Prophylactic Catheter Ablation for the Prevention of Defibrillator Therapy

Reddy, Vivek Y.; Reynolds, Matthew R.; Neužil, Petr; Richardson, Allison W.; Táborský, Miloš; Jongnarangsin, Krit; Královec, Štěpán; Šedivá, Lucie; Ruskin, Jeremy N.; Josephson, Mark E.

doi:10.1056/nejmoa065457

Cited by 811 publications

(544 citation statements)

References 25 publications

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“…4,5 However, no dramatic impedance changes were seen during the ablation in this case. The maximal power (50 W) was on the upper end of frequently used power settings, and we did not test for noncapture after delivering the initial RFA lesions, which could have potentially limited the number of lesions given, However, energy delivery and monitoring parameters were within those reported in large clinical trials 1,6 but still resulted in a LV transmural lesion and perforation. To our knowledge, this is the first time that an LV perforation has been reported during endocardial RFA for VT.…”

Section: Discussionmentioning

confidence: 99%

Left Ventricular Perforation During Cooled-Tip Radiofrequency Ablation for Ischemic Ventricular Tachycardia

Jiménez

Kuk

Ahmad

et al. 2011

Circ: Arrhythmia and Electrophysiology

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A 69-year-old man with a history of ischemic cardiomyopathy who had multiple implantable cardioverterdefibrillator shocks for sustained monomorphic ventricular tachycardia (VT) despite antiarrhythmic therapy underwent VT ablation. Because of the patient's severe peripheral vascular disease, left ventricular (LV) access was obtained via transseptal access using a Brockenbrough needle (BRK, St Jude Medical, Minnetonka, MN) over a medium curve, 8.5F Agilis sheath (St Jude Medical) under fluoroscopy and intracardiac ultrasound (ICE) guidance (AcuNav, Siemens, Mountainview, CA). Systemic heparin was given with the activated clotting time ranging from 250 to 340 seconds. A 7.5F bidirectional, deflectable, 3.5-mm-tip, external-irrigated ablation catheter (EZ STEER ThermoCool, Biosense Webster, Diamond Bar, CA) was advanced into the LV, and an electroanatomic map was created using the CARTO 3 mapping system (Biosense Webster). A large endocardial inferobasal scar was seen on the voltage map. Programmed electric stimulation and burst pacing were performed from several right ventricular and LV sites with 3 drive train cycle lengths and up to triple extrastimuli with a minimal coupling interval of 200 ms. During programmed electric stimulation, VT was induced with a right bundle-branch block morphology, right superior axis, and a tachycardia cycle length of 537 ms, matching the leadless electrogram morphology of the clinical VT. Pace mapping at the lateral edge of the inferobasal scar showed a 12/12 PM correlation with the clinical VT (Figure, D). Intermittent ICE imaging during the voltage/pace mapping showed no pericardial effusion. Radiofrequency ablation (RFA)was performed using a powered controlled setting (Stockert 70 RF Generator, Biosense Webster, Diamond Bar, CA) and a COOLFLOW irrigation system with a saline infusion rate of 30 mL/min, maximum power of 50 W (starting with 30 W and a gradual increase), temperature limit not to exceed 50°C, and an impedance delta no greater than 10 ⍀ (7 RF applications; mean RF duration of 87 seconds per lesion; total RF duration of 611 seconds). After 10 minutes of focal RFA for the clinical VT, further RF was delivered, extending the lesion set into the lateral aspect of the scar (6 RF applications; mean RF duration of 106 seconds per lesion; total RF duration of 640 seconds). No steam pops or sudden impedance drops were observed during ablation (Figure, B). Fluoroscopy did not reveal a significant change of the heart border. After the final RF lesions, programmed electric stimulation was performed, showing that VT was no longer inducible. Twelve minutes after the final RF delivery, a sudden drop in systemic blood pressure from 140/90 to 80/60 mm Hg was noted. ICE images revealed a 1.5-cm pericardial effusion (Supplemental Video 1). Intravenous heparin was discontinued, and fluids and protamine were given intravenously. An emergent pericardiocenthesis was performed with drainage of 650 mL of nonclotting blood. Initially, systemic blood pressure quickly recovered, but during the ...

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Section: Discussionmentioning

confidence: 99%

Left Ventricular Perforation During Cooled-Tip Radiofrequency Ablation for Ischemic Ventricular Tachycardia

Jiménez

Kuk

Ahmad

et al. 2011

Circ: Arrhythmia and Electrophysiology

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“…Recentemente, com a publicação do estudo MADIT-II 110 O EEF também está indicado nos pacientes com cardiopatia isquêmica já portadores de CDI, para guiar terapia de ablação com radiofrequência a fim de diminuir o número de choques aplicados pelo dispositivo 113 .…”

Section: -Avaliação Eletrofisiológica Invasiva Após Infarto Agudo Do unclassified

Diretrizes

2009

Arq. Bras. Cardiol.

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-Atendimento pré-hospitalarO interesse no atendimento pré-hospitalar do infarto agudo do miocárdio (IAM) teve início na década de 1960, devido ao grande número de óbitos que ocorriam antes que os paciente chegassem ao hospital.A maioria das mortes por IAM ocorre nas primeiras horas de manifestação da doença, sendo 40%-65% dos casos na primeira hora e, aproximadamente, 80% nas primeiras 24 horas [1][2][3] . Assim, a maior parte das mortes por IAM acontece fora do ambiente hospitalar, geralmente desassistidas pelos médicos 4 . A modalidade mais frequente de parada cardiorrespiratória nas primeiras horas do IAM é a fibrilação ventricular 3 . -Período pré-hospitalar.O período pré-hospitalar compreende dois momentos: a) do início dos sintomas (geralmente dor torácica aguda) até a decisão de procurar atendimento; b) da decisão de procurar atendimento até a chegada ao hospital.No infarto agudo do miocárdio com elevação do segmento ST (IAMCST), o tempo desde o início dos sintomas (oclusão da artéria coronária) até a instituição do tratamento (reperfusão química ou mecânica) é diretamente proporcional à ocorrência de eventos clinicamente relevantes. Esse tempo é fator fundamental para o benefício do tratamento, tanto imediato quanto tardio 5 .No entanto, sabe-se que a fase pré-hospitalar (em ambos os momentos descritos) é caracterizada por ser demorada, especialmente em pacientes idosos, do sexo feminino e com baixa condição socioeconômica 4 . Alguns fatores estão relacionados ao aumento desse tempo tão precioso (Quadro 1.1.1.1) 6 . O componente pré-hospitalar no atraso do atendimento ao paciente com dor torácica é de tal magnitude que, na prática clínica, apenas cerca de 20% destes pacientes chegam ao setor de emergência com até duas horas após o início dos sintomas 7 . -Medidas na fase pré-hospitalarApesar da significativa redução da mortalidade hospitalar do IAM nas últimas décadas 8,9 , houve pouco avanço no conhecimento sobre a epidemiologia e o tratamento na fase pré-hospitalar. É notória a necessidade de mudanças nesse cenário, embora poucas sejam as evidências geradas para este fim.A abordagem do paciente com suspeita de síndrome coronária aguda em ambiente extra-hospitalar deve, idealmente, ser feita por profissional de saúde, com realização de uma história clínica direcionada, investigando as características dos sintomas atuais (momento do início, tempo de duração, qualidade, intensidade, relação com o esforço e repouso) e a presença de doença coronária estabelecida (angina prévia). Algumas características são reconhecidamente determinantes para a manifestação atípica de um evento coronariano e devem ser lembradas quando um indivíduo for abordado na fase pré-hospitalar, por mascararem o quadro de IAM (Tabela 1.1.2.1) [10][11][12] .O eletrocardiograma executado no local de atendimento e interpretado por um médico habilitado (na ambulância ou em local remoto) mostrou ser um método que reduz em 34% o tempo porta-agulha e em 18% o tempo porta-balão, além de proporcionar maiores taxas de tempo porta-balão ideal (men...

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“…9 Ablation to modify the arrhythmia substrate significantly reduced the incidence of appropriate ICD therapy. The Ventricular Tachycardia Ablation in Coronary Heart Disease (VTACH) study included patients with ischaemic heart disease, and spontaneous VT who were receiving an ICD.…”

Section: Ventricular Tachycardia In Patients With Structural Heart DImentioning

confidence: 99%

“…Cooling is achieved by fluid circulated internally or by open saline irrigation of the electrode tip. 8,9 Open irrigation catheters carry the risk of intravascular fluid overload during ablation but may have a smaller risk for thrombus formation. Newer catheters incorporate feedback on contact force and have the potential for improving catheter contact with myocardium thereby potentially facilitating the creation of deeper and more consistent lesions.…”

Section: Mapping and Ablation Technologies And Procedural Considerationsmentioning

confidence: 99%

Catheter Ablation for Ventricular Arrhythmias

Nof

Stevenson

John

2013

Arrhythmia &Amp; Electrophysiology Review

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Sustained ventricular tachycardia (VT) and ventricular fibrillation (VF)are typically a manifestation of significant structural heart disease and often associated with a high risk of sudden cardiac death. Implantable cardioverter defibrillators (ICDs) remain the mainstay of therapy for prevention of sudden cardiac death associated with these arrhythmias. 1 However, ICDs treat the arrhythmia after it occurs and does not prevent the arrhythmia. Recurrent ventricular arrhythmias can lead to multiple ICD shocks that are painful, decrease quality of life and cause post-traumatic stress disorder. Spontaneous VT and ICD shocks are also associated with an increased risk of death and progressive heart failure.2 Antiarrhythmic drugs, notably amiodarone, reduce arrhythmias for some patients, but have limited efficacy for long-term management, particularly for scar-related re-entrant arrhythmias. 3In addition, antiarrhythmic drugs have the potential for significant adverse effects that includes negative inotropy, pro-arrhythmia and non-cardiac organ toxicities that limit their long-term use.3,4 Catheter ablation offers an alternative therapy for preventing arrhythmias, and can be life-saving when frequent episodes (VT storm) threaten survival.VT or repetitive premature ventricular contractions (PVCs) may also occur in the absence of structural heart disease.5 These arrhythmias are often termed 'idiopathic' and generally carry a benign prognosis, but symptoms warrant therapy in some patients. In addition, frequent ventricular arrhythmia can lead to ventricular dysfunction. 6 The cause of depressed ventricular function is often unclear at the initial presentation and the diagnosis of arrhythmia induced ventricular dysfunction may become apparent only after effective suppression of PVCs or VT. Mapping and Ablation Technologies and Procedural ConsiderationsRadiofrequency (RF) current remains the most commonly used energy source. Lesion size is limited by coagulum formation on the electrode when electrode temperature exceeds 70 degrees Celsius. AbstractCatheter ablation has emerged as an important and effective treatment option for many recurrent ventricular arrhythmias. The approach to ablation and the risks and outcomes are largely determined by the nature of the severity and type of underlying heart disease. In patients with structural heart disease, catheter ablation can effectively reduce ventricular tachycardia (VT) episodes and implantable cardioverter defibrillator (ICD) shocks. For VT and symptomatic premature ventricular beats that occur in the absence of structural heart disease, catheter ablation is often effective as the sole therapy. Advances in catheter technology, imaging and mapping techniques have improved success rates for ablation. This review discusses current approaches to mapping and ablation for ventricular arrhythmias.

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Prophylactic Catheter Ablation for the Prevention of Defibrillator Therapy

Cited by 811 publications

References 25 publications

Left Ventricular Perforation During Cooled-Tip Radiofrequency Ablation for Ischemic Ventricular Tachycardia

Left Ventricular Perforation During Cooled-Tip Radiofrequency Ablation for Ischemic Ventricular Tachycardia

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Catheter Ablation for Ventricular Arrhythmias

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