Endo-Epicardial Homogenization of the Scar Versus Limited Substrate Ablation for the Treatment of Electrical Storms in Patients With Ischemic Cardiomyopathy (original) (raw)
Related papers
Trials, 2015
Background: The role of epicardial substrate ablation of ventricular tachycardia (VT) as a first-line approach in patients with ischemic heart disease is not clearly defined. Epicardial ablation as a first-line option is standard for patients with nonischemic dilated cardiomyopathy and arrhythmogenic right ventricular cardiomyopathy. Several nonrandomized studies, including studies on patients with ischemic heart disease, have shown that epicardial VT ablation improves outcome but this approach was often used after a failed endocardial approach. The aim of this study is to determine whether a combined endo-epicardial scar homogenization as a first-line approach will improve the outcome of VT ablation. Methods/Design: The EPILOGUE study is a multicenter, two-armed, nonblinded, randomized controlled trial. Patients with ischemic heart disease who are referred for VT ablation will be randomly assigned to combined endo-epicardial scar homogenization or endocardial scar homogenization only (control group). The primary outcome is recurrence of sustained VT during a 2-year follow-up. Secondary outcomes include procedural success and safety. Discussion: This study is the first randomized trial that evaluates the role of a combined endo-epicardial scar homogenization versus endocardial scar homogenization for the treatment of ischemic scar-related VT.
Circulation, 2000
Background-Conventional activation mapping is difficult without inducible, stable ventricular tachycardia (VT). Methods and Results-We evaluated 16 patients with drug refractory, unimorphic, unmappable VT. Nine patients had ischemic and 7 had nonischemic cardiomyopathy. All patients had implantable defibrillators and had experienced 6 to 55 VT episodes during the month before treatment. Patients underwent bipolar catheter mapping during baseline rhythm. The amount of endocardium with an abnormal electrogram amplitude was estimated using fluoroscopy in 3 patients and a magnetic mapping system (CARTO) in 13 patients. For the magnetic mapping, normal endocardium was defined by an amplitude Ͼ1.5 mV; this measurement was based on sinus rhythm maps in 6 patients who did not have structural heart disease. Radiofrequency point lesions extended linearly from the "dense scar," which had a voltage amplitude Ͻ0.5 mV, to anatomic boundaries or normal endocardium. To limit radiofrequency applications, 12-lead ECG during VT and pacemapping guided placement of linear lesions. No new antiarrhythmic drug therapy was added. The amount of endocardium demonstrating an abnormal electrogram amplitude ranged from 25 to 127 cm 2. A total of 8 to 87 radiofrequency lesions (mean, 55) produced a median of 4 linear lesions that had an average length of 3.9 cm (range, 1.4 to 9.4 cm). Twelve patients (75%) have been free of VT during 3 to 36 months of follow-up (median, 8 months); 4 patients had VT episodes at 1, 3, 9, and 13 months, respectively. Only one of these patient had frequent VT. Conclusions-Radiofrequency linear endocardial lesions extending from the dense scar to the normal myocardium or anatomic boundary seem effective in controlling unmappable VT.
2012
Background-Ventricular tachycardia (VT) ablation in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) has a low success rate. A more extensive epicardial (Epi) arrhythmogenic substrate could explain the low efficacy. We report the results of combined endocardial (Endo) and Epi VT ablation and conducting channel (CC) elimination. Methods and Results-Eleven consecutive patients with ARVD/C were included in the study. A high-density 3D Endo (321Ϯ93 sites mapped) and Epi (302Ϯ158 sites mapped) electroanatomical voltage map was obtained during sinus rhythm to define scar areas (Ͻ1.5 mV) and CCs inside the scars, between scars, or between the tricuspid annulus and a scar. The end point of the ablation procedure was the elimination of all identified CCs (scar dechanneling) and the abolition of all inducible VTs. The mean procedure and fluoroscopy time were 177Ϯ63 minutes and 20Ϯ8 minutes, respectively. Epi scar area was larger in all cases (26Ϯ18 versus 94Ϯ45 cm 2 , PϽ0.01). The combined Endo and Epi VT ablation eliminated all clinical and induced VTs, and the addition of scar dechanneling resulted in noninducibility in all cases. Seven patients continued on sotalol. During a median follow-up of 11 months (6 -24 months), only 1 (9%) patient had a VT recurrence. There was a single major bleeding event that did not preclude a successful procedure.
57 REVIEW Recent Data on Epicardial Ablation of Ventricular Tachycardia in Nonischemic Heart Disease
Epicardial ablation has been adopted during the last years, mainly as a supplementary technique after a failed endocardial ablation procedure, both in patients with ischemic and nonischemic ventricular tachycardias (VTs). Sosa and colleagues were the first who described the percutaneous subxiphoidal puncture to approach the epicardial space in 1996. 1 Using the 3D electroanatomic mapping systems, the endocardial and epicardial substrate mapping have become feasible during the same procedure. Because of its complexity and its potential risks this process is performed only in high experienced centers by skilled operators with a large number of VT ablation procedures. Endocardial ablation in patients with left ventricular nonischemic cardiomyopathy (NICM) has shown worst outcome compared with ablation in ischemic cardiomyopathy. The main reason seems to be the progressive nature of the disease and the presence of epicardial and intramural slow conduction areas forming reentry circuits....
Epicardial ablation of ventricular tachycardia via the aortic cusps in ischemic cardiomyopathy
Revista Española de Cardiología (English Edition), 2020
We report the case of a 44-year-old woman who was referred for ablation of recurrent ventricular tachycardia (VT) in the setting of dilated cardiomyopathy secondary to myocarditis. The ECG displayed a right bundle branch block morphology and superior axis in the frontal plane, associated with a pseudo delta wave in the precordial leads that suggested an epicardial origin. Cardiac magnetic resonance performed prior to the procedure showed late gadolinium enhancement at the lateral wall of the left ventricle (LV) and excluded subendocardial fibrosis in either ventricle. This information was crucial and influenced the ablation strategy, identifying the target area as exclusively epicardial, thus avoiding unnecessary mapping of the endocardial surface of the LV. Epicardial activation mapping and ablation during VT were performed using the Orion ® highdensity catheter (Boston Scientific Inc.) and the Rhythmia ® mapping system (Boston Scientific Inc.). Applications near the exit site immediately terminated the tachycardia, which was no longer inducible. One year after the procedure the patient was still in sinus rhythm with no episodes of VT or non-sustained VT recorded by continuous monitoring via an implanted cardioverter-defibrillator.
Journal of the American College of Cardiology, 2015
Catheter ablation reduces ventricular tachycardia (VT) recurrence and implantable cardioverter defibrillator shocks in patients with VT and ischemic cardiomyopathy. The most effective catheter ablation technique is unknown. This study determined rates of VT recurrence in patients undergoing ablation limited to clinical VT along with mappable VTs ("clinical ablation") versus substrate-based ablation. Subjects with ischemic cardiomyopathy and hemodynamically tolerated VT were randomized to clinical ablation (n = 60) versus substrate-based ablation that targeted all…