Ventricular Tachycardia With Participation of the Left Bundle-Purkinje System in Patients With Structural Heart Disease: Identification of Slow Conduction During Sinus Rhythm

Background: It has been established that areas of slow conduction within a myocardial scar identified by isochronal mapping during sinus rhythm harbor the functional substrate that is involved in sustaining ventricular tachycardia (VT). We sought to test the hypothesis that targeting the region of slowest conduction during sinus rhythm would reduce VT recurrence following ablation. Methods and Results: 32 subjects underwent ablation for sustained monomorphic VT associated with structural heart disease from 2013 to 2014. Sustained VT recurred in 12 patients (37.5%). Isochronal late activation maps were created to display activation during sinus rhythm in the region of bipolar scar. The scar was divided into three zones of equal activation time. The zone with the densest isochrones was designated as having the slowest conduction . We retrospectively analyzed isochronal maps and measured the proportion of the slowest zone that was ablated (median 14%, IQR 0-50). During a mean follow-up of 6 months, recurrence of ventricular arrhythmia was significantly associated with ablation of the slowest zone (OR 0.126, CI 0.024-0.68, p 0.016). Furthermore, univariate logistic regression demonstrated reduction of 30% in the 6-month VT recurrence rate for every 10% increase in percent of the slowest zone ablated (OR 0.7, 95% CI 0.5-1.0, p=0.05). Conclusions: Patients who had ablation in the region of slowest conduction were significantly less likely to have recurrence of ventricular tachycardia. Our data suggests a strategy to target the slowest region of conduction for substrate modification may hold promise for improving outcomes of scar-mediated VT ablation.

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P1125 Safety and efficacy of ventricular tachycardia ablation during sinus rhythm in patients with structural heart disease

EP Europace ◽

10.1093/europace/euaa162.228 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

J Fernandez-Armenta Pastor ◽

E Silva ◽

D Soto-Iglesias ◽

D Penela ◽

J Acosta ◽

...

Keyword(s):

Heart Disease ◽

Ventricular Tachycardia ◽

Sinus Rhythm ◽

Structural Heart Disease ◽

Ventricular Assist Devices ◽

Ventricular Assist ◽

Arrhythmogenic Substrate ◽

Vt Ablation ◽

One Year ◽

Multicenter Registry

Abstract Funding Acknowledgements Project “PI-0057-2017”, funded by Junta de Andalucía and co-funded by European Union (ERDF/ESF, “Invesing in your future”) Background The best strategy for scar related ventricular tachycardia (VT) ablation is not yet established. Recently, the use of ventricular assist devices is being proposed to allow ablation during unstable VT. Purpose Analyze the results of a multicenter registry of substrate-guided VT ablation performed primarily during stable rhythm. Methods This prospective multicenter registry included 433 VT ablation procedures performed in 372 consecutive patients with structural heart disease undergoing VT ablation. Substrate ablation (scar dechanneling technique) during sinus rhythm without initial VT induction was the standard protocol. Any episode of sustained VT or appropriate ICD therapy was considered VT recurrence. Results Myocardial infarction was the arrhythmogenic substrate in 64% of patients. 90.5% of patients were male, mean age 64 ± 13 years. Mean LVEF was 38 ± 13%.No ventricular assist device was used in any case. After substrate ablation no VT was inducible in 69% of cases. End-procedure non-inducibility was achieved in 73.1% of cases. Complication rate was 6.7 %. 30-days mortality was 1.9% (7 patients), including one procedure related death. At one year after first procedure 17 patients died (4.5%). Age, chronic obstructive pulmonary disease and renal failure were independent predictors of mortality. One-year freedom from VT recurrence was 84%. Conclusion Substrate-guided VT ablation during stable rhythm as main approach for scar-related VT treatment is associated to low complication and recurrence rates in this prospective multicenter study.

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Faculty Opinions recommendation of Long-term Outcomes of Ventricular Tachycardia Ablation in Different Types of Structural Heart Disease.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.726122471.793533528 ◽

2017 ◽

Author(s):

Brian Olshansky

Keyword(s):

Heart Disease ◽

Ventricular Tachycardia ◽

Structural Heart Disease ◽

Long Term Outcomes ◽

Ventricular Tachycardia Ablation ◽

Different Types

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Advanced interatrial block precedes atrial fibrillation and stroke. The prospective interatrial Block And Yearly EventS (BAYES) registry

European Heart Journal ◽

10.1093/ehjci/ehaa946.0485 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M Martinez-Selles ◽

R Elosua ◽

M Ibarrola ◽

M De Andres ◽

P Diez-Villanueva ◽

...

Keyword(s):

Atrial Fibrillation ◽

Heart Disease ◽

Sinus Rhythm ◽

Structural Heart Disease ◽

P Wave ◽

Wave Duration ◽

P Wave Duration ◽

Previous Diagnosis ◽

Surface Ecg ◽

Interatrial Block

Abstract Background Advanced interatrial block (IAB), prolonged and bimodal P waves in surface ECG inferior leads, is an unrecognized surrogate of atrial dysfunction and a trigger of atrial dysrhythmias, mainly atrial fibrillation (AF). Our aim was to prospectively assess whether advanced IAB in sinus rhythm precedes AF and stroke in elderly outpatients with structural heart disease, a group not previously studied. Methods Prospective observational registry that included outpatients aged ≥70 years with structural heart disease and no previous diagnosis of AF. Patients were divided into three groups according to P-wave characteristics. Results Among 556 individuals, 223 had normal P-wave (40.1%), 196 partial IAB (35.3%), and 137 advanced IAB (24.6%). After a median follow-up of 694 days; 93 patients (16.7%) developed AF, 30 stroke (5.4%), and 34 died (6.1%). Advanced IAB was independently associated with AF (hazard ratio [HR] 2.9, 95% confidence interval [CI] 1.7–5.1, p<0.001), stroke (HR 3.8, 95% CI 1.4–10.7, p=0.010), and AF/stroke (HR 2.6, 95% CI 1.5–4.4, p=0.001). P-wave duration (ms) was independently associated with AF (HR 1.05, 95% CI 1.03–1.07, p<0.001), AF/stroke (HR 1.04, 95% CI 1.02–1.06, p<0.001), and mortality (HR 1.04, 95% CI 1.00–1.08, p=0.021). Conclusions The presence of advanced IAB in sinus rhythm is a risk factor for AF and stroke in an elderly population with structural heart disease and no previous diagnosis of AF. P-wave duration was also associated with all-cause mortality. Figure. Age- and sex-adjusted linear and non-linear association between P-wave duration (msec) and atrial fibrillation (A), stroke (B), and atrial fibrillation or stroke (C) risk. Results of a generalized additive model with spline smoothing functions and 4 degrees of freedom. Figure 1. Kaplan-Meyer curves of survival free of atrial fibrillation (A), stroke (B) and atrial fibrillation or stroke (C) in patients with normal P-wave, partial interatrial block (IAB) and advanced IAB. Funding Acknowledgement Type of funding source: None

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Mechanisms and Clinical Management of Ventricular Arrhythmias following Blunt Chest Trauma

Cardiology Research and Practice ◽

10.1155/2016/7270247 ◽

2016 ◽

Vol 2016 ◽

pp. 1-7 ◽

Cited By ~ 1

Author(s):

Daniel H. Wolbrom ◽

Aleef Rahman ◽

Cory M. Tschabrunn

Keyword(s):

Heart Disease ◽

Ventricular Tachycardia ◽

Ventricular Arrhythmias ◽

Blunt Chest Trauma ◽

Chest Trauma ◽

Motor Vehicle ◽

Structural Heart Disease ◽

Chest Injury ◽

Chronic Stage ◽

Chest Wall Injury

Nonpenetrating, blunt chest trauma is a serious medical condition with varied clinical presentations and implications. This can be the result of a dense projectile during competitive and recreational sports but may also include other etiologies such as motor vehicle accidents or traumatic falls. In this setting, the manifestation of ventricular arrhythmias has been observed both acutely and chronically. This is based on two entirely separate mechanisms and etiologies requiring different treatments. Ventricular fibrillation can occur immediately after chest wall injury (commotio cordis) and requires rapid defibrillation. Monomorphic ventricular tachycardia can develop in the chronic stage due to underlying structural heart disease long after blunt chest injury. The associated arrhythmogenic tissue may be complex and provides the necessary substrate to form a reentrant VT circuit. Ventricular tachycardia in the absence of overt structural heart disease appears to be focal in nature with rapid termination during ablation. Regardless of the VT mechanism, patients with recurrent episodes, despite antiarrhythmic medication in the chronic stage following blunt chest injury, are likely to require ablation to achieve VT control. This review article will describe the mechanisms, pathophysiology, and treatment of ventricular arrhythmias that occur in both the acute and chronic stages following blunt chest trauma.

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