Single-lead ICD with atrial-sensing electrodes shows a lower incidence of inappropriate ICD therapy compared with the absence of atrial-sensing electrodes, without additional operative burden or increased complications.
BackgroundCatheter ablation of slow-pathway (CaSP) has been reported to be effective in patients with dual atrioventricular nodal conduction properties (dcp-AVN) and clinical ECG documentation but without the induction of tachycardia during electrophysiological studies (EPS). However, it is unknown whether CaSP is beneficial in the absence of pre-procedural ECG documentation and without the induction of tachycardia during EPS. The aim of this study was to evaluate long-term results after a “pure” empirical CaSP (peCaSP).Methods334 consecutive patients who underwent CaSP (91 male, 47.5 ± 17.6 years) were included in this study. Sixty-three patients (19%) who had no pre-procedural ECG documentation, and demonstrated dcp-AVN with a maximum of one echo-beat were assigned to the peCaSP group. The remaining 271 patients (81%) were assigned to the standard CaSP group (stCaSP). Clinical outcomes of the two groups were compared, based on ECG documented recurrence or absence of tachycardia and patients’ recorded symptoms.ResultsCaSP was performed in all patients without any major complications including atrioventricular block. During follow-up (909 ± 435 days), 258 patients (77%) reported complete cessation of clinical symptoms. There was no statistically significant difference in the incidence of AVNRT recurrence between the peCaSP and stCaSP groups (1/63 [1.6%] vs 3/271 [1.1%], P = 0.75). Complete cessation of clinical symptoms was noted significantly less frequently in patients after peCaSP (39/63 [62%] vs 219/271 [81%], P = 0.0013). The incidence of non-AVNRT atrial tachyarrhythmias (AT) was significantly higher in patients after peCaSP (5/63 [7.9%] vs 1/271 [0.4%], P = 0.0011).ConclusionA higher incidence of other AT and subjective symptom persistence are demonstrated after peCaSP, while peCaSP improves clinical symptoms in 60% of patients with non-documented on–off tachycardia.
Background
Scar-related ventricular tachycardia (VT) is a challenging medical condition with catheter ablation providing a valuable treatment option. Whilst most VTs can be ablated endocardially, epicardial ablation is often required in patients with non-ischaemic cardiomyopathy (NICM). The percutaneous subxiphoid technique has become instrumental for epicardial access. However, it is not feasible in up to 28% of cases for multiple reasons.
Case Summary
A 47-year-old patient was managed at our centre for VT storm and recurrent implantable cardioverter–defibrillator (ICD) shocks for monomorphic VT (MMVT) despite maximum drug therapy. No scar was noted during endocardial mapping with confirmation of localised epicardial scar on cardiac magnetic resonance imaging (CMR). Following failed percutaneous epicardial access, a successful hybrid surgical epicardial VT cryoablation via median sternotomy was performed in the electrophysiology (EP) laboratory utilising data from CMR, prior endocardial ablation and conventional EP mapping. The patient has remained arrhythmia free for 30 months post-ablation without antiarrhythmic therapy.
Discussion
This case describes a practical multidisciplinary approach to managing a challenging clinical problem. Whilst the described technique is not entirely novel, this is the first case report which describes the practicalities, and demonstrates the safety and feasibility, of hybrid epicardial cryoablation via median sternotomy performed in the cardiac EP laboratory for the sole treatment of VT.
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