Substrate-based catheter ablation in previously undiagnosed arrhythmogenic right ventricular dysplasia by means of an electroanatomic mapping system using cutaneous patches (original) (raw)
Journal of the American College of Cardiology, 2007
This study sought to evaluate the outcomes of radiofrequency catheter ablation (RFA) of ventricular tachycardia (VT) in arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) patients. Particular focus was placed on defining the single-procedure efficacy over long-term follow-up. Background ARVD/C is an inherited cardiomyopathy characterized by VT and right ventricular dysfunction. Prior single-center studies have reported conflicting results concerning the efficacy of RFA of VT in ARVD/C patients. Methods The study population comprised 24 patients (age 36 Ϯ 9 years, 11 male), enrolled in the Johns Hopkins ARVD registry, who underwent 1 or more RFA procedures for treatment of VT. Patients were followed up for 32 Ϯ 36 months (range 1 day to 12 years). Recurrence was defined as the documentation of VT subsequent to the procedure. Results A total of 48 RFA procedures were performed using 3-dimensional electroanatomical (n ϭ 10) or conventional (n ϭ 38) mapping. Of these procedures, 22 (46%), 15 (31%), and 11 (23%) resulted in elimination of all inducible VTs, clinical VT but not all, and none of the inducible VTs, respectively. Forty (85%) procedures were followed by recurrence. The cumulative VT recurrence-free survival was 75%, 50%, and 25% after 1.5, 5, and 14 months, respectively. The cumulative VT recurrence-free survival did not differ by procedural success, mapping technique, or repetition of procedures. There was 1 procedure-related death. Conclusions Our study shows a high rate of recurrence in ARVD/C patients undergoing RFA of VT. This likely reflects the fact that ARVD/C is a diffuse cardiomyopathy with progressively evolving electrical substrate. Further studies are needed to define the precise role of RFA of VT in ARVD/C.
Ablation of Ventricular Arrhythmias in Arrhythmogenic Right Ventricular Dysplasia
Journal of Cardiovascular Electrophysiology, 2010
is a genetically determined myocardial disease characterized by fibrofatty replacement of the right ventricular wall. Ventricular tachyarrhythmias can be seen in the early stages of the disease, which is one of the most important causes of sudden death in young healthy individuals. Radiofrequency (RF) catheter ablation is an option for the treatment of medically refractory ventricular arrhythmias and it has shown to successfully abolish recurrent ventricular tachycardias (VT) as well as reduce the frequency in defibrillator therapies. However, variable acute and long-term success rates have been reported. The current mapping and ablation techniques include activation and entrainment mapping during tolerated VT and substrate ablation using 3-dimensional electroanatomic mapping systems. This article aims at providing a comprehensive review of RF catheter ablation of ventricular arrhythmias in the context of ARVD. (J Cardiovasc Electrophysiol, Vol. 21, pp. 473-486, April 2010) arrhythmogenic right ventricular dysplasia, right ventricular cardiomyopathy, ventricular tachycardia, catheter ablation
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
Heart Rhythm, 2013
BACKGROUND The right ventricular outflow tract (RVOT) is the most common site of origin of ventricular arrhythmias (VAs) in patients with idiopathic VAs. A left bundle branch block, inferior axis morphology arrhythmia is the hallmark of RVOT arrhythmias. VAs from other sites of origin can mimic RVOT VAs, and ablation in the RVOT typically fails for these VAs. OBJECTIVE To analyze reasons for failed ablations of RVOTlike VAs. METHODS Among a consecutive series of 197 patients with an RVOT-like electrocardiographic (ECG) morphology who were referred for ablation, 38 patients (13 men; age 46 Ϯ 14 years; left ventricular ejection fraction 47% Ϯ 14%) in whom a prior procedure failed within the RVOT underwent a second ablation procedure. ECG characteristics of the VA were compared to a consecutive series of 50 patients with RVOT VAs. RESULTS The origin of the VA was identified in 95% of the patients. In 28 of 38 (74%) patients, the arrhythmia origin was not in the RVOT. The VA originated from intramural sites (n ¼ 8, 21%), the pulmonary arteries (n ¼ 7, 18%), the aortic cusps (n ¼ 6, 16%), and the epicardium (n ¼ 5, 13%). The origin was within the RVOT in 10 (26%) patients. In 2 (5%) patients, the origin could not be identified despite biventricular, aortic, and epicardial mapping. The VA was eliminated in 34 of 38 (89%) patients with repeat procedures. The ECG features of patients with failed RVOT-like arrhythmias were different from the characteristics of RVOT arrhythmias. CONCLUSIONS In patients in whom ablation of a VA with an RVOTlike appearance fails, mapping of the pulmonary artery, the aortic cusps, the epicardium, the left ventricular outflow tract, and the aortic cusps will help identify the correct site of origin. The 12-lead ECG is helpful in differentiating these VAs from RVOT VAs.
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).