeted nuclear imaging for real-time delivery of targeted theranostics in the interventional laboratory may enable more personalized care for a wide variety of cardiovascular procedures and improve patient outcomes.
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Abstract
The pandemic of coronavirus 2019 disease (COVID-19) not only directly causes high morbidity and mortality of the disease, but also indirectly affects patients with pre-existing medical conditions, particularly cardiovascular diseases, with delayed or deferred outpatient care and procedure including nuclear medicine studies because of concerns about exposure to the virus. In this article, the impact of COVID-19 on hospital operation and nuclear medicine practice in the United States along with recommendations and guidance from major academic organizations are presented. Safe operation of specific nuclear medicine scans, such as lung scintigraphy and nuclear cardiac imaging, are reviewed in the context of balancing benefits to patients against the risk of exacerbating the spread of the virus. Thoughtful reintroduction of nuclear medicine services are discussed based on ethical considerations that maximize benefits to those who are likely to benefit most, taking into consideration baseline health inequities, and ensuring that all decisions reflect best available evidence with transparent communication. Finally, potential correlation between decreased volume of nuclear cardiac studies performed during the pandemic and corresponding increased deaths from ischemic and hypertensive cardiac disease is discussed.
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Affiliation(s)
| | | | - Vasken Dilsizian
- Address reprint requests to Vasken Dilsizian, MD, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland Medical Center, 22 S. Greene Street, Room N2W78, Baltimore, MD 21201-1595
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Noordman ABP, Maass AH, Groenveld H, Mulder BA, Rienstra M, Blaauw Y. Myocardial Scar Characterization and Future Ventricular Arrhythmia in Patients With Ischemic Cardiomyopathy and an Implantable Cardioverter-Defibrillator. Front Cardiovasc Med 2021; 8:708406. [PMID: 34485409 PMCID: PMC8415981 DOI: 10.3389/fcvm.2021.708406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/26/2021] [Indexed: 11/15/2022] Open
Abstract
Background: Implantable cardioverter-defibrillator (ICD) therapy is associated with several deleterious effects, which can be reduced by antiarrhythmic drugs or catheter ablation. However, it is largely unknown which patients might benefit from these therapies. Therefore, this study aimed to investigate whether myocardial scar characterization improves risk stratification for ventricular arrhythmia (VA) occurrence in patients with ischemic cardiomyopathy and an ICD. Methods: In this study, 82 patients with ischemic cardiomyopathy who received an ICD were enrolled retrospectively. Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) images were analyzed using an investigational software tool to obtain quantitative data regarding the total scar, core, and border zone (BZ). Data regarding the QRS complex was obtained from electrocardiography (ECG). The primary endpoint was appropriate ICD therapy. Results: During a median follow-up duration of 3.98 years [interquartile range (IQR) 2.89–5.14 years], appropriate therapy occurred in 24 (29.3%) patients. Patients with appropriate ICD therapy had a significantly larger total scar mass [60.0 (IQR 41.2–73.4) vs. 43.3 (IQR 31.2–61.2) g; P = 0.009] and BZ mass [32.9 (IQR 26.9–42.4) vs. 24.5 (IQR 18.8–32.5) g; P = 0.001] than those without appropriate therapy. In multivariable Cox regression analyses, total scar mass [hazard ratio (HR) 1.02 [95% confidence interval (CI) 1.00–1.04]; P = 0.014] and BZ mass (HR 1.04 [95% CI 1.01–1.07]; P = 0.009) independently predicted appropriate ICD therapy. Core mass and the QRS complex, however, were not significantly associated with the primary endpoint. Conclusion: LGE-CMR-based, but not ECG-based myocardial scar characterization improves risk stratification for VA occurrence in patients with ischemic cardiomyopathy who received an ICD.
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Affiliation(s)
- Alwin B P Noordman
- Department of Cardiology, Heart Center, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Alexander H Maass
- Department of Cardiology, Heart Center, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Hessel Groenveld
- Department of Cardiology, Heart Center, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Bart A Mulder
- Department of Cardiology, Heart Center, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Michiel Rienstra
- Department of Cardiology, Heart Center, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Yuri Blaauw
- Department of Cardiology, Heart Center, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
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Verschure DO, Nakajima K, Jacobson AF, Verberne HJ. 40 Years Anniversary of Cardiac 123I-mIBG Imaging: State of the Heart. Curr Cardiovasc Imaging Rep 2021. [DOI: 10.1007/s12410-021-09555-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Abstract
Purpose of Review
This narrative review reflects on the body of evidence on cardiac 123I-mIBG imaging that has accumulated since the introduction in the late 1970s and focusses on to what extent cardiac 123I-mIBG imaging has fulfilled its potential in cardiology especially.
Recent Findings
In contrast to the linear relationship between 123I-mIBG-derived parameters and overall prognosis in heart failure, there seems a “bell-shape” curve for 123I-mIBG-derived parameters and arrhythmic events. In addition, there is a potential clinical role for cardiac 123I-mIBG in optimizing patient selection for expensive devices (i.e., ICD and CRT). This needs of course to be established in future trials.
Summary
Cardiac 123I-mIBG imaging is, despite the numerous of studies, sometimes mistakenly seen as a nice to have technique rather than a must have imaging modality. Although cardiac 123I-mIBG imaging has grown and matured over the years, its full clinical potential has still not been tested to the maximum.
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Gimelli A, Liga R, Agostini D, Bengel FM, Ernst S, Hyafil F, Saraste A, Scholte AJHA, Verberne HJ, Verschure DO, Slart RHJA. The role of myocardial innervation imaging in different clinical scenarios: an expert document of the European Association of Cardiovascular Imaging and Cardiovascular Committee of the European Association of Nuclear Medicine. Eur Heart J Cardiovasc Imaging 2021; 22:480-490. [PMID: 33523108 DOI: 10.1093/ehjci/jeab007] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 01/08/2021] [Indexed: 02/06/2023] Open
Abstract
Cardiac sympathetic activity plays a key role in supporting cardiac function in both health and disease conditions, and nuclear cardiac imaging has always represented the only way for the non-invasive evaluation of the functional integrity of cardiac sympathetic terminals, mainly through the use of radiopharmaceuticals that are analogues of norepinephrine and, in particular, with the use of 123I-mIBG imaging. This technique demonstrates the presence of cardiac sympathetic dysfunction in different cardiac pathologies, linking the severity of sympathetic nervous system impairment to adverse patient's prognosis. This article will outline the state-of-the-art of cardiac 123I-mIBG imaging and define the value and clinical applications in the different fields of cardiovascular diseases.
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Affiliation(s)
- Alessia Gimelli
- Department of Imaging, Fondazione Toscana/CNR Gabriele Monasterio1, via Moruzzi n.1, Pisa 56124, Italy
| | - Riccardo Liga
- Cardiac-Thoracic-Vascular Department, Università di Pisa, Pisa, Italy
| | - Denis Agostini
- Department of Nuclear Medicine, University Hospital of Normandy, CHU Cote de Nacre, Caen, France
| | - Frank M Bengel
- Department of Nuclear Medicine, Hannover Medical School (MHH), Hannover, Germany
| | - Sabine Ernst
- Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College, London, UK
| | - Fabien Hyafil
- Department of Nuclear Medicine, European Hospital Georges-Pompidou, DMU IMAGINA, Assistance Publique-Hôpitaux de Paris, University of Paris, Paris, France
| | - Antti Saraste
- Turku PET Centre, University of Turku, Turku, Finland.,Heart Center, Turku University Hospital, Turku, Finland
| | - Arthur J H A Scholte
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hein J Verberne
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Derk O Verschure
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.,Department of Cardiology, Zaans Medical Center, Zaandam, the Netherlands
| | - Riemer H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Centre, University Medical Center Groningen, Groningen, The Netherlands.,Faculty of Science and Technology, Biomedical Photonic Imaging, University of Twente, Enschede, The Netherlands
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15
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Brito AXD, Glavam A, Bronchtein AI, Rosado-de-Castro PH. Autonomic Innervation Evaluation in Cardiac Disease. International Journal of Cardiovascular Sciences 2021. [DOI: 10.36660/ijcs.20200171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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16
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Teresińska A, Woźniak O, Maciąg A, Wnuk J, Jezierski J, Fronczak A, Biernacka EK. Quality and utility of [ 123I]I-metaiodobenzylguanidine cardiac SPECT imaging in nondiabetic postinfarction heart failure patients qualified for implantable cardioverter defibrillator. Ann Nucl Med 2021; 35:916-26. [PMID: 34023989 DOI: 10.1007/s12149-021-01628-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/11/2021] [Indexed: 12/02/2022]
Abstract
Objective Impaired cardiac adrenergic activity has been demonstrated in heart failure (HF) and in diabetes mellitus (DM). [123I]I-metaiodobenzylguanidine (MIBG) enables assessment of the cardiac adrenergic nervous system. Tomographic imaging of the heart is expected to be superior to planar imaging. This study aimed to determine the quality and utility of MIBG SPECT in the assessment of cardiac innervation in postinfarction HF patients without DM, qualified for implantable cardioverter defibrillator (ICD) in primary prevention of sudden cardiac death. Methods Consecutive patients receiving an ICD on the basis of contemporary guidelines were prospectively included. Planar MIBG studies were followed by SPECT. The essential analysis was based on visual assessment of the quality of SPECT images (“high”, “low” or “unacceptable”). The variables used in the further analysis were late summed defect score for SPECT images and heart-to-mediastinum rate for planar images. MIBG images were assessed independently by two experienced readers. Results Fifty postinfarction nondiabetic HF subjects were enrolled. In 13 patients (26%), the assessment of SPECT studies was impossible. In addition, in 13 of 37 patients who underwent semiquantitative SPECT evaluation, the assessment was equivocal. Altogether, in 26/50 patients (52%, 95% confidence interval 38–65%), the quality of SPECT images was unacceptable or low and was limited by low MIBG cardiac uptake and by comparatively high, interfering MIBG uptake in the neighboring structures (primarily, in the lungs). Conclusions The utility of MIBG SPECT imaging, at least with conventional imaging protocols, in the qualification of postinfarction HF patients for ICD, is limited. In approximately half of the postinfarction HF patients, SPECT assessment of cardiac innervation can be impossible or equivocal, even without additional damage from diabetic cardiac neuropathy. The criteria predisposing the patient to good-quality MIBG SPECT are: high values of LVEF from the range characterizing the patients qualified to ICD (i.e., close to 35%) and left lung uptake intensity in planar images comparable to or lower than heart uptake.
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17
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Gimelli A, Ernst S, Liga R. Multi-Modality Imaging for the Identification of Arrhythmogenic Substrates Prior to Electrophysiology Studies. Front Cardiovasc Med 2021; 8:640087. [PMID: 33996938 PMCID: PMC8113383 DOI: 10.3389/fcvm.2021.640087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/08/2021] [Indexed: 11/13/2022] Open
Abstract
Noninvasive cardiac imaging is crucial for the characterization of patients who are candidates for cardiac ablations, for both procedure planning and long-term management. Multimodality cardiac imaging can provide not only anatomical parameters but even more importantly functional information that may allow a better risk stratification of cardiac patients. Moreover, fusion of anatomical and functional data derived from noninvasive cardiac imaging with the results of endocavitary mapping may possibly allow a better identification of the ablation substrate and also avoid peri-procedural complications. As a result, imaging-guided electrophysiological procedures are associated with an improved outcome than traditional ablation procedures, with a consistently lower recurrence rate.
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Affiliation(s)
| | - Sabine Ernst
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Riccardo Liga
- Cardiothoracic and Vascular Department, Università di Pisa, Pisa, Italy
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18
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Ghzally Y, Imanli H, Smith M, Mahat J, Chen W, Jimenez Restrepo A, Sawan MA, Abdelmegid MAKF, Helmy HAER, Demitry S, See V, Shorofsky S, Dilsizian V, Dickfeld T. Metabolic Scar Assessment with 18F-FDG -PET: Correlation to Ischemic VT Substrate and Successful Ablation Sites. J Nucl Med 2021; 62:1591-1598. [PMID: 33893186 DOI: 10.2967/jnumed.120.246413] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 03/01/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Functional/molecular imaging characteristics of ischemic ventricular tachycardia (VT) substrate are incompletely understood. Objective: Compare regional 18F-FDG - PET tracer uptake with detailed electroanatomic maps (EAM) in a more extensive series of post-infarction VT patients to define metabolic properties of the VT substrate/successful ablation sites. Methods: 3D metabolic left ventricular (LV) reconstructions were created from perfusion-normalized 18F-FDG images in consecutive patients undergoing VT ablation. Metabolic defects were defined as severe (<50% uptake) or moderate (50-70% uptake) referenced to the maximal 17-segmental uptake. Color-coded PET scars reconstructions were co-registered with corresponding high-resolution 3D EAM. Results: All 56 patients had ischemic cardiomyopathy (EF=29±12%). Severe PET defect (<50%) was larger than EAM voltage scar (<0.5mV) with 63.0±48.4cm² vs. 13.8±33.1cm² (p<0.001). Similarly, moderate/severe PET defect (≤70%) was larger than areas with abnormal voltage (≤1.5mV) measuring 105.1±67.2cm² vs. 56.2±62.6cm² (p<0.001). Analysis of bipolar voltage (n = 23,389 mapping-points) showed decreased voltage among PET <50% (n = 10,364; 0.5±0.3mV) to PET 50-70% (n = 5,243; 1.5±0.9mV, p<0.01) with normal voltage among PET normal areas >70% (n = 7,782, 3.2±1.3mV, p<0.001). Eighty-eight percent of VT channel/exit sites (n = 44) were metabolically abnormal (PET <50%: 78%; PET 50-70%: 10%), while 12% (n = 6) were in metabolically normal areas (PET>70%). Metabolic channels (n = 26) existed in 45% (n = 25) of patients with average length/width of 17.6±12.5mm/10.3±4.2mm. Metabolic channels were oriented apex/base (86%) predominantly, harboring VT channel/exit sites in 31%. Metabolic Rapid Transition Areas (RTA: >50% change of 18F-FDG tracer uptake/15mm) were detected in 59% (n = 33) co-localizing to VT channels/exit sites (15%) or its proximity (85%, 12.8±8.5mm). Metabolism-voltage mismatches (MVM) with PET<50%/voltage>1.5mV) were seen in 21% (n = 12) harboring VT channel/exit sites in 41% of patients. Conclusion: Abnormal 18F-FDG uptake categories can be detected using incremental 3D step-up reconstructions. They predicted decreasing bipolar voltages and VT channel/exit sites in ~90%. Additionally, functional imaging allowed detecting novel molecular tissue characteristics within the ischemic VT substrate such as metabolic channels, RTA, and MVM demonstrating intra-substrate heterogeneity and providing possible targets for imaging-guided ablation.
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Affiliation(s)
| | - Hasan Imanli
- University of Maryland medical center, United States
| | - Mark Smith
- University of Maryland medical center, United States
| | - Jagat Mahat
- University of Maryland medical center, United States
| | - Wengen Chen
- University of Maryland medical center, United States
| | | | | | | | | | | | - Vincent See
- University of Maryland Medical center, United States
| | | | | | - Timm Dickfeld
- University of Maryland medical center, United States
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19
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Restrepo AJ, Dickfeld TM. Image Integration Using Intracardiac Echography and Three-dimensional Reconstruction for Mapping and Ablation of Atrial and Ventricular Arrhythmias. Card Electrophysiol Clin 2021; 13:365-380. [PMID: 33990275 DOI: 10.1016/j.ccep.2021.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This article reviews the basis for image integration of intracardiac echocardiography (ICE) with three-dimensional electroanatomic mapping systems and preprocedural cardiac imaging modalities to enhance anatomic understanding and improve guidance for atrial and ventricular ablation procedures. It discusses the technical aspects of ICE-based integration and the clinical evidence for its use. In addition, it presents the current technical limitations and future directions for this technology. This article also includes figures and videos of clinical representative arrhythmia cases where the use of ICE is key to a safe and successful outcome.
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Affiliation(s)
- Alejandro Jimenez Restrepo
- Section of Cardiology, Marshfield Clinic Health System, 1000 North Oak Avenue, Marshfield, WI 54449, USA.
| | - Timm Michael Dickfeld
- Section of Cardiac Electrophysiology, Maryland Arrhythmia and Cardiac Imaging Group (MACIG), University of Maryland School of Medicine, 22 South Greene Street, Room N3W77, Baltimore, MD 21201, USA
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20
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Giannopoulos AA, Pazhenkottil AP. Innervation imaging to guide ventricular arrhythmia ablation. J Nucl Cardiol 2021; 28:184-186. [PMID: 30719658 DOI: 10.1007/s12350-019-01632-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 01/24/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Andreas A Giannopoulos
- Cardiac Imaging, Department of Cardiology and Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Aju P Pazhenkottil
- Cardiac Imaging, Department of Cardiology and Nuclear Medicine, University Hospital Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
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21
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Gimelli A, Menichetti F, Soldati E, Liga R, Scelza N, Zucchelli G, Di Cori A, Segreti L, Vannozzi A, Bongiorni MG, Marzullo P. Predictors of ventricular ablation's success: Viability, innervation, or mismatch? J Nucl Cardiol 2021; 28:175-183. [PMID: 30603891 DOI: 10.1007/s12350-018-01575-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/07/2018] [Indexed: 10/27/2022]
Abstract
AIMS Sympathetic dys-innervation may play an important role in the development of post-ischemic ventricular arrhythmias (VA). Aim of this study was to prove that perfusion/innervation mismatch (PIM) evaluated by SPECT can identify areas of local abnormal ventricular activities (LAVA) on electroanatomic mapping (EAM). METHODS Sixteen patients referred to post-ischemic VA catheter ablation underwent pre-procedural and 1-month post-ablation 123I-MIBG/99mTc-tetrofosmin rest SPECT myocardial imaging. PIM was defined according to the segmental distributions of 99mTc-tetrofosmin and 123I-MIBG. A 17-segment LV analysis was used for either SPECT or LV EAM voltage map. All patients were followed up clinically for at least 1 year. RESULTS Before ablation, the mean voltage in the PIM segments was higher than in the scarred ones but lower than in the normal regions. The presence of PIM in a specific LV zone was an independent predictor of LAVA. After ablation, PIM value was significantly reduced, mainly due to an increase in perfusion summed rest score, in particular in patients that were responders to ablation. CONCLUSIONS PIM may associate with VA substrate expressed by LAVA and might provide a novel guide for substrate ablation. A significant reduction of PIM could predict a positive clinical response to ablation.
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Affiliation(s)
- Alessia Gimelli
- Fondazione Toscana G. Monasterio, Via Moruzzi, 1, 56124, Pisa, Italy.
| | - Francesca Menichetti
- Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
- Sant'Anna, School of Advanced Studies, Pisa, Italy
| | - Ezio Soldati
- Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Riccardo Liga
- Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Nicola Scelza
- Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Giulio Zucchelli
- Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Andrea Di Cori
- Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Luca Segreti
- Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Andrea Vannozzi
- Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | | | - Paolo Marzullo
- Fondazione Toscana G. Monasterio, Via Moruzzi, 1, 56124, Pisa, Italy
- CNR, Institute of Clinical Physiology, Pisa, Italy
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22
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Sáenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Europace 2020; 21:1143-1144. [PMID: 31075787 DOI: 10.1093/europace/euz132] [Citation(s) in RCA: 208] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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23
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Donal E, Delgado V, Bucciarelli-Ducci C, Galli E, Haugaa KH, Charron P, Voigt JU, Cardim N, Masci PG, Galderisi M, Gaemperli O, Gimelli A, Pinto YM, Lancellotti P, Habib G, Elliott P, Edvardsen T, Cosyns B, Popescu BA. Multimodality imaging in the diagnosis, risk stratification, and management of patients with dilated cardiomyopathies: an expert consensus document from the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging 2020; 20:1075-1093. [PMID: 31504368 DOI: 10.1093/ehjci/jez178] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 06/19/2019] [Indexed: 12/12/2022] Open
Abstract
Dilated cardiomyopathy (DCM) is defined by the presence of left ventricular or biventricular dilatation and systolic dysfunction in the absence of abnormal loading conditions or coronary artery disease sufficient to explain these changes. This is a heterogeneous disease frequently having a genetic background. Imaging is important for the diagnosis, the prognostic assessment and for guiding therapy. A multimodality imaging approach provides a comprehensive evaluation of all the issues related to this disease. The present document aims to provide recommendations for the use of multimodality imaging according to the clinical question. Selection of one or another imaging technique should be based on the clinical condition and context. Techniques are presented with the aim to underscore what is 'clinically relevant' and what are the tools that 'can be used'. There remain some gaps in evidence on the impact of multimodality imaging on the management and the treatment of DCM patients where ongoing research is important.
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Affiliation(s)
- Erwan Donal
- Service de Cardiologie et CIC-IT INSERM 1414, CHU Pontchaillou, 2 rue Henri Le Guilloux, Rennes, France.,LTSI, Université de Rennes 1, INSERM, UMR, Rennes, France
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Albinusdreef 2, Leiden RC, The Netherlands
| | - Chiara Bucciarelli-Ducci
- Bristol Heart Institute, University of Bristol, University Hospitals Bristol NHS Foundation Trust, Malborough St, Bristol, UK
| | - Elena Galli
- Service de Cardiologie et CIC-IT INSERM 1414, CHU Pontchaillou, 2 rue Henri Le Guilloux, Rennes, France.,LTSI, Université de Rennes 1, INSERM, UMR, Rennes, France
| | - Kristina H Haugaa
- Department of Cardiology, Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo, Norway
| | - Philippe Charron
- Centre de Référence pour les Maladies Cardiaques Héréditaires, APHP, ICAN, Hôpital de la Pitié Salpêtrière, Paris, France.,Université Versailles Saint Quentin & AP-HP, CESP, INSERM U1018, Service de Génétique, Hôpital Ambroise Paré, Boulogne-Billancourt, France
| | - Jens-Uwe Voigt
- Department of Cardiovascular Sciences, University of Leuven, Herestraat 49, Leuven, Belgium
| | - Nuno Cardim
- Cardiology Department, Hospital da Luz, Av. Lusíada, n° 100, Lisbon, Portugal
| | - P G Masci
- HeartClinic, Hirslanden Hospital Zurich, Witellikerstrasse 32, CH Zurich, Switzerland
| | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | - Oliver Gaemperli
- HeartClinic, Hirslanden Hospital Zurich, Witellikerstrasse 32, CH Zurich, Switzerland
| | - Alessia Gimelli
- Fondazione Toscana Gabriele Monasterio, Via Moruzzi, 1, Pisa, Italy
| | - Yigal M Pinto
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Patrizio Lancellotti
- Department of Cardiology, University of Liège Hospital, Domaine Universitaire du Sart Tilman, B Liège, Belgium
| | - Gilbert Habib
- Cardiology Department, APHM, La Timone Hospital, Boulevard Jean Moulin, Marseille, France.,Aix Marseille University, IRD, APHM, MEPHI, IHU-Méditerranée Infection, Boulevard Jean Moulin, Marseille, France
| | - Perry Elliott
- Institute of Cardiovascular Science, University College London, London, UK.,Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - Thor Edvardsen
- Department of Cardiology, Center for Cardiological Innovation, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, Oslo, Norway
| | - Bernard Cosyns
- Centrum voor Hart en Vaatziekten (CHVZ), Unversitair Ziekenhuis Brussel, Laarbeeklaan 101, Brussel, Belgium
| | - Bogdan A Popescu
- Department of Cardiology, University of Medicine and Pharmacy "Carol Davila"- Euroecolab, Emergency Institute of Cardiovascular Diseases "Prof. Dr. C. C. Iliescu", Sos. Fundeni 258, Sector 2, Bucharest, Romania
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24
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Muser D, Lavalle C, Guarracini F, Sassone B, Conte E, Magnani S, Notarstefano P, Barbato G, Sgarito G, Grandinetti G, Nucifora G, Ricci RP, Boriani G, De Ponti R, Casella M. Role of cardiac imaging in patients undergoing catheter ablation of ventricular tachycardia. J Cardiovasc Med (Hagerstown) 2020; 22:727-737. [PMID: 33136806 DOI: 10.2459/jcm.0000000000001121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Ventricular tachycardia is a major health issue in patients with structural heart disease (SHD). Implantable cardioverter defibrillator (ICD) therapy has significantly reduced the risk of sudden cardiac death (SCD) in such patients, but on the other hand, it has led to frequent ICD shocks as an emerging problem, being associated with poor quality of life, frequent hospitalizations and increased mortality. Myocardial scar plays a central role in the genesis and maintenance of re-entrant arrhythmias, as the coexistence of surviving myocardial fibres within fibrotic tissue leads to the formation of slow conduction pathways and to a dispersion of activation and refractoriness that constitutes the milieu for ventricular tachycardia circuits. Catheter ablation has repeatedly proven to be well tolerated and highly effective in treating VT and in the last two decades has benefited from continuous efforts to determine ventricular tachycardia mechanisms by integration with a wide range of invasive and noninvasive imaging techniques such as intracardiac echocardiography, cardiac magnetic resonance, multidetector computed tomography and nuclear imaging. Cardiovascular imaging has become a fundamental aid in planning and guiding catheter ablation procedures by integrating structural and electrophysiological information, enabling the ventricular tachycardia arrhythmogenic substrate to be characterized and effective ablation targets to be identified with increasing precision, and allowing the development of new ablation strategies with improved outcomes. In this review, we provide an overview of the role of cardiac imaging in patients undergoing catheter ablation of ventricular tachycardia.
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Affiliation(s)
- Daniele Muser
- Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Pennsylvania, USA.,Cardiology Division, Santa Maria della Misericordia Hospital, Udine
| | - Carlo Lavalle
- Department of Cardiology, Policlinico Universitario Umberto I, Roma
| | | | - Biagio Sassone
- Cardiology Division, SS.ma Annunziata Hospital, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara
| | - Edoardo Conte
- Cardiovascular Imaging Area and Clinical Cardiology Unit, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Silvia Magnani
- Heart Rhythm Center, Langone Medical Center, New York University, New York, USA.,Ospedale San Paolo, Milan
| | | | | | - Giuseppe Sgarito
- Cardiology Division, ARNAS Ospedale Civico e Benfratelli, Palermo
| | | | - Gaetano Nucifora
- Cardiac Imaging Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena
| | - Roberto De Ponti
- Department of Heart and Vessels, Ospedale di Circolo & Macchi Foundation, University of Insubria, Varese
| | - Michela Casella
- Heart Rhythm Center, Centro Cardiologico Monzino IRCCS, Milan.,Department of Clinical, Special and Dental Sciences, University Politecnica delle Marche, Ancona, Italy
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25
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Bella PD, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. J Interv Card Electrophysiol 2020; 59:145-298. [PMID: 31984466 PMCID: PMC7223859 DOI: 10.1007/s10840-019-00663-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, IN, USA
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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Restrepo AJ, Dickfeld TM. Perioperative Imaging to Guide Epicardial Mapping and Ablation. Card Electrophysiol Clin 2020; 12:281-293. [PMID: 32771183 DOI: 10.1016/j.ccep.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Accessing the epicardial space without a sternotomy or a surgical pericardial window to treat ventricular arrhythmias in Chagas disease became a medical necessity in South America. Since the introduction of the dry percutaneous epicardial access approach, epicardial access has been standard procedure for management of ventricular arrhythmias in ischemic and nonischemic cardiomyopathies and atrioventricular accessory pathways after failed conventional endocardial ablation. Understanding the epicardial space and neighboring structures has become an important subject of teachings in electrophysiology. The evolution of complex ablation procedures to treat atrial and ventricular arrhythmias and device interventions to prevent cardioembolic stroke requires thorough understanding of pericardial anatomy.
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Affiliation(s)
- Alejandro Jimenez Restrepo
- Section of Cardiology, Marshfield Clinic Health System, 1000 North Oak Avenue, Marshfield, WI 54449, USA.
| | - Timm Michael Dickfeld
- Section of Cardiac Electrophysiology and the Maryland Arrhythmia and Cardiac Imaging Group (MACIG), University of Maryland School of Medicine, 22 South Greene Street, Room N3W77, Baltimore, MD 21201, USA
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Farber G, Boczar KE, Wiefels CC, Zelt JG, Guler EC, deKemp RA, Beanlands RS, Rotstein BH. The Future of Cardiac Molecular Imaging. Semin Nucl Med 2020; 50:367-385. [DOI: 10.1053/j.semnuclmed.2020.02.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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28
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Yalin K, Liosis S, Palade E, Fink T, Schierholz S, Sawan N, Eitel C, Heeger CH, Sciacca V, Sano M, Vogler J, Tilz RR. Cardiac sympathetic denervation in patients with nonischemic cardiomyopathy and refractory ventricular arrhythmias: a single-center experience. Clin Res Cardiol 2020; 110:21-28. [PMID: 32328735 DOI: 10.1007/s00392-020-01643-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 04/03/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Cardiac sympathetic denervation (CSD) is an effective therapy for selected patients with drug refractory ventricular arrhythmias (VA). Data about the role of CSD in patients with structural heart disease and VAs are sparse. We herein present our experience of CSD in patients with nonischemic cardiomyopathy and VAs despite prior ablation procedure and/or antiarrhythmic drug (AAD) therapy. METHODS A total of ten patients (mean age 61.6 ± 19.6, mean LVEF 29.5 ± 12.1%) with nonischemic dilated cardiomyopathy (NICM) (n = 9) and hypertrophic cardiomyopathy (HCM) (n = 1) underwent CSD (left sided in six and bilateral in four patients) due to refractory VA despite multiple AADs (mean number of AADs was 1.6 ± 0.7) and prior VT ablation (mean number of procedures per patient was 1.5 ± 1.3). RESULTS Mean follow-up was 10.1 ± 6.9 months. The median number of VA and ICD shocks decreased significantly from 9.0 and 2.5 episodes 6 months prior to CSD to 0 and 0 episodes within 6 months after CSD (p = 0.012 and p = 0.011). Five patients remained free from sustained VA recurrences. Two patients experienced single ICD shock due to a polymorphic VT (triggered by severe hypokalemia in one patient) and one patient a single shock due to monomorphic VT. One patient had five episodes of slow VT under amiodarone therapy (three of them terminated by antitachycardia pacing) and underwent endo- epicardial re-ablation. Two patients died 1 month after CSD. One of them due to electrical storm and cardiogenic shock and the second one due to refractory cardiogenic shock, without recurrence of VAs though. No major complications of CSD occurred. No patient suffered from Horner syndrome. CONCLUSION In this study, CSD was effective for treatment of VAs in patients with structural heart disease refractory to antiarrhythmic drugs and catheter ablation. Further larger studies are required to confirm these findings.
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Affiliation(s)
- Kivanc Yalin
- Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, University Heart Center Lübeck, Medical Clinic II, Lübeck, Germany. .,Cerrahpasa Faculty of Medicine, Department of Cardiology, Istanbul University-Cerrahpasa, Istanbul, Turkey.
| | - Spyridon Liosis
- Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, University Heart Center Lübeck, Medical Clinic II, Lübeck, Germany
| | - Emanuel Palade
- Department of Surgery, Medical University of Schleswig-Holstein, Campus, Lübeck, Germany
| | - Thomas Fink
- Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, University Heart Center Lübeck, Medical Clinic II, Lübeck, Germany
| | - Stefanie Schierholz
- Department of Surgery, Medical University of Schleswig-Holstein, Campus, Lübeck, Germany
| | - Noureddin Sawan
- Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, University Heart Center Lübeck, Medical Clinic II, Lübeck, Germany
| | - Charlotte Eitel
- Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, University Heart Center Lübeck, Medical Clinic II, Lübeck, Germany
| | - Christian H Heeger
- Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, University Heart Center Lübeck, Medical Clinic II, Lübeck, Germany
| | - Vanessa Sciacca
- Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, University Heart Center Lübeck, Medical Clinic II, Lübeck, Germany
| | - Makoto Sano
- Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, University Heart Center Lübeck, Medical Clinic II, Lübeck, Germany
| | - Julia Vogler
- Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, University Heart Center Lübeck, Medical Clinic II, Lübeck, Germany
| | - Roland Richard Tilz
- Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, University Heart Center Lübeck, Medical Clinic II, Lübeck, Germany. .,German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Lübeck, Germany.
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Abstract
Autonomic innervation plays an important role in proper functioning of the cardiovascular system. Altered cardiac sympathetic function is present in a variety of diseases, and can be assessed with radionuclide imaging using sympathetic neurotransmitter analogues. The most studied adrenergic radiotracer is cardiac 123I-meta-iodobenzylguanidine (123I-mIBG). Cardiac 123I-mIBG uptake can be evaluated using both planar and tomographic imaging, thereby providing insight into global and regional sympathetic innervation. Standardly assessed imaging parameters are the heart-to-mediastinum ratio and washout rate, customarily derived from planar images. Focal tracer deficits on tomographic imaging also show prognostic utility, with some data suggesting that the best approach to tomographic image interpretation may differ from conventional methods. Cardiac 123I-mIBG image findings strongly correlate with the severity and prognosis of many cardiovascular diseases, especially heart failure and ventricular arrhythmias. Cardiac 123I-mIBG imaging in heart failure is FDA approved for prognostic purposes. With the robustly demonstrated ability to predict occurrence of potentially fatal arrhythmias, cardiac 123I-mIBG imaging shows promise for better selecting patients who will benefit from an implantable cardioverter defibrillator, but clinical use has been hampered by lack of the randomized trial needed for incorporation into societal guidelines. In patients with ischemic heart disease, cardiac 123I-mIBG imaging aids in assessing the extent of damage and in identifying arrhythmogenic regions. There have also been studies using cardiac 123I-mIBG for other conditions, including patients following heart transplantation, diabetic related cardiac abnormalities and chemotherapy induced cardiotoxicity. Positron emission tomographic adrenergic radiotracers, that improve image quality, have been investigated, especially 11C-meta-hydroxyephedrine, and most recently 18F-fluorbenguan. Cadmium-zinc-telluride cameras also improve image quality. With better spatial resolution and quantification, PET tracers and advanced camera technologies promise to expand the clinical utility of cardiac sympathetic imaging.
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Affiliation(s)
- Ningxin Wan
- Division of Nuclear Medicine, Department of Radiology, and Division of Cardiology, Department of Medicine, Montefiore Medical Center and The Albert Einstein College of Medicine, Bronx, NY
| | - Mark I Travin
- Division of Nuclear Medicine, Department of Radiology, and Division of Cardiology, Department of Medicine, Montefiore Medical Center and The Albert Einstein College of Medicine, Bronx, NY.
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Heart Rhythm 2019; 17:e2-e154. [PMID: 31085023 PMCID: PMC8453449 DOI: 10.1016/j.hrthm.2019.03.002] [Citation(s) in RCA: 165] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Indexed: 01/10/2023]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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32
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Abstract
PURPOSE OF REVIEW This review aims to describe the latest advances in autonomic neuromodulation approaches to treating cardiac arrhythmias, with a focus on ventricular arrhythmias. RECENT FINDINGS The increasing understanding of neuronal remodeling in cardiac diseases has led to the development and improvement of novel neuromodulation therapies targeting multiple levels of the autonomic nervous system. Thoracic epidural anesthesia, spinal cord stimulation, stellate ganglion modulatory therapies, vagal stimulation, renal denervation, and interventions on the intracardiac nervous system have all been studied in preclinical models, with encouraging preliminary clinical data. The autonomic nervous system regulates all the electrical processes of the heart and plays an important role in the pathophysiology of cardiac arrhythmias. Despite recent advances in the clinical application of cardiac neuromodulation, our comprehension of the anatomy and function of the cardiac autonomic nervous system is still limited. Hopefully in the near future, more preclinical data combined with larger clinical trials will lead to further improvements in neuromodulatory treatment for heart rhythm disorders.
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Kitamura T, Martin CA, Vlachos K, Martin R, Frontera A, Takigawa M, Thompson N, Cheniti G, Massouille G, Lam A, Bourier F, Duchateau J, Pambrun T, Denis A, Derval N, Hocini M, HaÏssaguerre M, Cochet H, JaÏs P, Sacher F. Substrate Mapping and Ablation for Ventricular Tachycardia in Patients with Structural Heart Disease: How to Identify Ventricular Tachycardia Substrate. J Innov Card Rhythm Manag 2019; 10:3565-3580. [PMID: 32477720 PMCID: PMC7252795 DOI: 10.19102/icrm.2019.100302] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 08/20/2018] [Indexed: 01/02/2023] Open
Abstract
Catheter ablation for ventricular tachycardia (VT) has been increasingly used over the past two decades in patients with structural heart disease (SHD). In these individuals, a substrate mapping strategy is being more commonly applied to identify targets for VT ablation, which has been shown to be more effective versus targeting mappable VTs alone. There are a number of substrate mapping methods in existence that aim to explore potential VT isthmuses, although their success rates vary. Most of the reported electrogram-based mapping studies have been performed with ablation catheters; meanwhile, the use of multipolar mapping catheters with smaller electrodes and closer interelectrode spacing has emerged, which allows for an assessment of detailed near-field abnormal electrograms at a higher resolution. Another recent advancement has occurred in the use of imaging techniques in VT ablation, particularly in refining the substrate. The goal of this paper is to review the key developments and limitations of current mapping strategies of substrate-based VT ablation and their outcomes. In addition, we briefly summarize the role of cardiac imaging in delineating VT substrate.
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Affiliation(s)
- Takeshi Kitamura
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France.,Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan
| | - Claire A Martin
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France.,Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Konstantinos Vlachos
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Ruairidh Martin
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France.,Newcastle University, Newcastle-upon-Tyne, UK
| | - Antonio Frontera
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France.,San Raffaele Hospital, Milan, Italy
| | - Masateru Takigawa
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Nathaniel Thompson
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Ghassen Cheniti
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Gregoire Massouille
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Anna Lam
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Felix Bourier
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Josselin Duchateau
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Thomas Pambrun
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Arnaud Denis
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Nicolas Derval
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Meleze Hocini
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Michel HaÏssaguerre
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Hubert Cochet
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Pierre JaÏs
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
| | - Frédéric Sacher
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Pessac-Bordeaux, France.,Electrophysiology and Ablation Unit, Bordeaux University Hospital (CHU), Pessac, France.,Centre de recherche Cardio-Thoracique de Bordeaux, University of Bordeaux, Bordeaux, France
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Zeppenfeld K. Ventricular Tachycardia Ablation in Nonischemic Cardiomyopathy. JACC Clin Electrophysiol 2018; 4:1123-1140. [PMID: 30236385 DOI: 10.1016/j.jacep.2018.06.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 06/14/2018] [Accepted: 06/15/2018] [Indexed: 01/06/2023]
Abstract
Catheter ablation is being increasingly performed as adjunctive treatment to prevent recurrent implantable cardioverter-defibrillator therapies in patients with nonischemic cardiomyopathy and ventricular tachycardia (VT). In the context of VT ablation, nonischemic cardiomyopathy usually refers to dilated cardiomyopathy (DCM) as one morphological phenotype. Over the past decades, progress has been made to better characterize distinct subtypes and to differentiate between causes of DCM, which has important practical and prognostic implications. The goal of this review is to summarize available data on VT ablation in patients with DCM and, more specifically, review procedural and outcome data in specific etiologies and substrate location. It will focus on our current understanding of nonischemic scars, as well as the value of multimodal imaging, image integration, and electroanatomic mapping for substrate identification, procedural planning, and ablation. In addition, recent findings from whole human heart histology of patients with DCM and VT and their potential implications for imaging and mapping will be discussed.
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Affiliation(s)
- Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands.
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35
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Sramko M, Hoogendoorn JC, Glashan CA, Zeppenfeld K. Advancement in cardiac imaging for treatment of ventricular arrhythmias in structural heart disease. Europace 2018; 21:383-403. [DOI: 10.1093/europace/euy150] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 07/23/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
- Marek Sramko
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, ZA, Leiden, The Netherlands
| | - Jarieke C Hoogendoorn
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, ZA, Leiden, The Netherlands
| | - Claire A Glashan
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, ZA, Leiden, The Netherlands
| | - Katja Zeppenfeld
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, ZA, Leiden, The Netherlands
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Spartalis M, Spartalis E, Tzatzaki E, Tsilimigras DI, Moris D, Kontogiannis C, Livanis E, Iliopoulos DC, Voudris V, Theodorakis GN. Novel approaches for the treatment of ventricular tachycardia. World J Cardiol 2018; 10:52-59. [PMID: 30079151 PMCID: PMC6068734 DOI: 10.4330/wjc.v10.i7.52] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 03/24/2018] [Accepted: 06/27/2018] [Indexed: 02/06/2023] Open
Abstract
Ventricular tachycardia (VT) is a crucial cause of sudden cardiac death (SCD) and a primary cause of mortality and morbidity in patients with structural cardiac disease. VT includes clinical disorders varying from benign to life-threatening. Most life-threatening episodes are correlated with coronary artery disease, but the risk of SCD varies in certain populations, with various underlying heart conditions, specific family history, and genetic variants. The targets of VT management are symptom alleviation, improved quality of life, reduced implantable cardioverter defibrillator shocks, prevention of reduction of left ventricular function, reduced risk of SCD, and improved overall survival. Antiarrhythmic drug therapy and endocardial catheter ablation remains the cornerstone of guideline-endorsed VT treatment strategies in patients with structural cardiac abnormalities. Novel strategies such as epicardial ablation, surgical cryoablation, transcoronary alcohol ablation, pre-procedural imaging, and stereotactic ablative radiotherapy are an appealing area of research. In this review, we gathered all recent advances in innovative therapies as well as experimental evidence focusing on different aspects of VT treatment that could be significant for future favorable clinical applications.
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Affiliation(s)
- Michael Spartalis
- ESC Working Group on Cardiac Cellular Electrophysiology, Sophia Antipolis Cedex 06903, France
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens 17674, Greece
| | - Eleftherios Spartalis
- Laboratory of Experimental Surgery and Surgical Research, University of Athens Medical School, Athens 11527, Greece
| | - Eleni Tzatzaki
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens 17674, Greece
| | - Diamantis I Tsilimigras
- Laboratory of Experimental Surgery and Surgical Research, University of Athens Medical School, Athens 11527, Greece
| | - Demetrios Moris
- Department of Surgery, Duke University, Durham, NC 27710, United States
| | - Christos Kontogiannis
- Department of Clinical Therapeutics, “Alexandra” Hospital, University of Athens, Athens 11528, Greece
| | - Efthimios Livanis
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens 17674, Greece
| | - Dimitrios C Iliopoulos
- Laboratory of Experimental Surgery and Surgical Research, University of Athens Medical School, Athens 11527, Greece
| | - Vassilis Voudris
- Division of Cardiology, Onassis Cardiac Surgery Center, Athens 17674, Greece
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Imanli H, Ume KL, Jeudy J, Bob-Manuel T, Smith MF, Chen W, Abdulghani M, Ghzally Y, Mahat JB, Itah R, Restrepo A, See VY, Shorofsky S, Dilsizian V, Dickfeld T. Ventricular Tachycardia (VT) Substrate Characteristics: Insights from Multimodality Structural and Functional Imaging of the VT Substrate Using Cardiac MRI Scar, 123I-Metaiodobenzylguanidine SPECT Innervation, and Bipolar Voltage. J Nucl Med 2018; 60:79-85. [PMID: 29959218 DOI: 10.2967/jnumed.118.211698] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 05/22/2018] [Indexed: 11/16/2022] Open
Abstract
Postischemic adaptation results in characteristic myocardial structural and functional changes in the ventricular tachycardia (VT) substrate. The aim of this study was to compare myocardial structural and functional adaptations (late gadolinium enhancement/abnormal innervation) with detailed VT mapping data to identify regional heterogeneities in postischemic changes. Methods: Fifteen patients with ischemic cardiomyopathy and drug-refractory VT underwent late gadolinium enhancement cardiac MRI (CMR), 123I-metaiodobenzylguanidine SPECT, and high-resolution bipolar voltage mapping to assess fibrosis (>3 SDs), abnormal innervation (<50% tracer uptake), and low-voltage area (<1.5 mV), respectively. Three-dimensional reconstructed CMR/123I-metaiodobenzylguanidine models were coregistered for further comparison. Results: Postischemic structural and functional adaptations in all 3 categories were similar in size (reported as median [quartile 1-quartile 3]: CMR scar, 46.1 cm2 [33.1-86.9 cm2]; abnormal innervation, 47.8 cm2 [40.5-68.1 cm2]; and low-voltage area, 29.5 cm2 [24.5-102.6 cm2]; P > 0.05). However, any single modality underestimated the total VT substrate area defined as abnormal in at least 1 of the 3 modalities (76.0 cm2 [57.9-143.2 cm2]; P < 0.001). Within the total VT substrate area, regions abnormal in all 3 modalities were most common (25.2%). However, significant parts of the VT substrate had undergone heterogeneous adaptation (abnormal in <3 modalities); the most common categories were "abnormal innervation only" (18.2%), "CMR scar plus abnormal innervation only" (14.9%), and "CMR scar only" (14.6%). All 14 VT channel/exit sites (0.88 ± 0.74 mV) were localized to myocardium demonstrating CMR scar and abnormal innervation. This specific tissue category accounted for 68.3% of the CMR scar and 31.2% of the total abnormal postischemic VT substrate area. Conclusion: Structural and functional imaging demonstrated regional heterogeneities in the postischemic VT substrate not appreciated by any single modality alone. The coexistence of abnormal innervation and CMR scar may identify a particularly "proarrhythmic" adaptation and may represent a potential novel target for VT ablation.
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Affiliation(s)
- Hasan Imanli
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kiddy L Ume
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jean Jeudy
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Tamunoinemi Bob-Manuel
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mark F Smith
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Wengen Chen
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Mohammed Abdulghani
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Yousra Ghzally
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland.,Assiut University, Arab Republic of Egypt
| | - Jagat Bandhu Mahat
- Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Alejandro Restrepo
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vincent Y See
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Stephen Shorofsky
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vasken Dilsizian
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | - Timm Dickfeld
- Maryland Arrhythmia and Cardiology Imaging Group (MACIG), Baltimore, Maryland.,Division of Cardiology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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Abstract
Ventricular tachycardia (VT) is a major cause of sudden cardiac death. The majority of malignant VTs occur in patients with structural heart disease. Multimodality imaging techniques play an integral role in determining the underlying etiology and prognostic significance of VT. In recent years, advances in imaging technology have enabled characterization of the structural arrhythmogenic substrate in patients with VT with increasing precision. In parallel with these advances, the role of cardiac imaging has expanded from a largely diagnostic tool to an adjunctive tool to guide interventional approaches for treatment of VT. Invasive and noninvasive imaging techniques, often used in combination, have made it possible to integrate structural and electrophysiological information during VT ablation procedures. An important area of current development is the use of noninvasive imaging techniques based on body surface electrocardiographic mapping to elucidate the mechanisms of VT. In the future, these techniques may provide a priori information on mechanisms of VT in patients undergoing interventional procedures. This review provides an overview of the role of cardiac imaging in patients with VT.
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Affiliation(s)
- Saagar Mahida
- Department of Cardiac Electrophysiology, Liverpool Heart and Chest Hospital, UK (S.M.)
| | - Frédéric Sacher
- L’Institut de Rythmologie et Modélisation Cardiaque (LIRYC), Centre Hospitalier Universitaire (CHU) de Bordeaux, France (F.S., R.D., M.H., P.J., H.C.)
| | - Rémi Dubois
- L’Institut de Rythmologie et Modélisation Cardiaque (LIRYC), Centre Hospitalier Universitaire (CHU) de Bordeaux, France (F.S., R.D., M.H., P.J., H.C.)
| | - Maxime Sermesant
- Inria Sophia Antipolis, Sophia Antipolis-Méditerranée, France (M.S.)
| | - Frank Bogun
- Division of Cardiology, University of Michigan, Ann Arbor (F.B.)
| | - Michel Haïssaguerre
- L’Institut de Rythmologie et Modélisation Cardiaque (LIRYC), Centre Hospitalier Universitaire (CHU) de Bordeaux, France (F.S., R.D., M.H., P.J., H.C.)
| | - Pierre Jaïs
- L’Institut de Rythmologie et Modélisation Cardiaque (LIRYC), Centre Hospitalier Universitaire (CHU) de Bordeaux, France (F.S., R.D., M.H., P.J., H.C.)
| | - Hubert Cochet
- L’Institut de Rythmologie et Modélisation Cardiaque (LIRYC), Centre Hospitalier Universitaire (CHU) de Bordeaux, France (F.S., R.D., M.H., P.J., H.C.)
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39
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Abstract
PURPOSE OF REVIEW Autonomic innervation is crucial for regulating cardiac function. Sympathetic innervation imaging with 123I-mIBG and analogous PET tracers assesses disease in ways that differ from customary methods. This review describes practical use in various clinical scenarios, discusses recent guidelines, presents new data confirming risk stratification power, describes an ongoing prospective study, and looks forward to wider use in patient management. RECENT FINDINGS ASNC 123I-mIBG guidelines are available, expanding on European guidelines. ADMIRE-HF patient follow-up increased to 2 years in ADMIRE HFX, demonstrating independent mortality risk reclassification. ADMIRE-HF findings were substantiated in a Japanese consortium study and in the PAREPET 11C-HED PET study. Exciting potential uses of adrenergic imaging are management of LVADs and VT ablation. CZT cameras provide advantages, but derived parameters differ from Anger camera values. Independent risk stratification utility of adrenergic imaging with 123I-mIBG and PET tracers is continuously being confirmed. An ongoing prospective randomized study promises to establish patient management utility. There is potential for wider use and improved images with newer cameras and PET.
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Affiliation(s)
- Mark I Travin
- Department of Radiology/Division of Nuclear Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East-210th Street, Bronx, NY, 10467-2490, USA.
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40
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Richardson T, Lugo R, Saavedra P, Crossley G, Clair W, Shen S, Estrada JC, Montgomery J, Shoemaker MB, Ellis C, Michaud GF, Lambright E, Kanagasundram AN. Cardiac sympathectomy for the management of ventricular arrhythmias refractory to catheter ablation. Heart Rhythm 2017; 15:56-62. [PMID: 28917558 DOI: 10.1016/j.hrthm.2017.09.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Catheter ablation is now a mainstay of therapy for ventricular arrhythmias (VAs). However, there are scenarios where either physiological or anatomical factors make ablation less likely to be successful. OBJECTIVE The purpose of this study was to demonstrate that cardiac sympathetic denervation (CSD) may be an alternate therapy for patients with difficult-to-ablate VAs. METHODS We identified all patients referred for CSD at a single center for indications other than long QT syndrome and catecholaminergic polymorphic ventricular tachycardia who had failed catheter ablation. Medical records were reviewed for medical history, procedural details, and follow-up. RESULTS Seven cases of CSD were identified in patients who had failed prior catheter ablation or had disease not amenable to ablation. All patients had VAs refractory to antiarrhythmic drugs, with a median arrhythmia burden of 1 episode of sustained VA per month. There were no acute complications of sympathectomy. One of 7 patients (14%) underwent heart transplant. No patient had sustained VA after sympathectomy at a median follow-up of 7 months. CONCLUSION Because of anatomical and physiological constraints, many VAs remain refractory to catheter ablation and remain a significant challenge for the electrophysiologist. While CSD has been described as a therapy for long QT syndrome and catecholaminergic polymorphic ventricular tachycardia, data regarding its use in other cardiac conditions are sparse. This series illustrates that CSD may be a viable treatment option for patients with a variety of etiologies of VAs.
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Affiliation(s)
| | - Ricardo Lugo
- Vanderbilt Heart and Vascular Institute, Nashville, Tennessee
| | - Pablo Saavedra
- Vanderbilt Heart and Vascular Institute, Nashville, Tennessee
| | - George Crossley
- Vanderbilt Heart and Vascular Institute, Nashville, Tennessee
| | - Walter Clair
- Vanderbilt Heart and Vascular Institute, Nashville, Tennessee
| | - Sharon Shen
- Vanderbilt Heart and Vascular Institute, Nashville, Tennessee
| | | | - Jay Montgomery
- Vanderbilt Heart and Vascular Institute, Nashville, Tennessee
| | | | | | | | - Eric Lambright
- Vanderbilt Heart and Vascular Institute, Nashville, Tennessee
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41
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Liga R, Gimelli A. Imaging the heart's brain: Simultaneous innervation/perfusion analysis in the era of new CZT cameras. J Nucl Cardiol 2017; 24:1374-1377. [PMID: 27194010 DOI: 10.1007/s12350-016-0541-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 05/04/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Riccardo Liga
- Cardio-Thoracic and Vascular Department, University Hospital of Pisa, Pisa, Italy
| | - Alessia Gimelli
- Fondazione Toscana Gabriele Monasterio, Via Moruzzi 1, 56124, Pisa, Italy.
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42
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Abstract
Ventricular arrhythmias are an important cause of cardiovascular morbidity and mortality, particularly in those with structural heart disease, inherited cardiomyopathies, and channelopathies. The goals of ventricular arrhythmia management include symptom relief, improving quality of life, reducing implantable cardioverter defibrillator shocks, preventing deterioration of left ventricular function, reducing risk of arrhythmic death, and potentially improving overall survival. Guideline-directed medical therapy and implantable cardioverter defibrillator implantation remain the mainstay of therapy to prevent sudden cardiac death in patients with ventricular arrhythmias in the setting of structural heart disease. Recent advances in imaging modalities and commercial availability of genetic testing panels have enhanced our mechanistic understanding of the disease processes and, along with significant progress in catheter-based ablative therapies, have enabled a tailored and more effective management of drug-refractory ventricular arrhythmias. Several gaps in our knowledge remain and require further research. In this article, we review the recent advances in the diagnosis and management of ventricular arrhythmias.
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Affiliation(s)
- Syeda Atiqa Batul
- Arrhythmia Division, Montefiore Medical Center, Bronx, New York, USA
| | | | - John D Fisher
- Arrhythmia Division, Montefiore Medical Center, Bronx, New York, USA
| | - Rakesh Gopinathannair
- Division of Cardiovascular Medicine, University of Louisville School of Medicine, Louisville, USA
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43
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Shirani J, Singh A, Agrawal S, Dilsizian V. Cardiac molecular imaging to track left ventricular remodeling in heart failure. J Nucl Cardiol 2017; 24:574-590. [PMID: 27480973 DOI: 10.1007/s12350-016-0620-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 07/13/2016] [Indexed: 12/11/2022]
Abstract
Cardiac left ventricular (LV) remodeling is the final common pathway of most primary cardiovascular diseases that manifest clinically as heart failure (HF). The more advanced the systolic HF and LV dysfunction, the worse the prognosis. The knowledge of the molecular, cellular, and neurohormonal mechanisms that lead to myocardial dysfunction and symptomatic HF has expanded rapidly and has allowed sophisticated approaches to understanding and management of the disease. New therapeutic targets for pharmacologic intervention in HF have also been identified through discovery of novel cellular and molecular components of membrane-bound receptor-mediated intracellular signal transduction cascades. Despite all advances, however, the prognosis of systolic HF has remained poor in general. This is, at least in part, related to the (1) relatively late institution of treatment due to reliance on gross functional and structural abnormalities that define the "heart failure phenotype" clinically; (2) remarkable genetic-based interindividual variations in the contribution of each of the many molecular components of cardiac remodeling; and (3) inability to monitor the activity of individual pathways to cardiac remodeling in order to estimate the potential benefits of pharmacologic agents, monitor the need for dose titration, and minimize side effects. Imaging of the recognized ultrastructural components of cardiac remodeling can allow redefinition of heart failure based on its "molecular phenotype," and provide a guide to implementation of "personalized" and "evidence-based" evaluation, treatment, and longitudinal monitoring of the disease beyond what is currently available through randomized controlled clinical trials.
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Affiliation(s)
- Jamshid Shirani
- Department of Cardiology, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, USA.
| | - Amitoj Singh
- Department of Cardiology, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, USA
| | - Sahil Agrawal
- Department of Cardiology, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA, USA
| | - Vasken Dilsizian
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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44
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Ernst S, Roy K, Lim E, Thomas G. Epicardial ablation of ventricular tachycardia in a patient with arrhythmogenic right ventricular dysplasia after failed conventional endocardial ablation: A case for remote navigation with functional image integration. Glob Cardiol Sci Pract 2016; 2016:e201639. [PMID: 28979908 PMCID: PMC5624191 DOI: 10.21542/gcsp.2016.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Arrhythmogenic right ventricular dysplasia (ARVD) is an inheritable heart muscle disease that predominantly affects the right ventricle (RV) and predisposes to ventricular arrhythmias and sudden cardiac death (SCD)1. The natural history is predominantly related to ventricular electric instability which may lead to arrhythmic SCD, mostly in young people and athletes2,3, but may progress with significant RV muscle disease and left-ventricular (LV) involvement and can result in right or biventricular heart failure4. We report on a 54-year-old male with ARVD who underwent an epicardial ventricular tachycardia (VT) ablation using remote magnetic navigation (RMN) after functional imaging from a nuclear perfusion study was fused with a 3D segmentation from computed tomography (CT) imaging.
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Affiliation(s)
- Sabine Ernst
- Department of Cardiology, Royal Brompton Hospital, London, UK.,NIHR Cardiovascular Biomedical Research Unit, Royal Brompton and National Heart and Lung Institute, Imperial College London, London, UK
| | - Karine Roy
- Department of Cardiology, Royal Brompton Hospital, London, UK
| | - Eric Lim
- Department of Cardiology, Royal Brompton Hospital, London, UK
| | - Glyn Thomas
- Department of Cardiology, University of Bristol, Bristol, UK
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45
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Affiliation(s)
- Christine M Albert
- From Harvard Medical School, Center for Arrhythmia Prevention, Division of Cardiovascular and Preventive Medicine (C.M.A.), and Department of Medicine, Harvard Medical School, Cardiac Arrhythmia Program, Division of Cardiovascular Medicine (W.G.S.), Brigham and Women's Hospital, Boston, MA.
| | - William G Stevenson
- From Harvard Medical School, Center for Arrhythmia Prevention, Division of Cardiovascular and Preventive Medicine (C.M.A.), and Department of Medicine, Harvard Medical School, Cardiac Arrhythmia Program, Division of Cardiovascular Medicine (W.G.S.), Brigham and Women's Hospital, Boston, MA
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46
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47
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Abstract
PURPOSE OF REVIEW This article summarizes current understanding of the arrhythmia substrate and effect of catheter ablation for infarct-related ventricular tachycardia, focusing on recent findings. RECENT FINDINGS Clinical studies support the use of catheter ablation earlier in the course of ischemic disease with moderate success in reducing arrhythmia recurrence and shocks from implantable defibrillators, although mortality remains unchanged. Ablation can be lifesaving for patients presenting with electrical storm. Advanced mapping systems with image integration facilitate identification of potential substrate, and several different approaches to manage hemodynamically unstable ventricular tachycardia have emerged. Novel ablation techniques that allow deeper lesion formation are in development. SUMMARY Catheter ablation is an important therapeutic option for preventing or reducing episodes of ventricular tachycardia in patients with ischemic cardiomyopathy. Present technologies allow successful ablation in the majority of patients, even when the arrhythmia is hemodynamically unstable. Failure of the procedure is often because of anatomic challenges that will hopefully be addressed with technological progress.
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48
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Gimelli A, Menichetti F, Soldati E, Liga R, Vannozzi A, Marzullo P, Bongiorni MG. Relationships between cardiac innervation/perfusion imbalance and ventricular arrhythmias: impact on invasive electrophysiological parameters and ablation procedures. Eur J Nucl Med Mol Imaging 2016; 43:2383-91. [DOI: 10.1007/s00259-016-3461-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 07/05/2016] [Indexed: 11/26/2022]
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49
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Njeim M, Desjardins B, Bogun F. Multimodality Imaging for Guiding EP Ablation Procedures. JACC Cardiovasc Imaging 2016; 9:873-886. [DOI: 10.1016/j.jcmg.2016.03.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 02/22/2016] [Accepted: 03/10/2016] [Indexed: 10/21/2022]
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50
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Rijnierse MT, Allaart CP, Knaapen P. Principles and techniques of imaging in identifying the substrate of ventricular arrhythmia. J Nucl Cardiol 2016; 23:218-34. [PMID: 26667814 PMCID: PMC4785206 DOI: 10.1007/s12350-015-0344-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 11/10/2015] [Indexed: 01/26/2023]
Abstract
Life-threatening ventricular arrhythmias (VA) are a major cause of death in patients with cardiomyopathy. To date, impaired left ventricular ejection fraction remains the primary criterion for implantable cardioverter-defibrillator therapy to prevent sudden cardiac death. In recent years, however, advanced imaging techniques such as nuclear imaging, cardiac magnetic resonance imaging, and computed tomography have allowed for a more detailed evaluation of the underlying substrate of VA. These imaging modalities have emerged as a promising approach to assess the risk of sudden cardiac death. In addition, non-invasive identification of the critical sites of arrhythmias may guide ablation therapy. Typical anatomical substrates that can be evaluated by multiple advanced imaging techniques include perfusion abnormalities, scar and its border zone, and sympathetic denervation. Understanding the principles and techniques of different imaging modalities is essential to gain more insight in their role in identifying the arrhythmic substrate. The current review describes the principles of currently available imaging techniques to identify the substrate of VA.
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Affiliation(s)
- Mischa T Rijnierse
- Department of Cardiology and Institute for Cardiovascular Research (IcaR-VU), VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Cornelis P Allaart
- Department of Cardiology and Institute for Cardiovascular Research (IcaR-VU), VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Paul Knaapen
- Department of Cardiology and Institute for Cardiovascular Research (IcaR-VU), VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands.
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