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1.
Heart Rhythm ; 2020 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-32389682

RESUMO

BACKGROUND: Electrical posterior wall isolation (PWI) is increasingly utilized for the treatment of patients with atrial fibrillation (AF). Little data exists on the durability of PWI using current technology. OBJECTIVE: To characterize the frequency and location of posterior wall reconnection at the time of repeat catheter ablation for AF. METHODS: We performed a single center retrospective cohort study of 50 patients undergoing repeat AF ablation after prior PWI. Durability of PWI was assessed at the time of repeat ablation based on posterior wall entrance and exit block. Sites of posterior wall reconnection were characterized based on review of recorded electrical signals and electroanatomic maps. RESULTS: At the time of repeat ablation, mean age was 67±10 years, 31 of 50 had persistent AF, and mean CHA2DS2-VASc score was 3.0±1.8. Of 50 patients, 30 had durable PWI at repeat ablation, 1.4±1.6 years following the index procedure. Patients with posterior wall reconnection required repeat ablation earlier (0.9±0.6 vs1.8±1.9 years from index PWI, p=0.048) and were more likely to have atypical atrial flutter (55 vs 27%, p=0.043). Among patients with posterior wall reconnection, the roof was the most common site of reconnection (14/20) and 12 patients had multiple regions of reconnection noted. CONCLUSIONS: Posterior wall reconnection is noted in 40% of patients undergoing repeat ablation following an index PWI. The roof of the left atrium is the most common site of posterior wall reconnection.

2.
Heart Rhythm ; 2020 May 23.
Artigo em Inglês | MEDLINE | ID: mdl-32454219

RESUMO

BACKGROUND: 12-lead electrocardiogram (ECG) criteria have been developed to identify idiopathic ventricular arrhythmias (VAs) from the left ventricular (LV) papillary muscles (PAPs), but accurate localization remains a challenge. OBJECTIVE: To develop ECG criteria for accurate localization of LV PAP VAs utilizing lead V1 exclusively. METHODS: Consecutive patients undergoing mapping and ablation of VAs from the LV PAPs guided by intracardiac echocardiography from 2007-2018 were reviewed (study group). The QRS morphology in V1 was compared to patients with VAs with a "RBBB" morphology from other LV locations (reference group). Patients with structural heart disease were excluded. RESULTS: 111 patients with LV PAP VAs (age 54±16, male 59%) including 64 (55%) from the posteromedial PAP and 47 (42%) from the anterolateral PAP. The reference group included patients with VAs from the following LV locations: fascicles (n=21), outflow tract (n=36), ostium (n=37), inferobasal segment (n=12), and apex (5). PAP VAs showed 3 distinct QRS morphologies in V1 93% of the time: Rr (53%), R with a slurred downslope (29%), and RR (11%). Sensitivity, specificity, and positive and negative predictive values for the 3 morphologies combined are 93%, 98%, 98%, and 93%, respectively. The intrinsicoid deflection of the PAP VAs in V1 were shorter than the reference group (63±13 ms versus 79±24 ms; p<0.001). An intrinsicoid deflection time less than 74 ms best differentiated the two groups (sensitivity, 79%; specificity, 87%). CONCLUSION: VAs originating from the LV PAPs manifest unique QRS morphologies in lead V1, which can aid in rapid and accurate localization.

3.
Artigo em Inglês | MEDLINE | ID: mdl-32298038

RESUMO

INTRODUCTION: In patients with nonischemic cardiomyopathy (NICM) little is known about the clinical impact of catheter ablation (CA) of septal ventricular tachycardia (VT) resulting in the collateral injury of the conduction system (CICS). METHODS AND RESULTS: Ninety-five consecutive patients with NICM underwent CA of septal VT. Outcomes in patients with no baseline conduction abnormalities who developed CICS (group 1, n = 28 [29%]) were compared to patients with no CICS (group 2, n = 17 [18%]) and to patients with preexisting conduction abnormalities or biventricular pacing (group 3, n = 50 [53%]). Group-1 patients were younger, had a higher left ventricular ejection fraction and a lower prevalence of New York Heart Association III/IV class compared to group 3 while no significant differences were observed with group 2. After a median follow-up of 15 months, VT recurred in 14% of patients in group 1, 12% in group 2 (P = .94) and 32% in group 3 (P = .08) while death/transplant occurred in 14% of patients in group 1, 18% in group 2 (P = .69) and 28% in group 3 (P = .15). A worsening of left ventricular ejection fraction (LVEF) (median LVEF variation, -5%) was observed in group 1 compared to group 2 (median LVEF variation, 0%; P < .01) but not group-3 patients (median LVEF variation, -4%; P = .08) with a consequent higher need for new biventricular pacing in group 1 (43%) compared to group 2 (12%; P = .03) and group 3 (16%; P < .01). CONCLUSIONS: In patients with NICM and septal substrate, sparing the abnormal substrate harboring the conduction system provides acceptable VT control while preventing a worsening of the systolic function.

5.
JACC Clin Electrophysiol ; 6(3): 272-281, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32192677

RESUMO

OBJECTIVES: This study describes the technique and outcomes of atrial fibrillation (AF) ablation via a superior approach in patients with interrupted or absent inferior vena cavas (IVCs). BACKGROUND: In patients with interrupted or absent IVCs, transseptal access cannot be obtained via standard femoral venous access. In these patients, alternative strategies are necessary to permit catheter ablation in the left atrium (LA). This study reports on the outcomes of AF ablation from a superior venous access with a radiofrequency (RF)-assisted transseptal puncture (TSP) technique. METHODS: This study identified patients with interrupted or absent IVCs who underwent AF ablation via a superior approach at 2 ablation centers from 2010 to 2019. RESULTS: Fifteen patients (mean age: 50.8 ± 11.2 years; 10 men; 10 with paroxysmal AF) with interrupted or absent IVCs underwent AF ablation with transseptal access via a superior approach. Successful TSP was performed either with a manually bent RF transseptal needle (early cases: n = 4) or using a RF wire (late cases: n = 11); this approach permitted LA mapping and ablation in all patients. Mean time required to perform single (n = 8) or double (n = 7) TSP was 16.1 ± 4.8 min, and mean total procedure time was 227.9 ± 120.7 min (fluoroscopy time: 57.0 ± 28.5 min). LA mapping and ablation were successfully performed in all patients. CONCLUSIONS: In patients with AF undergoing catheter ablation and who had a standard transseptal approach via femoral venous approach is impossible due to anatomic constraints, RF-assisted transseptal access via a superior approach can be an effective alternative strategy to permit LA mapping and ablation.

6.
Heart Rhythm ; 2020 Feb 27.
Artigo em Inglês | MEDLINE | ID: mdl-32112873

RESUMO

BACKGROUND: Postoperative bradycardia can complicate orthotopic heart transplantation (OHT). Previous studies suggested donor age and surgical technique as possible risk factors. However, risk factors in the era of bicaval anastomosis have not been elucidated. OBJECTIVE: We sought to examine the association between donor/recipient characteristics with need for chronotropic support and permanent pacemaker (PPM) implantation in patients with OHT. METHODS: All patients treated with OHT between January 2003 and January 2018 at the Hospital of the University of Pennsylvania were retrospectively evaluated until June 2018. Chronotropic support was given upon postoperative inability to increase the heart rate to patient's demands and included disproportionate bradycardia and junctional rhythm. RESULTS: A total of 820 patients (mean age 51.3 ± 12.6 years; 74% men) underwent 826 OHT procedures (95.3% bicaval anastomosis). Patients who were exposed to amiodarone (odds ratio [OR] 2.30; 95% confidence interval [CI] 1.58-3.34; P < .001) and have older donor (OR 1.02; 95% CI 1.01-1.04; P = .001) were more likely to develop need for chronotropic support. In multivariable analysis, recipient age (OR 1.03; 95% CI 1.00-1.06; P = .04) and biatrial anastomosis (OR 6.12; 95% CI 2.48-15.09) were significantly associated with PPM implantation within 6 months of OHT. No association was found between pre-OHT amiodarone use and PPM implantation. No risk factors assessed were associated with PPM implantation 6 months after OHT. CONCLUSION: Surgical technique and donor age were the main risk factors for the need for chronotropic support post-OHT, whereas surgical technique and recipient age were risk factors for early PPM implantation.

7.
JACC Clin Electrophysiol ; 6(2): 221-230, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32081227

RESUMO

OBJECTIVES: This study sought to examine clinical characteristics of procedural and long-term outcomes in patients undergoing catheter ablation (CA) of outflow tract ventricular arrhythmias (OT-VAs) over 16 years. BACKGROUND: CA is an effective treatment strategy for OT-VAs. METHODS: Patients undergoing CA for OT-VAs from 1999 to 2015 were divided into 3 periods: 1999 to 2004 (early), 2005 to 2010 (middle), and 2011 to 2015 (recent). Successful ablation site (right ventricular OT, aortic cusps/left ventricular OT, or coronary venous system/epicardium), VA morphology (right bundle branch block or left bundle branch block), and acute and clinical success rates were assessed. RESULTS: Six hundred eighty-two patients (336 female) were included (early: n = 97; middle: n = 204; recent: n = 381). Over time there was increase in use of irrigated ablation catheters and electroanatomic mapping, and more VAs were ablated from the aortic cusp/left ventricular OT or coronary venous system/epicardium (14% vs. 45% vs. 56%; p < 0.0001). Acute procedural success was achieved in 585 patients (86%) and was similar between groups (82% vs. 84% vs. 88%; p = 0.27). Clinical success was also similar between groups (86% vs. 87% vs. 88%; p = 0.94), but more patients in earlier periods required repeat ablation (18% vs. 17% vs. 9%; p = 0.02). Overall complication rate was 2% (similar between groups). CONCLUSIONS: Over a 16-year period there was an increase in patients undergoing CA for OT-VTs, with more ablations performed at non-right ventricular outflow tract locations using electroanatomic mapping and irrigated-tip catheters. Over time, single procedure success has improved and complications have remained limited.

8.
JACC Clin Electrophysiol ; 6(2): 231-240, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32081228

RESUMO

OBJECTIVES: This study sought to evaluate the prevalence, mapping features, and ablation outcomes of non-scar-related ventricular tachycardia (NonScar-VT) and Purkinje-related VT (Purkinje-VT) in patients with structural heart disease. BACKGROUND: VT in structural heart disease is typically associated with scar-related myocardial re-entry. NonScar-VTs arising from areas of normal myocardium or Purkinje-VTs originating from the conduction system are less common. METHODS: We retrospectively analyzed 690 patients with structural heart disease who underwent VT ablation between 2013 and 2017. RESULTS: A total of 37 (5.4%) patients (16 [43%] with ischemic cardiomyopathy, 16 [43%] with nonischemic dilated cardiomyopathy, and 5 [14%] others) demonstrated NonScar/Purkinje-VTs, which represented the clinical VT in 76% of cases. Among the 37 VTs, 31 (84%) were Purkinje-VTs (28 bundle branch re-entrant VT). The remaining 6 (16%) VTs were NonScar-VTs and included 4 idiopathic outflow tract VTs. A total of 16 patients had prior history of VT ablations: empirical scar substrate modification was performed in 6 (38%) patients and residual inducibility of VT had not been assessed in 7 (44%). In all 37 patients, the NonScar/Purkinje-VT was successfully ablated. After a median follow-up of 18 months, the targeted NonScar/Purkinje-VT did not recur in any patients, and 28 (76%) of patients were free from any recurrent VT episodes. CONCLUSIONS: NonScar/Purkinje-VTs can be identified in 5.4% of patients undergoing VT ablation in the setting of structural heart disease. Careful effort to induce, characterize, and map these VTs is important because substrate-based ablation strategies would fail to eliminate these types of VT.

9.
Circ Arrhythm Electrophysiol ; 13(1): e007611, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31922914

RESUMO

BACKGROUND: Data characterizing structural changes of arrhythmogenic right ventricular (RV) cardiomyopathy are limited. METHODS: Patients presenting with left bundle branch block ventricular tachycardia in the setting of arrhythmogenic RV cardiomyopathy with procedures separated by at least 9 months were included. RESULTS: Nineteen consecutive patients (84% males; mean age 39±15 years [range, 20-76 years]) were included. All 19 patients underwent 2 detailed sinus rhythm electroanatomic endocardial voltage maps (average 385±177 points per map; range, 93-847 points). Time interval between the initial and repeat ablation procedures was mean 50±37 months (range, 9-162). No significant progression of voltage was observed (bipolar: 38 cm2 [interquartile range (IQR), 25-54] versus 53 cm2 [IQR, 25-65], P=0.09; unipolar: 116 cm2 [IQR, 61-209] versus 159 cm2 [IQR, 73-204], P=0.36) for the entire study group. There was a significant increase in RV volumes (percentage increase, 28%; 206 mL [IQR, 170-253] versus 263 mL [IQR, 204-294], P<0.001) for the entire study population. Larger scars at baseline but not changes over time were associated with a significant increase in RV volume (bipolar: Spearman ρ, 0.6965, P=0.006; unipolar: Spearman ρ, 0.5743, P=0.03). Most patients with progressive RV dilatation (8/14, 57%) had moderate (2 patients) or severe (6 patients) tricuspid regurgitation recorded at either initial or repeat ablation procedure. CONCLUSIONS: In patients with arrhythmogenic RV cardiomyopathy presenting with recurrent ventricular tachycardia, >10% increase in RV endocardial surface area of bipolar voltage consistent with scar is uncommon during the intermediate term. Most recurrent ventricular tachycardias are localized to regions of prior defined scar. Voltage indexed scar area at baseline but not changes in scar over time is associated with progressive increase in RV size and is consistent with adverse remodeling but not scar progression. Marked tricuspid regurgitation is frequently present in patients with arrhythmogenic RV cardiomyopathy who have progressive RV dilation.

10.
JACC Clin Electrophysiol ; 6(1): 21-30, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31971902

RESUMO

OBJECTIVE: This study sought to investigate incidence of left atrial appendage (LAA) triggers of atrial fibrillation (AF) and/or organized atrial tachycardias (OAT) in patients undergoing AF ablation and to evaluate outcomes after ablation. BACKGROUND: Although LAA isolation is being increasingly performed during AF ablation, the true incidence of LAA triggers for AF remains unclear. METHODS: All patients with LAA triggers of AF and/or OAT during AF ablation from 2001 to 2017 were included. LAA triggers were defined as atrial premature depolarizations from the LAA, which initiated sustained AF and/or OAT. RESULTS: Out of 7,129 patients undergoing AF ablation over 16 years, LAA triggers were observed in 21 (0.3%) subjects (age 60 ± 9 years; 57% males; 52% persistent AF). Twenty (95%) patients were undergoing repeat ablation. The LAA was the only nonpulmonary vein trigger in 3 patients; the remaining 18 patients had both LAA and other nonpulmonary vein triggers. LAA triggers were eliminated in all patients (focal ablation in 19 patients; LAA isolation in 2 patients). Twelve months after ablation, 47.6% remained free from recurrent arrhythmia. After overall follow-up of 5.0 ± 3.6 years (median: 3.7 years; interquartile range: 1.4 to 8.9 years), 38.1% were arrhythmia-free. All 3 patients with triggers limited to the LAA remained free of AF recurrence. One patient undergoing LAA isolation developed LAA thrombus during follow-up. CONCLUSIONS: The incidence of true LAA triggers is very low (0.3%). Most patients with LAA triggers have additional nonpulmonary vein triggers, and despite elimination of LAA triggers, long-term arrhythmia recurrence rates remain high. Potential risks of empiric LAA isolation during AF ablation (especially first-time AF ablation) may outweigh benefits.

11.
J Cardiovasc Electrophysiol ; 31(2): 423-431, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31916273

RESUMO

BACKGROUND: We have previously demonstrated the feasibility of a nurse-led risk factor modification (RFM) program for improving weight loss and obstructive sleep apnea (OSA) care among patients with atrial fibrillation (AF). OBJECTIVE: We now report its impact on arrhythmia outcomes in a subgroup of patients undergoing catheter ablation. METHODS: Participating patients with obesity and/or need for OSA management (high risk per Berlin Questionnaire or untreated OSA) underwent in-person consultation and monthly telephone calls with the nurse for up to 1 year. Arrhythmias were assessed by office ECGs and ≥2 wearable monitors. Outcomes, defined as Arrhythmia control (0-6 self-terminating recurrences, with ≤1 cardioversion for nonparoxysmal AF) and Freedom from arrhythmias (no recurrences on or off antiarrhythmic drugs), were compared at 1 year between patients undergoing catheter ablation who enrolled and declined RFM. RESULTS: Between 1 November 2016 and 1 April 2018, 195 patients enrolled and 196 declined RFM (body mass index, 35.1 ± 6.7 vs 34.3 ± 6.3 kg/m2 ; 50% vs 50% paroxysmal AF; P = NS). At 1 year, enrolled patients demonstrated significant weight loss (4.7% ± 5.3% vs 0.3% ± 4.4% in declined patients; P < .0001) and improved OSA care (78% [n = 43] of patients diagnosed with OSA began treatment). However, outcomes were similar between enrolled and declined patients undergoing ablation (arrhythmia control in 80% [n = 48] vs 79% [n = 38]; freedom from arrhythmia in 58% [n = 35] vs 71% [n = 34]; P = NS). CONCLUSION: Despite improving weight loss and OSA care, our nurse-led RFM program did not impact 1-year arrhythmia outcomes in patients with AF undergoing catheter ablation.

12.
JAMA ; 322(21): 2084-2094, 2019 12 03.
Artigo em Inglês | MEDLINE | ID: mdl-31794625

RESUMO

Importance: Malignant spinal canal compression, a major complication of metastatic cancer, is managed with radiotherapy to maintain mobility and relieve pain, although there is no standard radiotherapy regimen. Objective: To evaluate whether single-fraction radiotherapy is noninferior to 5 fractions of radiotherapy. Design, Setting, and Participants: Multicenter noninferiority randomized clinical trial conducted in 42 UK and 5 Australian radiotherapy centers. Eligible patients (n = 686) had metastatic cancer with spinal cord or cauda equina compression, life expectancy greater than 8 weeks, and no previous radiotherapy to the same area. Patients were recruited between February 2008 and April 2016, with final follow-up in September 2017. Interventions: Patients were randomized to receive external beam single-fraction 8-Gy radiotherapy (n = 345) or 20 Gy of radiotherapy in 5 fractions over 5 consecutive days (n = 341). Main Outcomes and Measures: The primary end point was ambulatory status at week 8, based on a 4-point scale and classified as grade 1 (ambulatory without the use of aids and grade 5 of 5 muscle power) or grade 2 (ambulatory using aids or grade 4 of 5 muscle power). The noninferiority margin for the difference in ambulatory status was -11%. Secondary end points included ambulatory status at weeks 1, 4, and 12 and overall survival. Results: Among 686 randomized patients (median [interquartile range] age, 70 [64-77] years; 503 (73%) men; 44% had prostate cancer, 19% had lung cancer, and 12% had breast cancer), 342 (49.8%) were analyzed for the primary end point (255 patients died before the 8-week assessment). Ambulatory status grade 1 or 2 at week 8 was achieved by 115 of 166 (69.3%) patients in the single-fraction group vs 128 of 176 (72.7%) in the multifraction group (difference, -3.5% [1-sided 95% CI, -11.5% to ∞]; P value for noninferiority = .06). The difference in ambulatory status grade 1 or 2 in the single-fraction vs multifraction group was -0.4% (63.9% vs 64.3%; [1-sided 95% CI, -6.9 to ∞]; P value for noninferiority = .004) at week 1, -0.7% (66.8% vs 67.6%; [1-sided 95% CI, -8.1 to ∞]; P value for noninferiority = .01) at week 4, and 4.1% (71.8% vs 67.7%; [1-sided 95% CI, -4.6 to ∞]; P value for noninferiority = .002) at week 12. Overall survival rates at 12 weeks were 50% in the single-fraction group vs 55% in the multifraction group (stratified hazard ratio, 1.02 [95% CI, 0.74-1.41]). Of the 11 other secondary end points that were analyzed, the between-group differences were not statistically significant or did not meet noninferiority criterion. Conclusions and Relevance: Among patients with malignant metastatic solid tumors and spinal canal compression, a single radiotherapy dose, compared with a multifraction dose delivered over 5 days, did not meet the criterion for noninferiority for the primary outcome (ambulatory at 8 weeks). However, the extent to which the lower bound of the CI overlapped with the noninferiority margin should be considered when interpreting the clinical importance of this finding. Trial Registration: ISRCTN Identifiers: ISRCTN97555949 and ISRCTN97108008.


Assuntos
Fracionamento da Dose de Radiação , Metástase Neoplásica , Compressão da Medula Espinal/radioterapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Doses de Radiação , Radioterapia/métodos , Compressão da Medula Espinal/etiologia , Compressão da Medula Espinal/mortalidade , Taxa de Sobrevida
13.
JACC Clin Electrophysiol ; 5(11): 1292-1299, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31753435

RESUMO

OBJECTIVES: This study sought to compare efficacy and safety of the septal mitral isthmus line (SMIL) with that of the lateral mitral isthmus line (LMIL) for treatment of mitral annular flutter (MAF). BACKGROUND: MAF is the most common left atrial macro-re-entrant organized atrial tachycardia (OAT) occurring after catheter ablation of atrial fibrillation. The 2 most common lesion sets for treating MAF include linear ablation from the anteroseptal mitral annulus to the right superior pulmonary vein (SMIL) and from the lateral mitral annulus to left inferior pulmonary vein (LMIL). METHODS: The study included all mitral isthmus ablations performed at the Hospital of the University of Pennsylvania in 2016 and 2017. Acute procedural results and long-term arrhythmia-free survival were compared between groups. RESULTS: Of 114 total MILs, conduction block was achieved across 73 (93.6%) SMILs compared with 29 (80.6%) LMILs (p = 0.05). Although the length of the SMIL was longer (48.9 ± 12.8 cm vs. 38.7 ± 12.8 cm; p = 0.001), time required to achieve block was shorter (25.2 ± 15.9 min vs. 36.6 ± 21.3 min; p = 0.03). Coronary sinus ablation was required in 58.3% of LMILs due to inability to achieve conduction block with left atrial ablation alone. In multivariate analysis, only failure to achieve acute MIL block remained significantly associated with subsequent OAT recurrence (hazard ratio: 6.39; 95% confidence interval: 1.37 to 29.9; p = 0.02). CONCLUSIONS: The SMIL requires less time to complete and more frequently results in acute MIL block than the LMIL. Additionally, ablation is rarely required outside the left atrium. Failure to achieve acute MIL block is strongly associated with subsequent OAT recurrence.

14.
J Cardiovasc Electrophysiol ; 30(11): 2326-2333, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31424129

RESUMO

BACKGROUND: Catheter ablation (CA) of idiopathic premature ventricular complexes (PVCs) is typically guided by both activation and pace-mapping, with ablation ideally delivered at the site of the earliest local activation. However, activation mapping requires sufficient intraprocedural quantity of PVCs. This study aimed to investigate the outcome of CA of infrequent PVCs guided exclusively by pace-mapping. METHODS: We retrospectively analyzed all patients undergoing CA of idiopathic PVCs between 2014 and 2017. RESULTS: Among 327 patients, 24 (7.3%) had low intraprocedural PVC burden despite isoproterenol, including two patients with zero PVCs, rendering activation mapping impractical/impossible. All 24 had a history of symptomatic PVCs. During ablation, a median of 27 (17-55) pace-maps were performed, with best median PASO score of 97 (96-98)%. A median of 12 (8.75-18.75) radiofrequency (RF) lesions were delivered with 11.4 (8.5-17.6) minutes of total RF time. Clinical success, defined as more than 80% reduction in the burden of previously frequent PVCs and/or absence of symptoms as well as any documented clinical PVCs among those with infrequent or exercise-induced PVCs, was achieved in 19 (79%) patients over 9.2 (2.0-15.0) months of follow-up. CONCLUSIONS: When activation mapping cannot be performed due to inadequate intraprocedural PVC burden, detailed pace-mapping can frequently identify the precise arrhythmia site of origin, thereby guiding successful CA.

15.
Circ Arrhythm Electrophysiol ; 12(7): e007249, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31296041

RESUMO

BACKGROUND: There has been increasing awareness of the 3-dimensional nature of ventricular tachycardia (VT) circuits. VT circuits in patients with ischemic cardiomyopathies (ICM) and non-ICM (NICM) may differ in this regard. METHODS: Among patients with structural heart disease and at least 1 hemodynamically tolerated VT undergoing ablation, we retrospectively analyzed responses to all entrainment maneuvers. RESULTS: Of 445 patients (ICM 228, NICM 217) undergoing VT ablation, detailed entrainment mapping of at least 1 tolerated VT was performed in 111 patients (ICM 71, NICM 40). Of 89 ICM VTs, the isthmus could be identified by endocardial entrainment in 55 (62%), compared with only 8 of 47 (17%) NICM VTs ( P<0.01). With combined endocardial and epicardial mapping, the isthmus could be identified in 56 (63%) ICM VTs and 12 (26%) NICM VTs ( P<0.01), whereas any critical component (defined as entrance, isthmus or exit) could be identified in 76 (85%) ICM VTs and 37 (79%) NICM VTs ( P=0.3). Complete success (no inducible VT at the end of ablation, 82% versus 65%, P=0.04) and 1-year, single-procedure VT-free survival (82% versus 55%, P<0.01) were both higher among patients with ICM. CONCLUSIONS: Among mappable ICM VTs, critical circuit components can usually be identified on the endocardium. In contrast, among mappable NICM VTs, although some critical component can typically be identified with the addition of epicardial mapping, the isthmus is less commonly identified, possibly due to midmyocardial location.

16.
JACC Clin Electrophysiol ; 5(7): 801-813, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31320008

RESUMO

OBJECTIVES: This study sought to assess the performance of established risk models in predicting outcomes after catheter ablation (CA) in patients with nonischemic dilated cardiomyopathy (NIDCM) and ventricular tachycardia (VT). BACKGROUND: A correct pre-procedural risk stratification of patients with NIDCM and VT undergoing CA is crucial. The performance of different pre-procedural risk stratification approaches to predict outcomes of CA of VT in patients with NIDCM is unknown. METHODS: The study compared the performance of 8 prognostic scores (SHFM [Seattle Heart Failure Model], MAGGIC [Meta-analysis Global Group in Chronic Heart Failure], ADHERE [Acute Decompensated Heart Failure National Registry], EFFECT [Enhanced Feedback for Effective Cardiac Treatment-Heart Failure], OPTIMIZE-HF [Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure], CHARM [Candesartan in Heart Failure-Assessment of Reduction in Mortality], EuroSCORE [European System for Cardiac Operative Risk Evaluation], and PAINESD [Chronic Obstructive Pulmonary Disease, Age > 60 Years, Ischemic Cardiomyopathy, New York Heart Association Functional Class III or IV, Ejection Fraction <25%, Presentation With VT Storm, Diabetes Mellitus]) for the endpoints of death/cardiac transplantation and VT recurrence in 282 consecutive patients (age 59 ± 15 years, left ventricular ejection fraction: 36 ± 13%) with NIDCM undergoing CA of VT. Discrimination and calibration of each model were evaluated through area under the curve (AUC) of receiver-operating characteristic curve and goodness-of-fit test. RESULTS: After a median follow-up of 48 (interquartile range: 19-67) months, 43 patients (15%) died, 24 (9%) underwent heart transplantation, and 58 (21%) experienced VT recurrence. The prognostic accuracy of SHFM (AUC = 0.89; goodness-of-fit p = 0.68 for death/transplant and AUC = 0.77; goodness-of-fit p = 0.16 for VT recurrence) and PAINESD (AUC = 0.83; goodness-of-fit p = 0.24 for death/transplant and AUC = 0.68; goodness-of-fit p = 0.58 for VT recurrence) were significantly superior to that of other scores. CONCLUSIONS: In patients with NIDCM and VT undergoing CA, the SHFM and PAINESD risk scores are powerful predictors of recurrent VT and death/transplant during follow-up, with similar performance and significantly superior to other scores. A pre-procedural calculation of the SHFM and PAINESD can be useful to predict outcomes.

17.
JACC Clin Electrophysiol ; 5(7): 833-842, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31320012

RESUMO

OBJECTIVES: This study sought to characterize ventricular arrhythmia (VA) ablated from the basal inferoseptal left ventricular endocardium (BIS-LVe) and identify electrocardiographic characteristics to differentiate from inferobasal crux (IBC) VA. BACKGROUND: The inferior basal septum is an uncommon source of idiopathic VAs, which can arise from its endocardial or epicardial (crux) aspect. Because the latter are often targeted from the coronary venous system or epicardium, distinguishing between the 2 is important for successful ablation. METHODS: Consecutive patients undergoing ablation of idiopathic VA from the BIS-LVe or IBC from 2009 to 2018 were identified and clinical characteristics and electrocardiographs of VA were compared. RESULTS: Of 931 patients undergoing idiopathic VA ablation, Virginia was eliminated from the BIS-LVe in 19 patients (2%) (17 male, age 63.7 ± 9.2 years, LV ejection fraction: 45.0 ± 9.3%). QRS complexes typically manifested right bundle branch block morphology with "reverse V2 pattern break" and left superior axis (more negative in lead III than II). VA elimination was achieved after median of 2 lesions (interquartile range [IQR]: 1-6; range 1 to 20) (radiofrequency ablation time: 123 s [IQR: 75-311]). Compared with 7 patients with IBC VA (3 male, age 51.9 ± 20.1 years, LV ejection fraction: 51.4 ± 17.7%), BIS-LVe VA less frequently had initial negative forces (QS pattern) in leads II, III, and/or aVF (p < 0.001), R-S ratio <1 in lead V1 (p = 0.005), and notching in lead II (p = 0.006) were narrower (QRS duration: 178.2 ± 22.4 vs. 221.1 ± 41.9 ms; p = 0.04) and more frequently had maximum deflection index of <0.55 (p < 0.001). CONCLUSIONS: The BIS-LVe region is an uncommon source of idiopathic VA. Distinguishing these from IBC VA is important for procedural planning and ablation success.

18.
JACC Clin Electrophysiol ; 5(6): 719-727, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31221360

RESUMO

OBJECTIVES: This study sought to determine the impact of repeat catheter ablation (CA) prior to hospital discharge based on inducibility of clinical ventricular tachycardia (VT) during noninvasive programmed ventricular stimulation (NIPS). BACKGROUND: Inducibility of clinical VT during NIPS performed several days after CA identifies patients at high risk of recurrence. The impact of NIPS-guided repeat CA has not been reported. METHODS: Consecutive patients with structural heart disease undergoing CA of VT followed by NIPS were studied. Clinical VT was defined by comparison with 12-lead electrocardiograms and stored implantable cardioverter-defibrillator electrograms from spontaneous VT episodes. Among those with inducible clinical VT at NIPS, VT-free survival was compared between those in whom ablation was repeated (group 1) versus those in whom ablation was not repeated (group 2) prior to hospital discharge. RESULTS: Among 469 patients (64 ± 12 years of age; 85% males; 60% ischemic), 216 patients (46%) underwent NIPS 3 days (interquartile range: 2 to 4 days) after CA. Clinical VT was induced in 45 patients (21%). Among those 45, CA was repeated in 11 patients (24%). There were no significant differences in baseline clinical or index CA characteristics between groups 1 and 2. Over a median 36-month follow-up, only 1 patient (9%) in group 1 experienced VT recurrence compared to 24 patients (71%) in group 2 (p < 0.01). In univariate Cox regression, repeat CA guided by NIPS (hazard ratio: 0.07; 95% confidence interval: 0.01 to 0.58; p = 0.01) was the only predictor of VT-free survival. CONCLUSIONS: In patients with inducible clinical VT during post-ablation NIPS, repeat CA was associated with significantly lower risk of subsequent recurrence.

19.
Heart Rhythm ; 16(9): 1421-1428, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31226487

RESUMO

BACKGROUND: The slow pathway region (SPR) is commonly targeted during ablation of atrioventricular nodal reentrant tachycardia. However, its role in idiopathic ventricular arrhythmias (IVAs) remains unknown. OBJECTIVE: The purpose of this study was to describe the electrocardiographic and electrophysiological characteristics of IVAs that were successfully ablated from the SPR. METHODS: Medical records of consecutive patients undergoing ablation of IVAs in the para-Hisian region between 2010 and 2018 were reviewed to identify subjects whose ventricular arrhythmias were targeted from the SPR. RESULTS: Among 63 patients with para-Hisian IVAs undergoing ablation, the SPR was targeted in 12 (20%; mean age 64 ± 7 years; 9 men). All patients presented with ventricular premature depolarizations manifesting left bundle branch block morphology with variable precordial transition (leads V2-V5) and a mean QRS duration of 131 ± 11 ms. In all cases, leads I and aVL had positive forces (R or Rs) and lead aVR had negative forces (QS or Qr). In the majority of cases, lead II had positive forces (R or Rs; n = 9 [75%]) and lead III had negative forces (rS or QS; n = 9 [75%]). Mean activation at the SPR was 31 ± 5 ms pre-QRS. All patients had initial ablation with radiofrequency, resulting in junctional rhythm in 9 (75%); 3 (25%) patients required additional cryoablation. Ablation was successful in 11 patients (92%). One patient required a permanent pacemaker for heart block but subsequently recovered intrinsic conduction. CONCLUSION: The SPR can be a source of IVAs, which can be safely and successfully ablated in most cases using radiofrequency energy. IVAs arising from this location manifest unique electrocardiographic features.

20.
Arrhythm Electrophysiol Rev ; 8(2): 116-121, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31114686

RESUMO

Idiopathic outflow tract ventricular arrhythmias (VAs) occur typically in patients without structural heart disease. They are often symptomatic and can sometimes lead to left ventricular systolic dysfunction. Both activation and pace mapping are utilised for successful ablation of these arrhythmias. Pace mapping is particularly helpful when the VA is infrequent and/or cannot be elucidated during the ablation procedure. VAs originating from different sites in the outflow tract region have distinct QRS patterns on the 12-lead ECG and careful analysis of the latter can help predict the site of origin of these arrhythmias. Successful ablation of these VAs requires understanding of the detailed anatomy of the OT region, which can be accomplished through electroanatomic mapping tools and intracardiac echocardiography.

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