Abstract 18662: Ablation of Regions of Very Slow Conduction Within a Myocardial Scar and Recurrence of Ventricular Tachycardia After Catheter Ablation

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Asad A Aboud ◽  
M. Benjamin Shoemaker ◽  
Pablo Saavedra ◽  
Juan C Estrada ◽  
Sharon Shen ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Ventricular Tachycardia ◽  
Sinus Rhythm ◽  
Structural Heart Disease ◽  
Myocardial Scar ◽  
Activation Time ◽  
Substrate Modification ◽  
Slow Conduction ◽  
Vt Ablation

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.

Abstract 4090: Substrate Modification Using Electroanatomically-guided Linear Ablation During Sinus Rhythm To Treat Post-infarction Ventricular Tachycardia

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Thomas Deneke ◽  
Bernd Lemke ◽  
Leif-Ilja Boesche ◽  
Bernd Calcum ◽  
Andreas Muegge ◽  
...  
Keyword(s):  
Ventricular Tachycardia ◽  
Catheter Ablation ◽  
Ventricular Arrhythmia ◽  
Sinus Rhythm ◽  
Border Zone ◽  
Ablation Procedure ◽  
Substrate Modification ◽  
Linear Ablation ◽  
Partial Success

Catheter ablation of ventricular tachycardia (VT) in the setting of ischemic cardiomyopathy can be performed to modify the underlying substrate. We evaluated the efficacy of a linear VT ablation procedure based on sinus rhythm (SR) substrate maps to treat ischemic VT in consecutive patients. Methods: In 110 consecutive patients with ischemic VT (56% not tolerated) catheter ablation was attempted. During SR left ventricular scar mapping was performed identifying scar tissue (bipolar voltages 1.5mV). Regionalization of VT-exit regions was performed based on pace-mapping within the scar border zone. Ablation was directed towards the identified exit region performing linear ablation along the scar border. ICD-holter interrogation was performed during follow-up. Results: A mean of 2.7±1.6 different VTs were inducible per patient (total 286). In 97% (107) of all patients (74% of all inducible VTs ablated: 213/286) the clinical VT was successfully ablated. In 68 patients (62%) no sustained monomorphic VT (complete success) was inducible at the end of the ablation procedure whereas in 39 patients (35%) VTs (partial success) were still inducible. Over a median follow-up of 12 months (6 –39) 88 (80%) patients were free from any ventricular arrhythmia. 19 successfully ablated patients had recurrences in between 6 to 36 months post intervention but the number of episodes treated by the ICD was significantly reduced (16±4 within 3 months (3±2) (p=0.02). No difference in patients with tolerated compared to non-tolerated VTs were detected (recurrences in 7/48 (15%) tolerated and 15/62 (24%) non-tolerated; p=0.13). There was a significant difference in freedom from any VT in patients with complete (88%) versus partial success (72%) (p=0.04). Conclusions: Substrate modification targeting only the scar-border zone including the VT exit site based on SR-maps is highly effective in suppressing the occurrence of a clinical VT in patients with remote myocardial infarction (97%). Based on the electro-anatomical findings complete freedom from any ventricular arrhythmia over a median of 1 year can be achieved in 80% of all patients. No difference in regard to freedom from any ventricular arrhythmia can be documented in patients with tolerated and non-tolerated VTs.

129Magnetic resonance predictors of ventricular tachycardia recurrence after radiofrequency substrate ablation: septal and transmural channels

EP Europace ◽  
2020 ◽  
Vol 22 (Supplement_1) ◽  
Author(s):  
L Quinto ◽  
F Alarcon ◽  
P Sanchez ◽  
P Garre ◽  
F Zaraket ◽  
...  
Keyword(s):  
Ventricular Tachycardia ◽  
Tissue Characterization ◽  
Interventricular Septum ◽  
Structural Heart Disease ◽  
Left Ventricular ◽  
Border Zone ◽  
Left Ventricle Mass ◽  
Vt Ablation ◽  
Lge Cmr

Abstract   Ventricular tachycardia (VT) substrate-based ablation has become a gold standard in patients with structural heart disease. Success of VT ablation is related with mortality reduction. Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) is a powerful technique to assess substrate of VT. Myocardial fibrosis is electrically inert (Core) but it is surrounded by a ‘‘border-zone (BZ)’’ where normal cardiomyocytes intermingle with dense bundles of fibrosis. Slow impulse conduction in the BZ allows for the re-entry circuits leading to VT. Both the presence and extent of LGE have been associated with VT and SCD risk. LGE-CMR tissue characterization can be depicted as pixel signal intensity (PSI) maps and can guide VT ablation. The aim of this study was to analyze possible VT recurrence predictors in a long term follow-up of patients that underwent VT ablation (endo and/or epicardial) related with LGE-CMR PSI maps. We analyzed 234 consecutive patients (age: 63.2 ± 14 years, follow-up: 3.14 years ±1.8) undergoing VT ablation with scar-dechannelling technique at a single center from 2013 to 2018.  110 patients underwent a preprocedural LGE-CMR, and in 94 patients (85,5%) a CMR-aided ablation using the PSI maps was performed. All LGE-CMR images were semi-automatically processed using a dedicated software. PSI-based algorithm was applied to characterize the hyperenhanced area as core or BZ, using fixed threshold of the maximum intensity. A LV 3D shell was obtained and were imported into the navigation system. In the PSI maps, heterogenous tissue channels were defined as a continuous corridor of BZ surrounded by scar core or an anatomic barrier that connects 2 areas of healthy tissue. Results Overall recurrence of VT was 41.8 %. There was ICD shock reduction, from 43,6% to a 28,2% (ICD shocks before ablation 2,23 ± 7,32, after: 1,10 ± 2,92). Left ventricle mass predicted significantly VT recurrence (Mean 168,3 ± 53,3 vs 152,3 ± 46,4 g, HR 1,02 [1,01-1,02], p < 0.001). LGE distribuition was predictive of VT recurrence when a more than 40% of the interventricular septum was involved (62,5% vs 37,8%; HR 1,6 [1,01-1,02]; p = 0,044). No differences in recurrence were found among the patterns of LGE distribution (transmural/epicardial/subendocardial or peculiar segments localizations). The amount of BZ and the total amont of Core + BZ was related with VT recurrence (BZ 26,6 ± 13,9 vs 19,56 ± 9,69 g, HR 1,03 [1,01-1,06], p = 0,012; total Core + BZ 37,1 ± 18,2 vs 29,0 ± 16,3 g, HR 1,02 [1,00-1,04], p = 0,033). Finally VT recurrence was higher in patients with channels with transmural path (66,7% vs 31,4%, HR 3,25 [1,70-6,23], p < 0,001) or midmural channels (54,3% vs 27,6%, HR 2,49 [1,21–5,13], p = 0,013). CMR-aided scar dechanneling is a helpful and feasible technique which could identify patients with high risk of VT recurrence. High left ventricular mass, septal LGE distribution, transmural and midmural heterogeneous tissue channels were predictive factors of post ablation VT recurrence. Abstract Figure. VTchannel & heterogeoneus tissue channel

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

EP Europace ◽  
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.

5207Bilateral cardiac sympathetic denervation in structural heart disease

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
V Dusi ◽  
L Pugliese ◽  
I Passarelli ◽  
R Camporotondo ◽  
M Driussi ◽  
...  
Keyword(s):  
Heart Disease ◽  
Nyha Class ◽  
Case Series ◽  
Structural Heart Disease ◽  
Median Number ◽  
Sympathetic Denervation ◽  
Icd Shock ◽  
Vt Ablation ◽  
Cardiac Sympathetic Denervation

Abstract Background Left cardiac sympathetic denervation (LCSD) is an established therapy for refractory ventricular arrhythmias (VAs) in channelopathies. A multicentric American and Indian case series suggested a greater efficacy of bilateral denervation (BCSD) in patients with structural heart disease (SHD). Purpose To describe our single-center experience with BCSD in SHD. Methods Nine patients (78% male, mean 55±18 yrs, mean LVEF 31±14%) with SHD and refractory VAs underwent BCSD. All had a Video-Assisted Thoracoscopic Surgery (VATS), in 2 cases associated with the robotic technique. The underlying cardiomyopathy (CMP) was non-ischemic (NICMP) in most cases (n=5, 55%), ischemic in 2 cases, arrhythmogenic right ventricular (ARVC) in one and related to lamin A/C deficiency in one. All patients had an ICD, 44% (n=4) a CRT-D. NYHA functional class I was present in 4 patients, the rest were in NYHA class II (n=3) or III (n=2). Three patients were candidates to heart transplant/LV assistance device. The arrhythmic burden pre BCSD included in 7 pts (78%) a history of electrical storm (ES); the median number of shocks/patient in the 12 months before BCSD was 5 (IQ range 3–18). Except for 2 patients with previous thyrotoxicosis, the remaining were either on amiodarone (n=6) or on sotalol (n=1) before BCSD. Main BCSD indications were represented by drug refractory fast VT in 7 pts (cycle <250 msec) and by recurrent monomorphic VT episodes (mean cycle 351 msec) after endocardial VT ablation in 2 patients. Results No major complication occurred. One patient (NICMP, NYHA II), has an uneventful follow up (FU) of less than 1 month and was excluded from the efficacy analysis. The median FU in the remaining 8 patients is 10 months (IQ range 6–19), during which the median number of shocks/patients was 0.5 (IQ range 0–3). Overall, 4 patients (50%) had ICD shock recurrences. Two cases (mean LVEF 17.5%, NYHA class III) had an ES during severe hemodynamic instability and subsequently died because of cardiogenic shock respectively 1 and 7 months after BCSD. One case had three, not consecutive ICD shocks 20 months after BCSD in the setting of severe amiodarone-induced thyrotoxicosis. Finally, one patient received a single intra-hospital ICD shock 5 days after BCSD before reintroduction of full-dose beta-blockers. The figure summarizes ICD shocks burden in the 6 months before and after BCSD. Among the 5 patients with NICMP/ARVC (4 in NYHA class I), only 1 had a single ICD shock recurrence. ICD shocks pre versus post BCSD, n=8 Conclusions Our case series, although numerically small, has a good follow-up and is the first reported in Europe. The results are in agreement with the suggested remarkable efficacy of BCSD in patients with good functional capacity and fast VAs. Therefore, cardiac sympathetic denervation should always be considered in patients with SHD and refractory ventricular tachyarrhythmias, especially in case VT ablation is either not indicated or fails.

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.

scholarly journals LONG-TERM OUTCOMES OF SCAR-RELATED VT ABLATION FOR ICM IN SINUS RHYTHM BY SUBSTRATE MODIFICATION

2014 ◽  
Vol 63 (12) ◽  
pp. A306
Author(s):  
Jorge Romero ◽  
Patricia Chavez ◽  
Jay Doshi ◽  
Faraj Kargoli ◽  
Grushko Michael ◽  
...  
Keyword(s):  
Sinus Rhythm ◽  
Long Term Outcomes ◽  
Substrate Modification ◽  
Vt Ablation

scholarly journals Echocardiographic Predictors of Ventricular Tachycardia

2014 ◽  
Vol 8s4 ◽  
pp. CMC.S18499 ◽  
Author(s):  
John N. Catanzaro ◽  
John N. Makaryus ◽  
Amgad N. Makaryus ◽  
Cristina Sison ◽  
Christos Vavasis ◽  
...  
Keyword(s):  
Heart Disease ◽  
Ventricular Tachycardia ◽  
Left Atrial ◽  
Structural Heart Disease ◽  
Left Ventricular ◽  
Pharmacologic Therapy ◽  
Cardioverter Defibrillator ◽  
First Occurrence ◽  
Echocardiographic Parameters

Background Patients with structural heart disease are prone to ventricular tachycardia (VT) and ventricular fibrillation (VF), which account for the majority of sudden cardiac deaths (SCDs). We sought to examine echocardiographic parameters that can predict VT as documented by implantable cardioverter-defibrillator (ICD) appropriate discharge. We examine echocardiographic parameters other than ejection fraction that may predict VT as recorded via rates of ICD discharge. Methods Analysis of 586 patients (469 males; mean age = 68 ± 3 years; mean follow-up time of 11 ± 14 months) was undertaken. Echo parameters assessed included left ventricular (LV) internal end diastolic/systolic dimension (LVIDd, LVIDs), relative wall thickness (RWT), and left atrial (LA) size. Results The incidence of VT was 0.22 (114 VT episodes per 528 person-years of follow-up time). Median time-to-first VT was 3.8 years. VT was documented in 79 patients (59 first VT incidence, 20 multiple). The echocardiographic parameter associated with first VT was LVIDs >4 cm ( P = 0.02). Conclusion The main echocardiographic predictor associated with the first occurrence of VT was LVIDs >4 cm. Patients with an LVIDs >4 cm were 2.5 times more likely to have an episode of VT. Changes in these echocardiographic parameters may warrant aggressive pharmacologic therapy and implantation of an ICD.

scholarly journals Role of assist device implantation and heart transplantation in the long-term outcome of patients with structural heart disease after catheter ablation of ventricular tachycardia

2021 ◽  
Author(s):  
Angeliki Darma ◽  
Livio Bertagnolli ◽  
Borislav Dinov ◽  
Alireza Sepehri Shamloo ◽  
Federica Torri ◽  
...  
Keyword(s):  
Case Control Study ◽  
Structural Heart Disease ◽  
Control Group ◽  
Assist Device ◽  
Matched Case ◽  
Vt Ablation ◽  
Matched Case Control Study ◽  
Control Study

Abstract Introduction Ablation of ventricular tachycardias (VTs) in patients with structural heart disease (SHD) has been associated with advanced heart failure and poor survival. Methods and results This matched case-control study sought to assess the difference in survival after left ventricular assist device (LVAD) implantation and/or heart transplantation (HTX) in SHD patients undergoing VT ablation. From the initial cohort of 309 SHD patients undergoing VT ablation (187 ischemic cardiomyopathy, mean age 64 ± 12 years, ejection fraction of 34 ± 13%), 15 patients received an LVAD and nine patients HTX after VT ablation during a follow-up period of 44 ± 33 months. Long-term survival after LVAD did not differ from the matched control group (p = 0.761), although the cause of lethal events was different. All post-HTX patients survived during follow-up. Conclusion In this matched case-control study on patients with SHD undergoing VT ablation, patients that received LVAD implantation had similar survival compared to the control group after 4‑year follow-up, while the patients with HTX had a significantly better outcome.

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