Ganglionated Plexus Ablation Procedures to Treat Vasovagal Syncope.

Vasovagal syncope (VVS) refers to a heterogeneous group of conditions whereby the cardiovascular reflexes normally controlling the circulation are interrupted irregularly in response to a trigger, resulting in vasodilation, bradycardia, or both. VVS affects one-third of the population at least once in their lifetime or by the age of 60, reduces the quality of life, and may cause disability affecting certain routines. It poses a considerable economic burden on society, and, despite its prevalence, there is currently no proven pharmacological treatment for preventing VVS. The novel procedure of ganglionated plexus (GP) ablation has emerged rapidly in the past two decades, and has been proven successful in treating syncope. Several parameters influence the success rate of GP ablation, including specific ablation sites, localization and surgical techniques, method of access, and the integration of other interventions. This review aims to provide an overview of the existing literature on the physiological aspects and clinical effectiveness of GP ablation in the treatment of VVS. Specifically, we explore the association between GPs and VVS and examine the impact of GP ablation procedures as reported in human clinical trials. Our objective is to shed light on the therapeutic significance of GP ablation in eliminating VVS and restoring normal sinus rhythm, particularly among young adults affected by this condition.

Idiopathic right ventricular arrhythmias requiring additional ablation from the left-sided outflow tract: ECG characteristics and efficacy of an anatomical approach.

INTRODUCTION: Despite the characteristic electrocardiogram (ECG) findings of early activation during ventricular tachyarrhythmias (VAs) and/or excellent pacemapping in the right ventricular outflow tract (RVOT), some VAs may require additional, left-sided ablation for a cure. METHODS AND RESULTS: This study included five patients with idiopathic VAs whose QRS morphologies were highly suggestive of an RVOT origin. The ECG characteristics and intracardiac electrocardiograms during catheter ablation were assessed. In all patients, the clinical VAs had an LBBB QRS morphology and inferior axis with a precordial R/S transition through leads V3-V5, and negative components in lead I. The earliest activation during the VAs (local electrogram-QRS interval = -34 ± 6.8 ms) and excellent pacemapping were obtained at the posterior portion of the RVOT just beneath the pulmonary valve. However, ablation at those sites failed, and the QRS morphology of the VAs changed. During left-sided OT mapping, the earliest activation was found at sites just contralateral to the initially ablated sites of the RVOT (junction of the left and right coronary cusps = 2, left coronary cusp = 3). In spite of the late activation time and poor pacemapping scores, catheter ablation at those sites cured the VAs. Those successful sites were also near the transitional zone from the great cardiac vein to the anterior interventricular vein (GCV-AIV). CONCLUSIONS: Some VAs, highly suggestive of having RVOT origins, require catheter ablation in the left-sided OT near the initially ablated RVOT site. Those VAs have the same ECG characteristics and might have intramural origins in the superobasal LV surrounded by the RVOT, LVOT, and GCV-AIV.

Late elimination of challenging idiopathic ventricular arrhythmias originating from left ventricular summit by anatomical ablation.

Ablation of premature ventricular complexes (PVCs) originating from left ventricular outflow tract (LVOT)/left ventricular summit (LVS) is challenging with considerable rate of failure. Recently, in a novel approach to ablation of these arrythmias, application of radiofrequency energy to anatomically opposite sites of presumed origin of arrythmia, has been associated with moderate procedure success. Although late elimination of PVCs that are persistent following an ablation procedure has been previously reported, this observation has not been studied sufficiently. In this report, firstly, we present three cases of lately eliminated LVS PVCs, then, we discuss possible mechanism of this observation and conclude that after an initial failed attempt of anatomic ablation, operators may choose a period of watchful waiting before attempting a redo procedure.

Anatomical approach to suppression of para-Hisian ventricular arrhythmias with changes in QRS morphology after ablation at the earliest activation site.

BACKGROUND: The anatomical approach for the management of para-Hisian ventricular arrhythmias (VAs) with QRS morphological changes after catheter ablation (CA) has not been well investigated. OBJECTIVE: We aimed to evaluate the electrocardiographic and electrophysiological findings and ablation outcomes of para-Hisian VAs with QRS morphological changes after CA. METHODS: Of the 30 patients who underwent CA for para-Hisian VAs at 4 institutions, 10 (33%) had QRS morphological changes after ablation. All 10 patients underwent an anatomical approach, targeting the site anatomically opposite to the site where the QRS morphology had been changed by ablation. We investigated the safety and efficacy of the anatomical approach. RESULTS: Of the 10 patients evaluated, the approach was switched from the right ventricular septum to the left ventricular septum/aortic root in 7 (70%) (RL group) whereas 3 (30%) underwent left-to-right switches (LR group). After CA, the precordial transition zone tended to be earlier in the RL group and later in the LR group. In the RL group, successful VA suppression was achieved, despite suboptimal pace map concordance from the left side or a relatively delayed earliest activation time. Of the 10 patients who underwent an anatomical approach, 8 (80%) had procedural success, and ablation was discontinued in 1 (10%) because of the risk of atrioventricular block. CONCLUSION: The anatomical approach showed promising results regarding safety and efficacy. Therefore, it should be considered when QRS morphological changes are observed during or after CA of para-Hisian VAs.

Predictors of Successful Endocardial Ablation of Epicardial Left Ventricular Summit Arrhythmias.

Endocardial catheter ablation of ventricular arrhythmias (VAs) originating from the left ventricular summit (LVS) at remote structures adjacent to the LVS may be an alternative (anatomic approach) but may not be so successful. This type of catheter ablation is successful most commonly in the left ventricular outflow tract followed by the aortic cusps and rarely in the right ventricular outflow tract. A right bundle branch block QRS morphology and anatomic distance between the earliest ventricular activation site in the coronary venous system and endocardial ablation site (<13 mm) could be predictors of a successful endocardial catheter ablation of LVS VAs.

Effect of Direct Slow Pathway Capture Mapping-Guided Ablation on Typical Atrioventricular Nodal Re-Entrant Tachycardia.

BACKGROUND: Direct slow pathway capture (DSPC) mapping is a novel electrophysiological technique for detecting antegrade slow pathway input sites. However, the effect of DSPC mapping-guided ablation on atrioventricular nodal re-entrant tachycardia (AVNRT) is unknown. OBJECTIVES: This study aimed to evaluate the efficacy and safety of DSPC mapping-guided ablation in typical AVNRT patients. METHODS: A multicenter retrospective study was conducted in 301 consecutive typical AVNRT patients. The outcomes in patients who underwent DSPC mapping-guided ablation (DSPC group) and those who underwent conventional anatomical ablation (conventional group) were compared. The conventional group was established before introducing DSPC mapping-guided ablation. Positive DSPC sites were defined as sites with a return cycle atrioventricular prolongation of ≥20 ms with high-output (10-20 V) pacing during tachycardia or the last paced beat of the atrial extrastimulation. RESULTS: Among 116 patients in the DSPC group, 102 (88%) had positive DSPC sites, and 86 (74%) had a successful ablation at that site. Of the remaining 30 patients, 27 had a successful anatomical ablation. The DSPC group had a significantly lower frequency of radiofrequency applications and shorter total application time than the conventional group (median: 5.5 [IQR: 3-11] times vs 9 [IQR: 5-15] times, and 168 [IQR: 108-266] seconds vs 244 [IQR: 158-391] seconds, respectively; P < 0.01). Moreover, the DSPC group had a numerically lower incidence of permanent pacemaker implantations and AVNRT recurrences than the conventional group (0% vs 1.6%; P = 0.17, and 1.7% vs 3.2%; P = 0.43, respectively). CONCLUSIONS: DSPC mapping-guided ablation was associated with a lower operative time, which can reduce the risk of AV conduction injury in typical AVNRT.

Marshall bundle elimination, Pulmonary vein isolation, and Line completion for ANatomical ablation of persistent atrial fibrillation (Marshall-PLAN): Prospective, single-center study.

BACKGROUND: Beyond pulmonary vein isolation (PVI), the optimal ablation strategy for persistent atrial fibrillation (AF) remains poorly defined. OBJECTIVE: The purpose of this study was to examine a novel comprehensive ablation strategy (Marshall bundle elimination, Pulmonary vein isolation, and Line completion for ANatomical ablation of persistent atrial fibrillation [Marshall-PLAN]) strictly based on anatomical considerations. METHODS: Left atrial (LA) sites were sequentially targeted as follows: (1) coronary sinus and vein of Marshall (CS-VOM) musculature; (2) PVI; and (3) anatomical isthmuses (mitral, roof, and cavotricuspid isthmus [CTI]). The primary endpoint was 12-month freedom from AF/atrial tachycardia (AT). RESULTS: Seventy-five consecutive patients were included (age 61 ± 9 years; 10 women; AF duration 9 ± 11 months; mean LA volume 197 ± 43 mL). VOM ethanol infusion was completed in 69 patients (92%). The full Marshall-PLAN lesion set (VOM, PVI, mitral, roof, and CTI with block) was successfully completed in 68 patients (91%). At 12 months, 54 of 75 patients (72%) were free from AF/AT after a single procedure (no antiarrhythmic drugs) in the overall cohort. In the subset of patients with a complete Marshall-PLAN lesion set (n = 68), the single procedure success rate was 79%. After 1 or 2 procedures, 67 of 75 patients (89%) remained free from AF/AT (no antiarrhythmic drugs). After 1 or 2 procedures, VOM ethanol infusion was complete in 72 of 75 patients (96%). CONCLUSION: A novel ablation strategy that systematically targets anatomical atrial structures (VOM ethanol infusion, PVI, and prespecified linear lesions) is feasible, safe, and associated with a high rate of freedom from arrhythmia recurrence at 12 months in patients with persistent AF.

[Application of anatomical approach osteoligaments repair technique in treatment of pronation ankle fractures].

OBJECTIVE: To investigate the safety and effectiveness of anatomical approach osteoligaments repair technique in treatment of pronation ankle fractures. METHODS: The clinical data of 53 patients with pronation ankle fractures between April 2015 and October 2016, who were treated with anatomical approach osteoligaments repair technique applied for fracture reduction and internal fixation, were analysed retrospectively. There were 35 males and 18 females with an average age of 33.1 years (range, 18-60 years). The cause of injury included traffic accidents in 27 cases, tumbling in 5 cases, fall from height in 4 cases, twisted injury in 6 cases, sports injuries in 4 cases, and bruises in 7 cases. According to Lauge-Hansen classification, there were 44 cases of pronation external rotation stage Ⅳ and 9 cases of pronation abduction stage Ⅲ. The interval between injury and operation was 4-10 days (mean, 7 days). Postoperative pain and function of ankles were assessed by American Orthopedic Foot and Ankle Score (AOFAS) and visual analogue pain scale (VAS) score. The medial clear space (MCS), tibiofibular clear space (TFCS), distal fibular tip to lateral process of talus (DFTL), the anterior and posterior tibiofibular syndesmosis distance, and the lateral malleolus twist angle were measured by X-ray films and CT of bilateral ankle joints. RESULTS: The tourniquet application time was 55-90 minutes (mean, 72.5 minutes); the frequency of fluoroscopy was 5-13 times (mean, 8.9 times). All incisions healed by first intention and no infection, deep vein thrombosis occurred after operation. All patients were followed up 28-48 months (mean, 36 months). There was no significant difference in postoperative MCS, TFCS, DFTL, the anterior and posterior tibiofibular syndesmosis distance, and the lateral malleolus twist angle between bilateral ankle joints ( P>0.05). At last follow-up, no ankle instability occurred and the degenerative changes of ankle joints (Kellgren-Lawrence grading Ⅱ) occurred in 5 cases. The average AOFAS score of the ankle joint was 90.84 (range, 85-95); mean VAS score was 1.23 (range, 0-5). The average dorsiflexion and plantar flexion of ankle joints was 20.24° (range, 15-25°) and 42.56° (range, 30-50°), respectively. CONCLUSION: Anatomical approach osteoligaments repair technique in treatment of pronation ankle fractures can expose the talocrural joint and lower tibiofibular syndesmosis clearly, repair the osteoligaments injury directly, and assist the syndesmosis and talocrural joint reduction, and decline the incidence of ankle degeneration.

Repair of syndesmosis injury in ankle fractures: Current state of the art.

Conventional treatment of syndesmosis injuries in rotationally unstable ankle fractures is associated with an unacceptably high rate of malreduction, and this has led to a paradigm shift in the approach to a newer concept of anatomical repair.In the anatomical approach, the principle is to 'directly fix what is broken and repair what is torn'. The approach is effective in reducing the rate of syndesmosis malreduction, increasing the biomechanical strength of syndesmosis fixation and avoiding the need for trans-syndesmotic fixation and its secondary removal.The objective of this review article is to compare the conventional treatment of these injuries (accepted usage, general consent, traditional, generally accepted) with a newer anatomical approach to be considered as a shift in thinking. Cite this article: EFORT Open Rev 2018;3:24-29. DOI: 10.1302/2058-5241.3.170017.

Study on the clinical application value of V-shaped anatomical approach in laparoscopic complex cholecystectomy / 国际外科学杂志

Objective:To investigate the "V" -shaped anatomical approach in the prevention of bile duct injury during laparoscopic complex cholecystectomy and its clinical application value.Methods:The patients with complex gallbladder from June 2020 to June 2021 in the First Affiliated Hospital of Baotou Medical College, Inner Mongolia University of Science and Technology were selected as the research objects, and they were randomly divided into observation group and control group, with 60 cases in each group. All patients underwent laparoscopic cholecystectomy. The observation group underwent laparoscopic cholecystectomy through the triangle "V" shape of the gallbladder, and the control group did not use the "V" shape anatomy. The operation status, complications and postoperative recovery of the two groups of patients were compared.The measurement data of normal distribution were expressed by ( Mean± SD), and t test was used for comparison between groups, and chi-square test was used for comparison between groups of count data. Results:The conversion rate to laparotomy, intraoperative bleeding and operation time of observation group were 3.33%, (97.31±13.27) mL, (65.27±13.82) min, which were significantly lower than those in the control group[8.33%, (111.27±25.18) mL, (81.35±12.12) min], the differences between the two groups were statistically significant( P<0.05). The incidence of biliary injury, total incidence of complications of the observation group were 0, 8.33%, which were significantly lower than those in the control group(6.67%, 28.33%), the differences between the two groups were statistically significant( P<0.05). The postoperative exhaust time, drainage tube retention time, hospitalization cost and hospitalization time of the observation group were (9.89±3.58) h, (32.58±5.17) h, (3 142.92±137.93) yuan, (4.73±1.42) d, and significantly lower than those in the control group [(11.65±2.45) h, (46.18±6.49) h, (3 424.29±156.34) yuan, (5.38±1.25) d], the differences between the two groups were statistically significant ( P<0.05). Conclusions:For laparoscopic complex cholecystectomy, the use of the triangular "V" -shaped gallbladder anatomical approach is more conducive to the operation, can reduce the patient's operation time and intraoperative blood loss, reduce the rate of intraoperative conversion to laparotomy, and reduce biliary tract injury and bile leakage. Such as the incidence of complications, prompting patients to recover as soon as possible, it is worthy of clinical application and promotion.

Anatomical Ablation Strategy for Noninducible Fascicular Tachycardia.

The presence of structural heart disease does not exclude fascicular ventricular tachycardia (VT), especially if the VT is verapamil sensitive. An empirical anatomic approach is effective when fascicular VT is noninducible or if diastolic Purkinje potential (P1) cannot be recorded during VT mapping. Pace mapping at the successful ablation site is usually not effective because selective pacing of P1 is difficult and there is an antidromic activation of the proximal P1 potential.