Safety, Long-Term Results, and Predictors of Recurrence After Complete Endocardial Ventricular Tachycardia Substrate Ablation in Patients With Previous Myocardial Infarction

Arenal, Ángel; Hernández, Jesús; Calvo, David; Ceballos, Cecilia; Atéa, Leonardo; Datino, Tomás; Atienza, Felipe; González‐Torrecilla, Esteban; Eidelman, Gabriel; Miracle, Ángel; Ávila, Pablo; Bermejo, Javier; Fernández-Avilés, Francisco

doi:10.1016/j.amjcard.2012.10.031

Cited by 46 publications

(28 citation statements)

References 22 publications

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“…8 Such an association was not observed in our study population, where LP abolition was associated with reduced VT recurrence. Last but not least, we had the opportunity to assess for the first time the prognostic value of EAM characteristics for cardiac death.…”

Section: Prognostic Value Of Eam Characteristicscontrasting

confidence: 40%

“…6 Further research focused on identification of critical VT isthmuses and conducting channels between unexcitable scar areas. 7,8 More recent substrate ablation strategies focused on EGM characteristics beyond scar identification. In this setting, we have consistently presented that complete LPs abolition based on remapping, in combination with VT noninducibility, constitutes an excellent procedural end-point.…”

Section: Evolution Of Substrate-based Ablation Strategiesmentioning

confidence: 99%

“…6 A variety of alternative substrate-based methods have evolved to overcome the shortcomings of activation and entrainment mapping. [6][7][8][9][10][11][12] Substrate ablation during sinus rhythm consists of late potential (LP) abolition, elimination of local abnormal ventricular activities (LAVAs), conduction channel ablation, linear isthmus ablation, electric isolation of low voltage area, and scar homogenization, all identified by electroanatomical mapping (EAM). [6][7][8][9][10][11][12] The purpose of this study was to analyze the endo-epicardial EAM voltage and morphology characteristics to describe the appropriateness of each substrate ablation strategy, the interrelationship of EAM characteristics, their association with clinical data, and their prognostic value in a large cohort of post-MI patients undergoing EAM-based catheter ablation for VT.…”

mentioning

confidence: 99%

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Electroanatomical Voltage and Morphology Characteristics in Postinfarction Patients Undergoing Ventricular Tachycardia Ablation

Tsiachris

Silberbauer

Maccabelli

et al. 2015

Circ: Arrhythmia and Electrophysiology

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Background-Catheter ablation is an important therapeutic option in postmyocardial infarction patients with ventricular tachycardia (VTAll patients had unipolar low voltage areas, whereas 18% had no identifiable endocardial bipolar DS areas. Endocardial bipolar DS area >22.5 cm 2 best predicted scar transmurality. Endo-epicardial LPs were recorded in 2/3 patients, more frequently in nonseptal myocardial segments and were abolished in 51%. Endocardial bipolar DS area >7 cm 2 and endocardial bipolar scar density >0.35 predicted epicardial LPs. Isolated LPs are located mainly epicardially and EPs endocardially. As a primary strategy, LPs and VT-mapping ablation occurred in 48%, only VT-mapping ablation in 27%, only LPs ablation in 17%, and EPs ablation in 6%. Endocardial LP abolition was associated with reduced VT recurrence and increased unipolar penumbra area predicted cardiac death. Conclusions-Endocardial scar extension and density predict scar transmurality and endo-epicardial presence of LPs, although DS is not always identified in postmyocardial infarction patients. LPs, most frequently located in nonseptal myocardial segments, were abolished in 51% resulting in improved outcome. (Circ Arrhythm Electrophysiol.

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Section: Prognostic Value Of Eam Characteristicscontrasting

confidence: 40%

Section: Evolution Of Substrate-based Ablation Strategiesmentioning

confidence: 99%

mentioning

confidence: 99%

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Electroanatomical Voltage and Morphology Characteristics in Postinfarction Patients Undergoing Ventricular Tachycardia Ablation

Tsiachris

Silberbauer

Maccabelli

et al. 2015

Circ: Arrhythmia and Electrophysiology

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“…Thus, the most frequent strategy currently used for VT ablation is a combination of activation and substrate mapping. 22,23 Substrate mapping currently involves careful delineation of the scar and surrounding areas during sinus rhythm or ventricular pacing 24 to target sites of fractionated, double, or LPs. The identification of LPs or local abnormal ventricular activations (LAVAs) is subjective, and in some cases, scar border zones may be abundant with LAVA.…”

Section: Discussionmentioning

confidence: 99%

Decrement Evoked Potential Mapping

Jackson

Gizurarson

Viswanathan

et al. 2015

Circ: Arrhythmia and Electrophysiology

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Background-Substrate-based mapping for ventricular tachycardia (VT) ablation is hampered by its inability to determine critical sites of the VT circuit. We hypothesized that those potentials, which delay with a decremental extrastimulus (decrement evoked potentials or DEEPs), are more likely to colocalize with the diastolic pathways of VT circuits. Methods and Results-DEEPs were identified in intraoperative left ventricular maps from 6 patients with ischemic cardiomyopathy (total 9 VTs) and were compared with late potential (LP) and activation maps of the diastolic pathway for each VT. Mathematical modeling was also used to further validate and elucidate the mechanisms of DEEP mapping. All patients demonstrated regions of DEEPs and LPs. The mean endocardial surface area of these potentials was 18±4% and 21±6%, respectively (P=0.13). The mean sensitivity for identifying the diastolic pathway in VT was 50±23% for DEEPs and 36±32% for LPs (P=0.31). The mean specificity was 43±23% versus 20±8% for DEEP and LP mapping, respectively (P=0.031). The electrograms that displayed the greatest decrement in each case had a sensitivity and specificity for the VT isthmus of 29±10% and 95±1%, respectively. Mathematical modeling studies recapitulated DEEPs at the VT isthmus and demonstrated their role in VT initiation with a critical degree of decrement. Conclusions-In this preliminary study, DEEP mapping was more specific than LP mapping for identifying the critical targets of VT ablation. The mechanism of DEEPs relates to conduction velocity restitution magnified by zigzag conduction within scar channels.

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“…This approach has been studied extensively in patients with scar-related VT and has shown improved long-term prognosis. [42][43][44] Due to the probabilistic nature of substrate modification, it is accepted that a large amount of ablation will be required. In fact, some centres have suggested a more extensive endocardial and epicardial scar ablation strategy in patients with IHD, termed scar homogenisation.…”

Section: Substrate Modificationmentioning

confidence: 99%

Ventricular Tachycardia Ablation – The Right Approach for the Right Patient

Sadek¹,

Schaller²,

Supple³

et al. 2014

Arrhythm Electrophysiol Rev

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Scar-related reentrant ventricular tachycardia (VT) may be present in a variety of structural heart disease (SHD) phenotypes. In this setting, VT circuits are comprised of viable myocytes separated by fibrosis, allowing for the slow conduction needed to facilitate reentry.1,2 Aetiologies of fibrosis include ischaemic heart disease (IHD), inflammatory conditions, infiltrative cardiomyopathy, dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy and arrhythmogenic right ventricular (RV) dysplasia.Implantable cardioverter defibrillators (ICDs) are the mainstay of therapy for the prevention of sudden cardiac death in patients with SHD.3 However, ICD shocks are associated with diminished quality of life and increased mortality.4-6 Anti-arrhythmic drugs (AADs) have an important role in shock reduction; however these agents often have limited efficacy and significant side-effects. 7,8 Catheter ablation has assumed an increasingly important role in the management of VT. In patients with IHD and drug-refractory VT, ablation has been shown to reduce arrhythmia recurrence and ICD therapies. 9-11Patients who have VT rendered non-inducible by an ablation procedure have a lower VT recurrence rate and mortality compared with those who still have inducible arrhythmias after the ablation.12 Catheter ablation has also been shown to be effective in the treatment of VT storm in patients with SHD receiving chronic AAD therapy. 13In the setting of non-ischaemic SHD, catheter ablation outcome varies according to the nature of the underlying heart disease, with a greater need for epicardial mapping and ablation, higher recurrence rate and more AAD use in long-term follow-up.14-16 For the most part, VT ablation remains underutilised and some patients may benefit from earlier intervention. 17Although ablation also has an important role in the management of patients with idiopathic VT, this review will focus on ablation of scarrelated reentrant VT, the most common mechanism of monomorphic VT in patients with SHD. Pre-procedural PlanningHeart failure optimisation is important for decreasing the risk of Electrocardiographic CharacterisationTwelve-lead electrocardiograms (ECGs) of all clinical VTs are important in localising VT exit sites, identifying potential ablation targets and directing the best ablation strategy including possible epicardial access.In the setting of non-ischaemic IHD, morphological criteria suggesting Abstract Scar-related reentry is the most common mechanism of monomorphic ventricular tachycardia (VT) in patients with structural heart disease. Catheter ablation has assumed an increasingly important role in the management of VT in this setting, and has been shown to reduce VT recurrence and implantable cardioverter defibrillator (ICD) shocks. The approach to mapping and ablation will depend on the underlying heart disease etiology, VT inducibility and haemodynamic stability. This review explores pre-procedural planning, approach to ablation of both mappable and unmappable VT, and post-procedural testing. Future de...

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Safety, Long-Term Results, and Predictors of Recurrence After Complete Endocardial Ventricular Tachycardia Substrate Ablation in Patients With Previous Myocardial Infarction

Cited by 46 publications

References 22 publications

Electroanatomical Voltage and Morphology Characteristics in Postinfarction Patients Undergoing Ventricular Tachycardia Ablation

Electroanatomical Voltage and Morphology Characteristics in Postinfarction Patients Undergoing Ventricular Tachycardia Ablation

Decrement Evoked Potential Mapping

Ventricular Tachycardia Ablation – The Right Approach for the Right Patient

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