Late Potentials Abolition as an Additional Technique for Reduction of Arrhythmia Recurrence in Scar Related Ventricular Tachycardia Ablation (original) (raw)
Related papers
Catheter Ablation for Scar-related Ventricular Tachycardias
Current Problems in Cardiology, 2009
Patients with scar-related ventricular tachycardia (VT) are subject to frequent arrhythmia recurrences; antiarrhythmic drug therapy has been disappointing due to poor efficacy and side effects. Patients receiving multiple implantable cardioverter-defibrillator shocks because of VT have impaired quality of life. The role of catheter ablation in the treatment of ventricular arrhythmias has been increasing in the last 2 decades. As more knowledge is gained about the mechanisms of VT, the potential for doing ablation has increased. Now, multiple VTs and unstable VTs can be targeted by ablation strategies. Also, electroanatomic mapping systems have made substrate mapping feasible. The purpose of this article is to review the selection and preparation of patients who require catheter ablation for scar-related VT, the different mapping techniques, and the ablation strategies employed. An overview of the pathophysiology of scarrelated VT and the variety of heart diseases that are related to scar-related VT is provided. (Curr Probl Cardiol 2009;34: 225-270.)
Ablation of Ventricular Tachycardia in Patients with Structural Heart Disease
Pace-pacing and Clinical Electrophysiology, 2008
Catheter ablation is an important therapeutic option for controlling recurrent ventricular arrhythmias in patients with heart disease. Although implantable defibrillators are generally first line therapy in this patient population, a substantial number of patients require additional therapy with either antiarrhythmic drugs, ablation, or both. Studies of mapping and ablation have produced further insights into pathophysiologic mechanisms of these arrhythmias, which are now well characterized. The majority is due to reentry through regions of ventricular scar. Methods for identifying scar based on electrogram characteristics now allow arrhythmogenic areas to be targeted for ablation during stable sinus rhythm, such that ablation is often an option even when multiple and unstable ventricular tachycardia are present. Ablation failure can also be due to anatomical obstacles; however, methods for accessing the pericardial space for mapping and ablation and technological progress can be expected to further improve its efficacy.
Substrate based ablation of ventricular tachycardia through an epicardial approach
Indian pacing and electrophysiology journal, 2009
Ventricular tachycardia (VT) occurring late after myocardial infarction is often due to reentry circuit in the peri-infarct zone. The circuit is usually located in the sub-endocardium, though subepicardial substrates are known. Activation mapping during VT to identify target regions for ablation can be difficult if VT is non inducible or poorly tolerated. In the latter, a substrate based approach of mapping during sinus rhythm in conjunction with pace mapping helps to define the reentry circuit and select target sites for ablation in majority of patients with hemodynamically unstable VT. Percutaneous epicardial catheter ablation has been attempted as an approach where ablation by a conventional endocardial access has been unsuccessful. We report a case of post myocardial infarction scar VT which could be successfully ablated with a substrate based approach from the epicardial aspect.
Revista Portuguesa de Cardiologia, 2021
Introduction: Recurrent ventricular tachycardia (VT) episodes have a negative impact on the clinical outcome of implantable cardioverter-defibrillator (ICD) patients. Modification of the arrhythmogenic substrate has been used as a promising approach for treating recurrent VTs. However, there are limited data on long-term follow-up. Aim: To analyze long-term results of VT substrate-based ablation using high-density mapping in patients with severe left ventricular (LV) dysfunction and recurrent appropriate ICD therapy. Methods: We analyzed 20 patients (15 men, 55% with non-ischemic cardiomyopathy, age 58±15 years, LV ejection fraction 32±5%) and repeated appropriate shocks or arrhythmic storm (>2 shocks/24 h) despite antiarrhythmic drug therapy and optimal heart failure medication. All patients underwent ventricular programmed stimulation (600 ms/S3) to document VT. A sinus rhythm (SR) voltage map was created with a three-dimensional electroanatomic mapping system (CARTO, Biosense Webster, CA) using a PentaRay ® high-density mapping catheter (Biosense Webster, CA) to delineate areas of scarred myocardium (ventricular bipolar voltage ≤0.5 mV-dense scar; 0.5-1.5 mV-border zone; ≥1.5 mV-healthy tissue) and to provide high-resolution electrophysiological mapping. Substrate modification included elimination of local abnormal ventricular activities (LAVAs) during SR (fractionated, split, low-amplitude/long-lasting, late potentials, pre-systolic), and linear ablation to obtain scar homogenization and dechanneling. Pace-mapping techniques were used when capture was possible. The LV approach was retrograde in nine cases, transseptal in five and epi-endocardial in four. In two patients ablation was performed inside the right ventricle. Results: LAVAs and scar areas were modified in all patients. Mean procedure duration was 149 min (105-220 min), with radiofrequency ranging from 18 to 70 min (mean 33 min
Ventricular Tachycardia Ablation Guided by Functional Substrate Mapping: Practices and Outcomes
Journal of Cardiovascular Development and Disease
Catheter ablation of ventricular tachycardia has demonstrated its important role in the treatment of ventricular tachycardia in patients with structural cardiomyopathy. Conventional mapping techniques used to define the critical isthmus, such as activation mapping and entrainment, are limited by the non-inducibility of the clinical tachycardia or its poor hemodynamic tolerance. To overcome these limitations, a voltage mapping strategy based on bipolar electrograms peak to peak analysis was developed, but a low specificity (30%) for VT isthmus has been described with this approach. Functional mapping strategy relies on the analysis of the characteristics of the electrograms but also their propagation patterns and their response to extra-stimulus or alternative pacing wavefronts to define the targets for ablation. With this review, we aim to summarize the different functional mapping strategies described to date to identify ventricular arrhythmic substrate in patients with structural ...
Circulation, 2012
Background-Catheter ablation of ventricular tachycardia (VT) is effective and particularly useful in patients with frequent defibrillator interventions. Various substrate modification techniques have been described for unmappable or hemodynamically intolerable VT. Noninducibility is the most frequently used end point but is associated with significant limitations, so the optimal end point remains unclear. We hypothesized that elimination of local abnormal ventricular activities (LAVAs) during sinus rhythm or ventricular pacing would be a useful and effective end point for substrate-based VT ablation. As an adjunct to this strategy, we used a new high-density mapping catheter and frequently used epicardial mapping. Methods and Results-Seventy patients (age, 67Ϯ11 years; 7 female) with VT and structurally abnormal ventricle(s) were prospectively enrolled. Conventional mapping was performed in sinus rhythm in all, and a high-density Pentaray mapping catheter was used in the endocardium (nϭ35) and epicardially. LAVAs were recorded in 67 patients (95.7%; 95% confidence interval, 89.2-98.9). Catheter ablation was performed targeting LAVA with an irrigated-tip catheter placed endocardially via a transseptal or retrograde aortic approach or epicardially via the subxiphoid approach. LAVAs were successfully abolished or dissociated in 47 of 67 patients (70.1%; 95% confidence interval, 58.7-80.1). In multivariate analysis, LAVA elimination was independently associated with a reduction in recurrent VT or death (hazard ratio, 0.49; 95% confidence interval, 0.26-0.95; Pϭ0.035) during long-term follow-up (median, 22 months). Conclusions-LAVAs can be identified in most patients with scar-related VT. Elimination of LAVAs is feasible and safe and is associated with superior survival free from recurrent VT.
Journal of cardiovascular electrophysiology, 2016
Substrate-based ablation for scar-related ventricular tachycardia (VT) has gained prominence: however, there is limited data comparing it to ablation guided predominantly by activation and entrainment mapping of inducible and hemodynamically tolerated VTs. We compared the acute procedural efficacy and outcomes of predominantly substrate-based ablation versus ablation guided predominantly by activation and entrainment mapping. Database searches through April 2016 identified 6 eligible studies (enrolling 403 patients, with 1 randomized study) comparing the two strategies. The relative risk of VT recurrence at follow-up was assessed as the primary outcome using a random-effects meta-analysis. Secondary endpoints of acute success (based on non-inducibility of VT), procedural complications, and mortality were assessed using weighted mean difference with the random effects model. At a median follow-up of 18 months, the relative risk (RR) of VT recurrence was not significantly different wi...
Europace, 2006
Aims For ablation of ventricular tachycardia (VT) in patients after myocardial infarction, a threedimensional mapping system is often used. We report on our overall success rate of VT ablation using CARTO in 47 patients, with a subgroup analysis comparing VT mapping with the results of mapping that had to be performed during sinus rhythm or pacing (substrate mapping). Methods and results A CARTO map was performed and VT ablation attempted using two strategies: Patients in the VT-mapping group had incessant VT (four patients) or inducible stable VT (18 patients) such that the circuit of the clinical VT could be reconstructed using CARTO. During VT, the critical area of slow conduction was identified using diastolic potentials and conventional concealed entrainment pacing. In contrast, patients in the substrate-mapping group had initially inducible VT. However, a complete VT map was not possible because of catheter-induced mechanical block (six patients) or because haemodynamics deteriorated during the ongoing VT (19 patients). Therefore, pathological myocardium was identified by fragmented, late-and/or low-amplitude (,1.5 mV) bipolar potentials during sinus rhythm or pacing, and the ablation site was primarily determined by pace mapping inside or at the border of this pathological myocardium. Acute ablation success in all patients with regard to noninducibility of the clinical VT or any slower VT was 79% after a single ablation procedure, but increased to 95% after a mean of 1.2 ablation procedures. However, chronic success was 75%, when it was defined as freedom from any ventricular tachyarrhythmia (VT or VF) during a follow-up of 25 + 13 months. In the subgroup analysis, patients in the VT-mapping group were not significantly different from patients in the substrate-mapping group with regard to age (65+7 vs. 65+9 years), ejection fraction (30+7 vs. 30 + 8%), VT cycle length (448 + 81 vs. 429 + 82 ms), number of radiofrequency applications (17+9 vs. 14+6 applications), use of an irrigated tip catheter (23 vs. 32%), and ablation results. Conclusion When using a CARTO-guided approach for VT ablation in patients with coronary artery disease, the freedom from any ventricular arrhythmia is high (75%), but leaves the patient at a 23% risk of developing fast VT/VF during follow-up. Mapping during sinus rhythm or pacing is as successful as mapping during VT.