P1377Substrate-based ablation in patients with frequent appropriate ICD therapy and dilated cardiomyopathy: long-term experience with high-density mapping

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
M M O Oliveira ◽  
P S C Cunha ◽  
B V Valente ◽  
G Portugal ◽  
A Lousinha ◽  
...  
Keyword(s):  
Left Ventricular ◽  
High Density ◽  
Border Zone ◽  
Long Term Results ◽  
Icd Therapy ◽  
Electroanatomic Mapping System ◽  
Density Mapping ◽  
Substrate Modification ◽  
Lv Dysfunction

Abstract Recurrent ventricular tachydisrhythmias (VT) episodes have a negative impact in the outcome of patients (P) already with an implantable cardioverter-defibrillator (ICD). Elimination of arrhythmic reentry circuits represents a difficult challenge, mainly due to the induction of intolerable VTs, with multiple ECG morphologies, requiring rapid interruption. Substrate guided ablation has been used as a promising approach strategy to treat recurrent VTs. Aim: to assess long-term results of a VT substrate-based ablation using high-density mapping in P with an ICD, severe left ventricular (LV)  dysfunction and recurrent appropriate ICD therapy. Methods: 16P (12 men, non-ischemic cardiomyopathy 67%, 55 ± 13 years, LV ejection fraction 32 ± 6%) and recurrent appropriate shocks despite antiarrhythmic drug therapy and optimal heart failure medication. All P underwent a protocol of ventricular programmed stimulation (600 ms/S3) to obtain baseline VT documentation. A sinus rhythm (SR) voltage map was created using a 3D electroanatomic mapping system (CARTO) with a high-density mapping catheter (PentaRay) 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 provide high-resolution electrophysiological mapping. The substrate modification included catheter elimination of local abnormal ventricular activities (LAVA) - fractionated, splited, low-amplitude/long-lasting, late potentials, pre-systolic potentials - and linear ablation to obtain scars homogenization and scar dechanneling. Pace-mapping techniques were used when capture was possible. LV approach was retrograde in 6 cases, transeptal in 4 and endo-epicardial in 2 cases. In 2P the ablation was performed in the right ventricle. Results: VTs were induced and interrupted with bursts or external DC shocks. LAVA were identified and ablated in all P. Eleven P underwent modification of scar areas. The mean duration of the procedure was 153 mn (103-218 mn), with radiofrequency ranging from 18 to 60 mn (mean 33 min), and a mean fluoroscopy time of 16 mn. Non-inducibility was achieved in 75% of the cases. There was 1 pericardial tamponade drained successfully. During a follow-up of 48 ± 18 months, 75% had no VT recurrences, 2P underwent redo ablation, 1P died from stroke. Conclusion: Catheter ablation of VT based on substrate modification guided by high-density mapping is feasible and safe in P with LV dysfunction. This approach may be of clinical relevance, with potential benefits in reducing VT burden.

P1036Acute and long-term ablation results of extra pulmonary vein drivers detected by ultra high density mapping on top of PVI in persistent AF

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
B Enache ◽  
D G Latcu ◽  
K Hasni ◽  
S S Bun ◽  
N Saoudi
Keyword(s):  
Pulmonary Vein ◽  
Low Voltage ◽  
Respiratory Gating ◽  
Persistent Atrial Fibrillation ◽  
High Density ◽  
Long Term Results ◽  
Contact Mapping ◽  
Density Mapping ◽  
Extra Pulmonary

Abstract Background Whether ultra-high density (UHD) contact mapping is useful in radiofrequency ablation of persistent atrial fibrillation (AF) is unknown. Purpose To sequentially map the left atrial (LA) activation during AF ablation (circumferential PVI and ablation of extra pulmonary vein drivers). Methods Time reference was an LA appendage (LAA) electrogram (EGM). Points were acquired with respiratory gating if reference, cycle length (10 ms tolerance) and electrode location were stable. For fragmented EGM the timing of the surrounding area was used. In case of extremely low voltage (<0.01 mV) or lack of local statistical coherence no colour-code was displayed (grey area). Circular propagation around single points was defined as organized rotating drivers (see figure). All pts had PVI followed by remapping and ablation of the centre of rotational regions and at sites with focal type propagation. DC or chemical cardioversion were not performed in the first 48 h. Results Out of 41 patients (pts) undergoing first time ablation with the above described protocol, 30 (66±8 y, mean current episode duration 8 months) were followed for a mean time of 14,7 months. At 48 hours post-procedure, 70% of pts were no longer in AF: 6 (20%) in sinus rhythm and 15 (50%) in atrial tachycardias. At 1 year after a single procedure, freedom from AF was 87% and freedom from AF and AT was 60%. Conclusion In persistent AF, sequential UHD activation mapping is useful in guiding and potentially improving long term results of ablation of extra pulmonary vein drivers after PVI.

scholarly journals Chronic Mitral Regurgitation: When the Optimal Timing of Surgical Intervention?

1970 ◽  
Vol 1 (2) ◽  
pp. 142-147
Author(s):  
H Oemar ◽  
K Yusoff ◽  
HB Abdulgani
Keyword(s):  
Mitral Regurgitation ◽  
Surgical Intervention ◽  
Clinical Symptoms ◽  
Left Ventricular ◽  
Long Term Results ◽  
Lv Function ◽  
Optimal Timing ◽  
Pathophysiological Mechanism ◽  
Lv Dysfunction

Optimal timing of surgery in mitral regurgitation (MR) is a complex problem that has been studied widely. The pathophysiological mechanism and hemodynamic changes whereby MR exerts its deleterious effects on survival is well recognized. Early reports in the literatures and newer prospective studies suggest that severe MR is not a benign state and it has a high morbidity and eventually mortality. Thus, it is obviously rationale in understanding pathophysiological construct and be able to identify disease condition in choosing the golden moment for surgical intervention. Surgical intervention has been exposed to be the only efficient management, but its optimal timing remains a matter of controversy. The ultimate goal of patient care is obviously no longer the relief of limiting symptoms but the achievement of an optimal long-term outcome with regard to mortality and morbidity. Preoperative developments of severe symptoms, left ventricular (LV) dysfunction, LV enlargement, chronic atrial fibrillation, or progressive pulmonary hypertension were found to be associated with an unfavorable outcome. The timing of surgical correction for MR depends chiefly on three factors: clinical symptoms, LV function and the severity of MR. In term of waiting symptoms, the surgery has changed considerably from a relatively passive response to the development of severe symptoms, to an early surgery concept preceding the signs of LV dysfunction. This because clinical symptoms can remain absent or minimal despite severe regurgitation caused by adaptive remodeling of LV and left atrium, or because of patient adaptation of the disease. Thus, in chronic severe MR, there should be no waiting for LV function to decline before intervening, because the long-term results of that approach are not gratifying. Recent data underscored that mitral surgery is associated with a considerably decreased subsequent risk of mortality and heart failure. The reduction in the risk of death associated with surgery is greater among patients with a larger effective regurgitant orifice (ERO) assessed echocardiographically than among those with a smaller ERO and results in normalization of the life expectancy. These data provide a firm basis for considering surgery in patients with asymptomatic chronic mitral regurgitation who have an ERO of at least 40 mm². Key words: Mitral regurgitation; Mitral valve surgery; Echocardiography. DOI: http://dx.doi.org/10.3329/cardio.v1i2.8120 Cardiovasc. j. 2009; 1(2) : 142-147

Long-term results of thoracoscopic ablation of paroxysmal atrial fibrillation: is the glass half full or half empty?

2021 ◽  
Author(s):  
Igor Belluschi ◽  
Elisabetta Lapenna ◽  
Davide Carino ◽  
Cinzia Trumello ◽  
Manuela Cireddu ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Confidence Interval ◽  
Paroxysmal Atrial Fibrillation ◽  
Left Ventricular ◽  
Class I ◽  
Long Term Results ◽  
Left Ventricular Ejection ◽  
Af Recurrence

Abstract OBJECTIVES Previous series showed the outcomes of thoracoscopic ablation of stand-alone symptomatic paroxysmal atrial fibrillation (AF) for up to 7 years of follow-up. The goal of this study was to assess the long-term durability of surgical pulmonary vein isolation (PVI) beyond 7 years. METHODS Fifty consecutive patients {mean age 55 [standard deviation (SD): 11.2] years, previous catheter ablation in 56%, left ventricular ejection fraction 60% (SD: 4.6), left atrium volume 65 ml (SD: 17)} with stand-alone symptomatic paroxysmal AF underwent PVI through bilateral thoracoscopy ablation between 2005 and 2014. The CHA2DS2-VASc score was ≥2 in 12 patients (24%). RESULTS No hospital deaths occurred. At hospital discharge all patients but 1 (2%) were in sinus rhythm (SR). Follow-up was 100% complete [mean 8.4 years (SD: 2.3), max 15]. The 8-year cumulative incidence function of AF recurrence, with death as a competing risk, on or off class I/III antiarrhythmic drugs (AADs)/electrocardioversion/re-transcatheter ablation (TCA) was 20% (SD: 5; 95% confidence interval: 10, 32); and off class I/III AADs/electrocardioversion/re-TCA was 52% (SD: 7; 95% confidence interval: 0.83, 8.02). At 8 years, the predicted prevalence of patients in SR was 87% and 53% were off class I/III AADs/electrocardioversion/re-TCA. The recurrent arrhythmia was AF in all patients except 2, who had atypical atrial flutter (4%). No predictors of AF recurrence were identified. At the last follow-up, 76% of the patients showed European Heart Rhythm Association class I. No strokes or thromboembolic events were documented and 76% of the subjects were off anticoagulation therapy. CONCLUSIONS Despite a considerable AF recurrence rate, our single-centre, long-term outcome of surgical PVI showed encouraging data, with the majority of patients remaining in SR, although many of them were on antiarrhythmic therapy.

P3778Long-term outcome of non-pharmacologial treatment of atrial fibrillation in hypertrophic cardiomyopathy: a large single-centre experience

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
L Dinshaw ◽  
M Lemoine ◽  
J Hartmann ◽  
B Schaeffer ◽  
N Klatt ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Left Atrial ◽  
High Density ◽  
Term Outcome ◽  
Long Term Outcome ◽  
Density Mapping ◽  
Ablation Success

Abstract Introduction Atrial fibrillation (AF) is common in hypertrophic cardiomyopathy (HCM) and is generally associated with a significant deterioration of clinical status. Non-pharmacological treatment such as surgical and catheter ablation has become an established therapy for symptomatic AF but in patients with HCM often having a chronically increased left atrial pressure and extensive atrial cardiomyopathy the long-term outcome is uncertain. Purpose The present study aimed to analyse the long-term outcome of AF ablation in HCM and the mechanism of recurrent atrial arrhythmias using high-density mapping systems. Methods A total of 65 patients (age 64.5±9.9 years, 42 (64.6%) male) with HCM undergoing AF ablation for symptomatic AF were included in our study. The ablation strategy for catheter ablation included pulmonary vein isolation in all patients and biatrial ablation of complex fractionated electrograms with additional ablation lines if appropriate. In patients with suspected atrial tachycardia (AT) high-density activation and substrate mapping were performed. A surgical ablation at the time of an operative myectomy for left ventricular outflow tract obstruction was performed in 8 (12.3%) patients. The outcome was analysed using clinical assessment, Holter ECG and continuous rhythm monitoring of cardiac implantable electric devices. Results Paroxysmal AF was present in 27 (41.6%), persistent AF in 37 (56.9%) and primary AT in 1 (1.5%) patients. The mean left atrial diameter was 54.1±12.5 ml. In 11 (16.9%) patients with AT high-density mapping was used to characterize the mechanism of the ongoing tachycardia. After 1.9±1.2 ablation procedures and a follow-up of 48.5±37.2 months, ablation success was demonstrated in 58.9% of patients. The success rate for paroxysmal and persistent AF was 70.0% and 55.8%, respectively (p=0.023). Of those patients with AT high-density mapping guided ablation was successful in 44.4% of patients. The LA diameter of patients with a successful ablation was smaller (52.2 vs. 58.1 mm; p=0.003). Conclusion Non-pharmacological treatment of AF in HCM is effective during long-term follow-up. Paroxysmal AF and a smaller LA diameter are favourable for successful ablation. In patients with complex AT the use of high-density mapping can guide ablation resulting in further ablation success in a reasonable number of patients.

P1457Does high density mapping increase the efficacy of ischemic ventricular tachycardia ablation?

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
A Nunes Ferreira ◽  
G Silva ◽  
N Cortez-Dias ◽  
P Silverio-Antonio ◽  
T Rodrigues ◽  
...  
Keyword(s):  
Ventricular Tachycardia ◽  
High Density ◽  
Electrical Storm ◽  
High Morbidity ◽  
Amiodarone Therapy ◽  
Ventricular Tachycardia Ablation ◽  
Density Mapping ◽  
Vt Ablation

Abstract Introduction  The treatment of ventricular tachycardia (VT) in patients (pts) with ischemic heart disease (IHD) represents a challenge because of its high morbidity and mortality rates and low long-term success rates. In the VANISH clinical trial, 51% of pts undergoing the conventional ablation technique developed within 2 years the combined outcome of mortality or electrical storm (ES) or appropriate CDI shock. The use of high-density substrate maps can lead to greater precision in substrate evaluation and ideally to improved ablation success. Objectives  To assess the efficacy of substrate-guided ischemic VT ablation using high-density mapping. Methods  Single-center prospective study of consecutive IHD pts submitted to endocardial ablation of substrate-guided VT using multipolar catheters (PentaRayTM or HDGridTM) and three-dimensional mapping systems with automatic annotation software. The maps were evaluated in order to identify the intra-cicatricial channels (areas of bipolar voltage &lt;1.5mV) in which sequential propagation of local abnormal ventricular activities (LAVAs) were observed, during or after QRS. The ablation strategy aimed at the abolition of all intra-cicatricial LAVAs, directing the radiofrequency applications primarily to the entrances of the channels. The success of ablation was assessed by the primary outcome (death by any cause or ES or appropriate CDI shock) at 2 years and compared to the population of the VANISH study undergoing conventional ablation, using Cox regression and Kaplan- Meier survival analysis. Results  We included 40 patients, 95% males, 70 ± 8 years, mean ejection fraction 34 ± 10%. 82% on previous amiodarone therapy and 72% were ICD carriers. 32% underwent ablation during hospitalization for ES and 20% had previously undergone VT ablation. The median duration of substrate mapping was 74 minutes, with a mean of 2290 collected points. Major complications were seen in 1 patient (aortic dissection). During a mean follow-up time of 17.3 ± 12.9 months, the long-term success rate of VT ablation was 75%. Additionally, there was a reduction in the proportion of patients receiving amiodarone before vs after ablation (82% vs. 45% respectively). The rate of events observed during follow-up was lower than expected, namely by comparison with the population of the VANISH study undergoing conventional ablation (25% vs 51% at 24 months, HR 0.42 CI 95% 0.2-0.88, p = 0.022), reflecting a relative risk reduction of 58%. Conclusions  High density mapping allows a detailed characterization of the dysrhythmic substrate in patients with VT in an IHD context. Our results suggest that these technological innovations may be improving the clinical success of VT ablation. Abstract Figure.

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