Core Isolation of Critical Arrhythmia Elements for Treatment of Multiple Scar-Based Ventricular Tachycardias
BACKGROUND—Radiofrequency ablation of multiple or unmappable ventricular tachycardias (VTs) remains a challenge with unclear end points. We present our experience with a new strategy isolating core elements of VT circuits. METHODS AND RESULTS—Patients with structural heart disease presenting for VT...
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| Veröffentlicht in: | Circulation. Arrhythmia and electrophysiology 2015-04, Vol.8 (2), p.353-361 |
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| creator | Tzou, Wendy S Frankel, David S Hegeman, Timothy Supple, Gregory E Garcia, Fermin C Santangeli, Pasquale Katz, David F Sauer, William H Marchlinski, Francis E |
| description | BACKGROUND—Radiofrequency ablation of multiple or unmappable ventricular tachycardias (VTs) remains a challenge with unclear end points. We present our experience with a new strategy isolating core elements of VT circuits.
METHODS AND RESULTS—Patients with structural heart disease presenting for VT radiofrequency ablation at 2 centers were included. Strategy involved entrainment/activation mapping if VT was hemodynamically stable, and voltage mapping with electrogram analysis and pacemapping. Core isolation (CI) was performed incorporating putative isthmus and early exit site(s) based on standard criteria. If VT was noninducible, the dense scar ( |
| doi_str_mv | 10.1161/CIRCEP.114.002310 |
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METHODS AND RESULTS—Patients with structural heart disease presenting for VT radiofrequency ablation at 2 centers were included. Strategy involved entrainment/activation mapping if VT was hemodynamically stable, and voltage mapping with electrogram analysis and pacemapping. Core isolation (CI) was performed incorporating putative isthmus and early exit site(s) based on standard criteria. If VT was noninducible, the dense scar (<0.5 mV) region was isolated. Successful CI was defined by exit block (20 mA at 2 ms) within the isolated region. VT inducibility was also assessed. Forty-four patients were included (mean age, 63; 95% male; 73% ischemic cardiomyopathy; mean left ventricular ejection fraction, 31%; 68% with multiple unstable VTs [mean, 3+2]). CI area was 11+12 versus 55+40 cm total scar area. Additional substrate modification was performed in 27 (61%), and epicardial radiofrequency ablation was performed in 4 (9%) patients. CI was achieved in 37 (84%) and led to better VT-free survival (log rank P=0.013).
CONCLUSIONS—CI is a novel strategy with a discrete and measurable end point beyond VT inducibility to treat patients with multiple or unmappable VTs. The CI region can be selected based on standard characterization of suspected VT isthmus surrogates thus limiting ablation target size. Exit block within the isolated area is achievable in most and may further improve long-term success.</description><identifier>ISSN: 1941-3149</identifier><identifier>EISSN: 1941-3084</identifier><identifier>DOI: 10.1161/CIRCEP.114.002310</identifier><identifier>PMID: 25681389</identifier><language>eng</language><publisher>United States: American Heart Association, Inc</publisher><subject>Action Potentials ; Aged ; Catheter Ablation - adverse effects ; Cicatrix - diagnosis ; Cicatrix - etiology ; Cicatrix - physiopathology ; Cicatrix - surgery ; Colorado ; Electrophysiologic Techniques, Cardiac ; Feasibility Studies ; Female ; Heart Ventricles - physiopathology ; Heart Ventricles - surgery ; Humans ; Male ; Middle Aged ; Philadelphia ; Predictive Value of Tests ; Recurrence ; Risk Factors ; Stroke Volume ; Tachycardia, Ventricular - diagnosis ; Tachycardia, Ventricular - etiology ; Tachycardia, Ventricular - physiopathology ; Tachycardia, Ventricular - surgery ; Time Factors ; Treatment Outcome ; Ventricular Function, Left</subject><ispartof>Circulation. Arrhythmia and electrophysiology, 2015-04, Vol.8 (2), p.353-361</ispartof><rights>2015 American Heart Association, Inc.</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c4130-90ec8d6a3eb67c3d08fc2008b8b597b8a2f9d53b6c19bc1e98e09c6a9b72f933</citedby><cites>FETCH-LOGICAL-c4130-90ec8d6a3eb67c3d08fc2008b8b597b8a2f9d53b6c19bc1e98e09c6a9b72f933</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>314,776,780,3674,27901,27902</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/25681389$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Tzou, Wendy S</creatorcontrib><creatorcontrib>Frankel, David S</creatorcontrib><creatorcontrib>Hegeman, Timothy</creatorcontrib><creatorcontrib>Supple, Gregory E</creatorcontrib><creatorcontrib>Garcia, Fermin C</creatorcontrib><creatorcontrib>Santangeli, Pasquale</creatorcontrib><creatorcontrib>Katz, David F</creatorcontrib><creatorcontrib>Sauer, William H</creatorcontrib><creatorcontrib>Marchlinski, Francis E</creatorcontrib><title>Core Isolation of Critical Arrhythmia Elements for Treatment of Multiple Scar-Based Ventricular Tachycardias</title><title>Circulation. Arrhythmia and electrophysiology</title><addtitle>Circ Arrhythm Electrophysiol</addtitle><description>BACKGROUND—Radiofrequency ablation of multiple or unmappable ventricular tachycardias (VTs) remains a challenge with unclear end points. We present our experience with a new strategy isolating core elements of VT circuits.
METHODS AND RESULTS—Patients with structural heart disease presenting for VT radiofrequency ablation at 2 centers were included. Strategy involved entrainment/activation mapping if VT was hemodynamically stable, and voltage mapping with electrogram analysis and pacemapping. Core isolation (CI) was performed incorporating putative isthmus and early exit site(s) based on standard criteria. If VT was noninducible, the dense scar (<0.5 mV) region was isolated. Successful CI was defined by exit block (20 mA at 2 ms) within the isolated region. VT inducibility was also assessed. Forty-four patients were included (mean age, 63; 95% male; 73% ischemic cardiomyopathy; mean left ventricular ejection fraction, 31%; 68% with multiple unstable VTs [mean, 3+2]). CI area was 11+12 versus 55+40 cm total scar area. Additional substrate modification was performed in 27 (61%), and epicardial radiofrequency ablation was performed in 4 (9%) patients. CI was achieved in 37 (84%) and led to better VT-free survival (log rank P=0.013).
CONCLUSIONS—CI is a novel strategy with a discrete and measurable end point beyond VT inducibility to treat patients with multiple or unmappable VTs. The CI region can be selected based on standard characterization of suspected VT isthmus surrogates thus limiting ablation target size. Exit block within the isolated area is achievable in most and may further improve long-term success.</description><subject>Action Potentials</subject><subject>Aged</subject><subject>Catheter Ablation - adverse effects</subject><subject>Cicatrix - diagnosis</subject><subject>Cicatrix - etiology</subject><subject>Cicatrix - physiopathology</subject><subject>Cicatrix - surgery</subject><subject>Colorado</subject><subject>Electrophysiologic Techniques, Cardiac</subject><subject>Feasibility Studies</subject><subject>Female</subject><subject>Heart Ventricles - physiopathology</subject><subject>Heart Ventricles - surgery</subject><subject>Humans</subject><subject>Male</subject><subject>Middle Aged</subject><subject>Philadelphia</subject><subject>Predictive Value of Tests</subject><subject>Recurrence</subject><subject>Risk Factors</subject><subject>Stroke Volume</subject><subject>Tachycardia, Ventricular - diagnosis</subject><subject>Tachycardia, Ventricular - etiology</subject><subject>Tachycardia, Ventricular - physiopathology</subject><subject>Tachycardia, Ventricular - surgery</subject><subject>Time Factors</subject><subject>Treatment Outcome</subject><subject>Ventricular Function, Left</subject><issn>1941-3149</issn><issn>1941-3084</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2015</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp9kEFv1DAQhS1ERUvhB3BBPnJJ64kTxz6WaNuu1KoIVlwjx5koBme92I6q_fd4lZYjh9G80fvmHR4hn4BdAQi4brff2823rKsrxkoO7A25AFVBwZms3r5qqNQ5eR_jL8YESBDvyHlZCwlcqgviWh-QbqN3Olm_p36kbbDJGu3oTQjTMU2z1XTjcMZ9inT0ge4C6nQ6T_Tj4pI9OKQ_jA7FVx1xoD-zF6xZnM6wNtMxW4PV8QM5G7WL-PFlX5Ld7WbX3hcPT3fb9uahMBVwViiGRg5Cc-xFY_jA5GhKxmQv-1o1vdTlqIaa98KA6g2gksiUEVr1TXY4vyRf1thD8H8WjKmbbTTonN6jX2IHoqnzlE2VUVhRE3yMAcfuEOysw7ED1p067taOs666teP88_klfulnHP59vJaagXoFnr1LGOJvtzxj6CbULk3_Cf4LTkeJww</recordid><startdate>201504</startdate><enddate>201504</enddate><creator>Tzou, Wendy S</creator><creator>Frankel, David S</creator><creator>Hegeman, Timothy</creator><creator>Supple, Gregory E</creator><creator>Garcia, Fermin C</creator><creator>Santangeli, Pasquale</creator><creator>Katz, David F</creator><creator>Sauer, William H</creator><creator>Marchlinski, Francis E</creator><general>American Heart Association, Inc</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope></search><sort><creationdate>201504</creationdate><title>Core Isolation of Critical Arrhythmia Elements for Treatment of Multiple Scar-Based Ventricular Tachycardias</title><author>Tzou, Wendy S ; Frankel, David S ; Hegeman, Timothy ; Supple, Gregory E ; Garcia, Fermin C ; Santangeli, Pasquale ; Katz, David F ; Sauer, William H ; Marchlinski, Francis E</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c4130-90ec8d6a3eb67c3d08fc2008b8b597b8a2f9d53b6c19bc1e98e09c6a9b72f933</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2015</creationdate><topic>Action Potentials</topic><topic>Aged</topic><topic>Catheter Ablation - adverse effects</topic><topic>Cicatrix - diagnosis</topic><topic>Cicatrix - etiology</topic><topic>Cicatrix - physiopathology</topic><topic>Cicatrix - surgery</topic><topic>Colorado</topic><topic>Electrophysiologic Techniques, Cardiac</topic><topic>Feasibility Studies</topic><topic>Female</topic><topic>Heart Ventricles - physiopathology</topic><topic>Heart Ventricles - surgery</topic><topic>Humans</topic><topic>Male</topic><topic>Middle Aged</topic><topic>Philadelphia</topic><topic>Predictive Value of Tests</topic><topic>Recurrence</topic><topic>Risk Factors</topic><topic>Stroke Volume</topic><topic>Tachycardia, Ventricular - diagnosis</topic><topic>Tachycardia, Ventricular - etiology</topic><topic>Tachycardia, Ventricular - physiopathology</topic><topic>Tachycardia, Ventricular - surgery</topic><topic>Time Factors</topic><topic>Treatment Outcome</topic><topic>Ventricular Function, Left</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Tzou, Wendy S</creatorcontrib><creatorcontrib>Frankel, David S</creatorcontrib><creatorcontrib>Hegeman, Timothy</creatorcontrib><creatorcontrib>Supple, Gregory E</creatorcontrib><creatorcontrib>Garcia, Fermin C</creatorcontrib><creatorcontrib>Santangeli, Pasquale</creatorcontrib><creatorcontrib>Katz, David F</creatorcontrib><creatorcontrib>Sauer, William H</creatorcontrib><creatorcontrib>Marchlinski, Francis E</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><jtitle>Circulation. Arrhythmia and electrophysiology</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Tzou, Wendy S</au><au>Frankel, David S</au><au>Hegeman, Timothy</au><au>Supple, Gregory E</au><au>Garcia, Fermin C</au><au>Santangeli, Pasquale</au><au>Katz, David F</au><au>Sauer, William H</au><au>Marchlinski, Francis E</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Core Isolation of Critical Arrhythmia Elements for Treatment of Multiple Scar-Based Ventricular Tachycardias</atitle><jtitle>Circulation. Arrhythmia and electrophysiology</jtitle><addtitle>Circ Arrhythm Electrophysiol</addtitle><date>2015-04</date><risdate>2015</risdate><volume>8</volume><issue>2</issue><spage>353</spage><epage>361</epage><pages>353-361</pages><issn>1941-3149</issn><eissn>1941-3084</eissn><abstract>BACKGROUND—Radiofrequency ablation of multiple or unmappable ventricular tachycardias (VTs) remains a challenge with unclear end points. We present our experience with a new strategy isolating core elements of VT circuits.
METHODS AND RESULTS—Patients with structural heart disease presenting for VT radiofrequency ablation at 2 centers were included. Strategy involved entrainment/activation mapping if VT was hemodynamically stable, and voltage mapping with electrogram analysis and pacemapping. Core isolation (CI) was performed incorporating putative isthmus and early exit site(s) based on standard criteria. If VT was noninducible, the dense scar (<0.5 mV) region was isolated. Successful CI was defined by exit block (20 mA at 2 ms) within the isolated region. VT inducibility was also assessed. Forty-four patients were included (mean age, 63; 95% male; 73% ischemic cardiomyopathy; mean left ventricular ejection fraction, 31%; 68% with multiple unstable VTs [mean, 3+2]). CI area was 11+12 versus 55+40 cm total scar area. Additional substrate modification was performed in 27 (61%), and epicardial radiofrequency ablation was performed in 4 (9%) patients. CI was achieved in 37 (84%) and led to better VT-free survival (log rank P=0.013).
CONCLUSIONS—CI is a novel strategy with a discrete and measurable end point beyond VT inducibility to treat patients with multiple or unmappable VTs. The CI region can be selected based on standard characterization of suspected VT isthmus surrogates thus limiting ablation target size. Exit block within the isolated area is achievable in most and may further improve long-term success.</abstract><cop>United States</cop><pub>American Heart Association, Inc</pub><pmid>25681389</pmid><doi>10.1161/CIRCEP.114.002310</doi><tpages>9</tpages></addata></record> |
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| subjects | Action Potentials Aged Catheter Ablation - adverse effects Cicatrix - diagnosis Cicatrix - etiology Cicatrix - physiopathology Cicatrix - surgery Colorado Electrophysiologic Techniques, Cardiac Feasibility Studies Female Heart Ventricles - physiopathology Heart Ventricles - surgery Humans Male Middle Aged Philadelphia Predictive Value of Tests Recurrence Risk Factors Stroke Volume Tachycardia, Ventricular - diagnosis Tachycardia, Ventricular - etiology Tachycardia, Ventricular - physiopathology Tachycardia, Ventricular - surgery Time Factors Treatment Outcome Ventricular Function, Left |
| title | Core Isolation of Critical Arrhythmia Elements for Treatment of Multiple Scar-Based Ventricular Tachycardias |
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