Surgical Catheter Ablation of Ventricular Tachycardia Using Left Thoracotomy in a Patient with Hindered Access to the Left Ventricle (original) (raw)
Related papers
Circulation. Arrhythmia and electrophysiology, 2015
-In patients with mechanical aortic and mitral valves and left ventricular tachycardia (VT) catheter ablation may be prevented by limited access to the left ventricle. -In our series of six patients, two patients underwent direct surgical ablation and four underwent epicardial catheter ablation via a pericardial window. All patients had abnormal low voltage areas with fractionated or delayed isolated potentials on the apical epicardium. Most of the VTs were targeted by pace mapping. Sites with a good pace match or abnormal electrograms were ablated using an irrigated RF ablation catheter. A microscopic pathological evaluation of the resected tissue from two of the open-heart ablation patients revealed dense fibrosis on the epicardium as compared to the endocardium, supporting the feasibility of an epicardial ablation for the VT. -Epicardial catheter ablation of VT is a potentially useful therapy in patients who have mechanical aortic and mitral valves.
Epicardial catheter ablation of ventricular tachycardia
2008
T he feasibility of catheter ablation of ventricular tachycardia (VT) associated with structural heart disease has improved dramatically with the use of substrate identification using the electroanatomical mapping systems and cardiac MRI. Sustained VT after valve surgery has been reported either early after surgery or years later, and a reentrant mechanism in a region of scar is the most common mechanism. 1-3 However, in patients with prior mechanical mitral and aortic valves, the access to the left ventricle (LV) is limited, preventing an endocardial approach to ablation via a retrograde aortic or atrial transseptal approach. Here, to the best of our knowledge, we report the largest series of ablation for VT in these patients, demonstrate approaches including epicardial catheter ablation via a surgical pericardial window, surgical epicardial cryoablation, and surgical approach to endocardial catheter mapping, and provide the details of the arrhythmia substrate. Methods Patients with drug refractory VTs with aortic and mitral mechanical valve prostheses were included in the study. Ethical approval was obtained from the local institutional review committee. All patients gave their informed consent when retrospective data collection started. Echocardiography was performed, and the LV function was evaluated before the catheter ablation. All patients were anticoagulated with warfarin for the mechanical valves, and the warfarin was discontinued and bridged with a heparin infusion before the ablation or open-heart surgery. Heparin was discontinued 4 hours before the procedure. Multielectrode catheters were inserted and placed at the His recording site, coronary sinus and right ventricular apex. Programmed stimulation was performed to identify the target VT. Bundle branch re-entry or VT originating from the right ventricle was ruled out. If the VT was from the LV, a surgical pericardial window was used as an access to the epicardium with anticipation of pericardial adhesions. A 3-dimensional electroanatomical mapping system (Carto system, Biosense Webster, or EnSite NavX, St. Jude Medical) was used to identify the substrate and map the VT if allowed. Sites with abnormal potentials, such as fractionated signals,
Heart Rhythm, 2011
BACKGROUND Most idiopathic right ventricular (RV) ventricular tachycardias (VTs) originate from the outflow tract. Data on VT from the lower body of the RV are limited. OBJECTIVE The purpose of this study was to describe a large experience with idiopathic VT detailing the prevalence and characteristics of VT arising from the body of the RV. METHODS The distribution of mapping confirmed VTs within the RV body, ECG characteristics, and results of radiofrequency (RF) ablation were analyzed. RESULTS Among 278 patients who underwent ablation for idiopathic VT or ventricular premature depolarizations (VPDs) arising from the RV, 29 (10%) had VT/VPDs from the lower RV body. Fourteen (48%) patients had VT/VPDs within 2 cm of the tricuspid valve annulus (TVA), 8 (28%) from the basal and 7 (24%) from the apical RV segments. Among the VT/VPDs from the TVA, 8 (57%) originated from the free wall and 6 (43%) from the septum. All but one RV basal or apical VT/VPDs originated from the free wall. All VT/VPDs had a left bundle branch block pattern. VT/VPDs from the free wall had longer QRS duration (P ϭ .0032) and deeper S wave in lead V 2 (P ϭ .042) and V 3 (P ϭ .046) than those from the septum. Apical VT/VPDs more often had precordial R wave transition ՆV 6 (P ϭ .0001) and smaller R wave in lead II (P ϭ .024) and S wave in lead aVR (P ϭ .001) compared to VT/VPDs from basal RV or TVA. RF catheter ablation eliminated VT/VPDs in 96% of patients. No complications were observed. During median follow-up of 27 months (range 4-131 months), 81% of patients had elimination of all symptomatic VT/VPDs. Nineteen percent had rare symptoms (8% without medications, 11% on beta-blocker). CONCLUSION Idiopathic VT/VPDs from the body of RV comprise an important subgroup of idiopathic RV VTs. Although most VTs originate from the RV free wall and nearly 50% from the TVA region, septal and more apical VTs are common. ECG characteristics distinguish free-wall versus septal and more apical origin of VTs, and RF catheter ablation provides good long-term arrhythmia control. KEYWORDS Catheter ablation; Idiopathic ventricular arrhythmia; Right ventricle; Ventricular premature depolarization; Ventricular tachycardia ABBREVIATIONS ARVC/D ϭ arrhythmogenic right ventricular cardiomyopathy/dysplasia; ECG ϭ electrocardiographic; EP ϭ electrophysiology; ICD ϭ implantable cardioverter-defibrillator; ICE ϭ intracardiac echocardiography; LBBB ϭ left bundle branch block; RBBB ϭ right bundle branch block; RF ϭ radiofrequency; RV ϭ right ventricle; RVOT ϭ right ventricular outflow tract; TVA ϭ tricuspid valve annulus; VPD ϭ ventricular premature depolarization; VT ϭ ventricular tachycardia
Long-term results of catheter ablation of idiopathic right ventricular tachycardia
Circulation, 1990
Ten consecutive patients with recurrent episodes of symptomatic, idiopathic, sustained monomorphic ventricular tachycardia (VT) originating in the right ventricle underwent an attempt at catheter ablation of the ventricular tachycardia. There were seven women and three men, with a mean age of 39±14 years (±SD). None of the patients had any evidence of structural heart disease. The VT had a left bundle branch block configuration and an inferior axis in each patient, and the mean cycle length was 313±75 msec. Based on the methods of induction of the VT and the response of the VT to verapamil, the VT mechanism was presumed to be reentry in six patients, triggered activity in three patients, and catecholamine-sensitive automaticity in one patient. Sites for ablation were guided by pace mapping, and an
Pacing and Clinical Electrophysiology, 1995
KOTTKAMP, H., ET AL.: Idiopathic Left Ventricular Tachycardia: New Insights into Electrophysiological Characteristics and Radiofrequency Catheter Ablation. Objectives: This study was performed to investigate the electrophysiological characteristics of idiopathic left ventricular tachycardia and to determine the feasibility of radiofrequency catheter ablation for nonpharmacological cure. Background: The underlying electrophysiological mechanism of idiopathic left ventricular tachycardia with right bundle branch block morphology and left-axis deviation is presently not known. Additionally, only limited data describing the results of radiofrequency catheter ablation for treatment of idiopathic left ventricular tachycardia so far exist. Methods: Electrophysiological studies and radiofrequency catheter ablation were performed in 5 patients (3 male and 2 female, mean age 31 k 10 years) with idiopathic left ventricular tachycardia (cycle length 376 k 72 msec). The patients had a history of recurrent palpitations of 4 k 1 years and had been treated unsuccessfully with 2 k 1 antiarrhythmic drugs. Sustained ventricular tachycardia with right bundle branch block morphology and leftor right-axis deviation was documented in all patients. Results: Inducibility with critically timed ventricular extrastimuli, inverse relationships of the coupling interval of the initiating extrastimulus and the interval to the first beat of the tachycardia, continuous diastolic or mid-diastolic electrical activity during ventricular tachycardia, and fragmented late potentials during sinus rhythm suggested reentrant activation as the underlying mechanism in three patients. On the other hand, induction dependent on isoproterenol infusion and rapid ventricular pacing and exercise inducibility indicated different electrophysiological characteristics in the remaining two patients. During electrophysiological study, intravenous verapamil terminated ventricular tachycardia in all patients, whereas ventricular tachycardia did not respond to intravenous adenosine, autonomic maneuvers, or intravenous /3-blocking agent esmolol. Catheter mapping revealed earliest endocardia1 activation during ventricular tachycardia in different areas of the left ventricular septum being distributed from the base to the midapical portion of the septum in all patients. In 4 of 5 patients, radiofrequency catheter ablation (median number of pulses 4, range 2-91 resulted in complete abolition of idiopathic left ventricular tachycardia during a follow-up of 4-43 months (median 10) without antiarrhythmic drugs. Successful target sites for catheter ablation included continuous diastolic or mid-diastolic electrical activity during ventricular tachycardia and late potentials during sinus rhythm (2 patients), polyphasic fragmented presystolic potentials during ventricular tachycardia (1 patient), and pace mapping with identical QRS morphology compared to the ventricular tachycardia and "earliest" detectable activity during tachycardia f1 patient). No procedure related complications occurred. Conclusions: Two different patterns of electrophysiological properties of idiopathic left ventricular tachycardia were observed, indicating that this arrhythmia entity does not represent a homogeneous group. The "origin" of the tachycardias as identified by successful radiofrequency catheter ablation was located in different areas of the left ventricular septum and was distributed from the base to the mid-apical region. Radiofrequency catheter ablation was an effective and safe treatment modality in most of these patients. Distinct target site characteristics for successful catheter ablation including polyphasic diastolic activity during tachycardia and fragmented late potentials during sinus rhythm could be identified. 18:1285-1297 idiopathic left ventricular tachycardia, radiofrequency catheter ablation, reentrant activation, microreentry Partially supported by a grant from the Deutsche Forschungsgemeinschraft (Br 759/1-2).