scholarly journals Practical Guide to Ablation for Epicardial Ventricular Tachycardia: When to Get Access, How to Deal with Anticoagulation and How to Prevent Complications

2018 ◽  
Vol 7 (3) ◽  
pp. 159 ◽  
Author(s):  
Ramanan Kumareswaran ◽  
Francis E Marchlinski ◽  
◽  
Keyword(s):  
Patient Safety ◽  
Ventricular Tachycardia ◽  
Best Practices ◽  
Coronary Arteries ◽  
Phrenic Nerve ◽  
High Likelihood ◽  
Epicardial Ablation ◽  
Voltage Mapping ◽  
Systemic Anticoagulation ◽  
Epicardial Access

Epicardial ablation is needed to eliminate ventricular tachycardia (VT) in some patients with nonischaemic cardiomyopathy. The 12-lead electrocardiogram of VT, pre-procedural imaging and endocardial unipolar voltage maps can predict a high likelihood of epicardial substrate and VT. A septal VT substrate may preclude the need for epicardial access and mapping and can be identified with imaging, pacing and voltage mapping. Pericardial access is usually obtained prior to systemic anticoagulation or after reversal of systemic anticoagulation. A unique set of complications can be encountered with epicardial access, mapping and ablation, which include haemopericardium, phrenic nerve injury, damage to major coronary arteries and pericarditis. Anticipating, preventing and, if necessary, managing these complications are paramount for patient safety. Best practices are reviewed.

scholarly journals Epicardial voltage mapping in patients with postinfarction ventricular tachycardia: a pilot study

2020 ◽  
Vol 27 ◽  
pp. 22-27
Author(s):  
K. A. Simonova ◽  
E. N. Mikhaylov ◽  
R. B. Tatarskiy ◽  
A. V. Kamenev ◽  
D. V. Panin ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Ventricular Tachycardia ◽  
Low Voltage ◽  
Epicardial Mapping ◽  
Voltage Mapping ◽  
Arrhythmogenic Substrate ◽  
Ablation Success ◽  
History Of ◽  
Ventricular Activity ◽  
Epicardial Access

Introduction. Radiofrequency ablation (RFA) is an established treatment of post-myocardial infarction ventricular tachycardia (VT). Endocardial VT ablation can be insufficient for VT termination when the scar is intramural/epicardial.Purpose: to assess the extent of epicardial electrophysiological VT substrate in patients with remote myocardial infarction.Materials and methods. Thirteen patients with sustained postinfarction VT, who signed an informed consent, were included into the study. All patients underwent full clinical evaluation. Electroanatomical voltage bi- and unipolar mapping of endocardial and epicardial surfaces was performed. Maps were evaluated for the presence of low-voltage areas and local abnormal ventricular activity (LAVA). RFA was performed at LAVA sites. The end-point of the procedure was scar LAVA abolition and VT noninducibility (procedure success). VT recurrence was detected using an implantable cardioverter-defibrillator and/or ECG monitoring.Results. Epicardial access was successful in 12 patients. Epicardial access was performed at a first procedure in 7 patients, 4 patients had a history of previous endocardial ablation. Epicardial LAVA sites were detected in 9 patients. Endocardial and epicardial arrhythmogenic substrate localization coincided in 8 patients. One patient had only epicardial scar, 1 patient had only septal endocardial scar. In one patient LAVA sites had different localizations on epicardial and endocardial maps. Acute ablation success was noted in 12 patients.Conclusion. In our patient group transmural scar and epicardial electrophysiological arrhythmogenic substrate was detected in 82% of cases. Isolated endocardial ablation may be unsuccessful, in such cases epicardial mapping and ablation might be useful.

scholarly journals Epicardial Radiofrequency Ablation: Who, When, and How?

2021 ◽  
Author(s):  
Chin-Yu Lin
Keyword(s):  
Ventricular Tachycardia ◽  
Radiofrequency Ablation ◽  
Ischemic Cardiomyopathy ◽  
Imaging Modalities ◽  
Disease Entity ◽  
Potential Complication ◽  
Epicardial Mapping ◽  
Epicardial Ablation ◽  
The Past ◽  
Epicardial Access

In the past decades, it has been known that reentry circuits for ventricular tachycardia or focal triggers of premature ventricular complexes are not limited to the subendocardial myocardium. Rather, intramural or subepicardial substrates may also give rise to ventricular tachycardia, particularly in those with non-ischemic cardiomyopathy. Besides, some of the idiopathic ventricular tachycardia might be originated from epicardial foci. Percutaneous epicardial mapping and ablation have been successfully introduced to treat this sub-epicardiac ventricular tachycardia. Herein, this chapter reviews the indications for epicardial ablation and the identification of epicardial ventricular tachycardia by disease entity, electrocardiography and imaging modalities. This chapter also described the optimal technique for epicardial access and the potential complication.

scholarly journals Phrenic nerve displacement by intrapericardial balloon inflation during epicardial ablation of ventricular tachycardia: Four case reports

2020 ◽  
Vol 12 (1) ◽  
pp. 55-66
Author(s):  
Sergio Conti ◽  
Vito Bonomo ◽  
Antonio Taormina ◽  
Umberto Giordano ◽  
Giuseppe Sgarito
Keyword(s):  
Ventricular Tachycardia ◽  
Phrenic Nerve ◽  
Case Reports ◽  
Balloon Inflation ◽  
Epicardial Ablation

scholarly journals Endocardial vs endo-epicardial ablation of ventricular arrhythmia in arrhythmogenic right ventricular cardiomyopathy: a single center experience

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
K.A Simonova ◽  
A.V Kamenev ◽  
R.B Tatarskiy ◽  
M.A Naymushin ◽  
V.S Orshanskaya ◽  
...  
Keyword(s):  
Ventricular Arrhythmia ◽  
Low Voltage ◽  
Arrhythmogenic Right Ventricular Cardiomyopathy ◽  
Control Group ◽  
Definite Diagnosis ◽  
Premature Ventricular Contractions ◽  
Single Center Experience ◽  
Voltage Mapping ◽  
Epicardial Access

Abstract Background The majority of patients have a sub-epicardial scar as a substrate for VT episodes. Purpose We sought to compare the efficacy of endocardial (ENDO) and epicardial (EPI) substrate modification in patients with ARVC. Methods 20 consecutive ARVC patients (mean age 41,4±13,8, 70% males; ICD previously implanted in 10 patients) with indications to ventricular arrhythmia ablation (RFA) were included into a prospective observational study. The EPI group consisted of 10 patients with sustained ventricular tachycardia (VT) (definite diagnosis ARVC – 8 patients; borderline – 1, possible – 1) who signed an informed consent to epicardial access. The ENDO group included 10 patients (definite diagnosis ARVC – 9 patients), five of them demonstrated sustained VT and 5 patients had frequent symptomatic premature ventricular contractions (PVC). Epicardial access in the EPI group was obtained through subxyphoid puncture. Bi- and unipolar voltage mapping of endocardial and epicardial surfaces was performed. Maps were evaluated for the presence of local abnormal ventricular electrical activity (LAVA, low-voltage areas and sites with highly fractionated or late activity). Ablation was performed at sites of LAVA on either side of the ventricular wall. In the ENDO group endocardial only ablation at LAVA sites was performed. RF energy ablation was 40W at the epicardial surface and 40–50W at the endocardial surface. Results In the EPI group endocardially mapped area of unipolar endocardial low voltage zone (LVZ) significantly prevailed over bipolar endocardial area of LVZ: 75.4 cm2 [IQR: 23.2; 211.9] vs 6.7 cm2 [IQR: 4.4; 35.5](P=0.009). Epicardial bipolar LVZ area prevailed over unipolar epicardial LVZ area: 65.3 cm2 [IQR: 55.6; 91.3] vs 6.7 cm2 [IQR: 4.4; 35.3] (P=0.005). Endocardial unipolar LVZ area in the EPI group was larger than in the ENDO group (P>0,05). After ablation non-inducibility of any ventricular arrhythmia was achieved in 90% of patients in the EPI group and in 80% of cases in the ENDO group. During a mean follow-up period of 22.3±10.5 months freedom of ventricular arrhythmia recurrence was 70% in the EPI group and 100% in the control group. Conclusions Although epicardial area of abnormal potentials significantly prevails over endocardial area, endocardial unipolar mapping and higher RF ablation power allow performing successful ventricular arrhythmia treatment in the majority of ARVC patients. Funding Acknowledgement Type of funding source: None

Characterization of the phrenic nerve course within the epicardial substrate of patients with nonischemic cardiomyopathy and ventricular tachycardia

Heart Rhythm ◽  
2009 ◽  
Vol 6 (1) ◽  
pp. 59-64 ◽  
Author(s):  
Roger Fan ◽  
Oscar Cano ◽  
Siew Yen Ho ◽  
Rupa Bala ◽  
David J. Callans ◽  
...  
Keyword(s):  
Ventricular Tachycardia ◽  
Phrenic Nerve ◽  
Nonischemic Cardiomyopathy

Ventricular tachycardia ablation in nonischemic cardiomyopathy

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
D Nascimento Matos ◽  
D Cavaco ◽  
P Carmo ◽  
MS Carvalho ◽  
G Rodrigues ◽  
...  
Keyword(s):  
Ventricular Tachycardia ◽  
Catheter Ablation ◽  
Left Ventricular ◽  
Scientific Development ◽  
Left Ventricular Ejection ◽  
Drug Resistant ◽  
Nonischemic Cardiomyopathy ◽  
Epicardial Ablation ◽  
Ventricular Ejection Fraction ◽  
Ventricular Tachycardia Ablation

Abstract Funding Acknowledgements Type of funding sources: None. INTRODUCTION Catheter ablation outcomes for drug-resistant ventricular tachycardia (VT) in nonischemic cardiomyopathy (NICM) are suboptimal when compared to ischemic cardiomyopathy. We aimed to analyse the long-term efficacy and safety of percutaneous catheter ablation in this subset of patients. METHODS Single-center observational retrospective registry including consecutive NICM patients who underwent catheter ablation for drug-resistant VT during a 10-year period. The efficacy endpoint was defined as VT-free survival after catheter ablation, while safety outcomes were defined by 30-days mortality and procedure-related complications. Independent predictors of VT recurrence were assessed by Cox regression. RESULTS In a population of 68 patients, most were male (85%), mean left ventricular ejection fraction (LVEF) was 34 ± 12%, and mean age was 58 ± 15 years. All patients had an implantable cardioverter-defibrillator. Twenty-six (38%) patients underwent epicardial ablation (table 1). Over a median follow-up of 3 years (IQR 1-8), 41% (n = 31) patients had VT recurrence and 28% died (n = 19). Multivariate survival analysis identified LVEF (HR= 0.98; 95%CI 0.92-0.99, p = 0.046) and VT storm at presentation (HR = 2.38; 95%CI 1.04-5.46, p = 0.041) as independent predictors of VT recurrence. The yearly rates of VT recurrence and overall mortality were 21%/year and 10%/year, respectively. No patients died at 30-days post-procedure, and mean hospital length of stay was 5 ± 6 days. The complication rate was 7% (n = 5, table 1), mostly in patients undergoing epicardial ablation (4 vs 1 in endocardial ablation, P = 0.046). CONCLUSION LVEF and VT storm at presentation were independent predictors of VT recurrence in NICM patients after catheter ablation. While clinical outcomes can be improved with further technical and scientific development, a tailored endocardial/epicardial approach was safe, with low overall number of complications and no 30-days mortality. Abstract Figure.

Abstract 646: Epicardial Ablation Of Ventricular Tachycardia - A Single Centre Experience

Circulation ◽  
2008 ◽  
Vol 118 (suppl_18) ◽  
Author(s):  
Boris Schmidt ◽  
KR Julian Chun ◽  
Buelent Koektuerk ◽  
Feifan Ouyang ◽  
Karl-Heinz Kuck
Keyword(s):  
Ventricular Tachycardia ◽  
Success Rate ◽  
Single Centre ◽  
Epicardial Ablation ◽  
Single Centre Experience ◽  
Radiofrequency Current ◽  
Acute Success ◽  
Procedural Success ◽  
Lv Aneurysm

Background: Radiofrequency current ablation (RFA) of ventricular tachycardia (VT) focuses on endocardial (endo) substrates. However, if endo RFA fails, an epi approach is a potential treatment option. We report a single centre experience of epi VT ablation. Patients and Methods: Between 06/2005 and 02/2008 42 pts (14 female, mean age 49 ± 18 years) underwent electroanatomical endo and epi mapping and ablation for intractable VT, syncope or VT storm with multiple ICD discharges. Pts with normal heart (n=7), ischemic cardiomyopathy (ICM; n=8), NICM (n=11), ARVD (n=8), LV-aneurysm (n=7) or sarcoidosis (n=1) were studied. Mean LV ejection fraction was 45±12%. 20/42 had had at least 1 previous ablation attempt for VT (range 1– 4 ablations). Acute success was defined as non-inducibility of the previously inducible VT. Chronic success was defined as recurrence of any VT. Results: Acute procedural success rate was 79% (30/38). In 4 pts VTs were not inducible during EPS. In 28/42 pts endo mapping revealed no pathologic potentials. In 23/38 pts and 7/38 the succesful RFC ablation site was epi and endo, respectively. In 9/38 pts endo ablation failed and VT could only be ablated from epi. Further 7/38 pts needed both endo and epi ablation. In In 4/8 failed ablations epi RFC ablation was impossible due to failed access to target site (adhesions; n=2), close vicinity of a coronary artery (n=1) or the phrenic nerve (n=1). Procedure duration was 263±97 min. Unfortunately, 1 pt died due to perforation of RV and 1 pt had severe hepatic bleeding after epi puncture. One pt died in cardiogenic shock 1 d after the procedure. In 2 pts a sterile pericarditis occurred which resolved without any further intervention. After a median follow-up of 293 days (1–929 days) 53% of pts were alive and free from any VT. Conclusion: In pts with failed endo RFC ablation for VT due to different etiologies epi RFC ablation was acutely successful in 61% of pts with a moderate chronic success rate. However, major complications occured in approximately 5% of pts. Epi mapping should be considered if endo pathologic potentials are absent or if endo ablation failed.

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