Transcoronary Ethanol Ablation for Recurrent Ventricular Tachycardia After Failed Catheter Ablation

Tokuda, Michifumi; Sobieszczyk, Piotr; Eisenhauer, Andrew C.; Kojodjojo, Pipin; Inada, Keiichi; Koplan, Bruce A.; Michaud, Gregory F.; John, Roy M.; Epstein, Laurence M.; Sacher, Frédéric; Stevenson, William G.; Tedrow, Usha B.

doi:10.1161/circep.111.966283

Cited by 134 publications

(79 citation statements)

References 21 publications

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“…Transcoronary ethanol ablation is another option, but it can be limited by coronary anatomy and also has significant risks. 5 Surgical ablation can be an option as well, but requires thoracotomy. 9 Intramyocardial needle ablation with saline infusion has been demonstrated to create deep RF ablation lesions in animal models.…”

Section: Discussionmentioning

confidence: 99%

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Initial Human Feasibility of Infusion Needle Catheter Ablation for Refractory Ventricular Tachycardia

et al. 2013

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2289Background-Ablation of ventricular tachycardia (VT) is sometimes unsuccessful when ablation lesions are of insufficient depth to reach arrhythmogenic substrate. We report the initial experience with the use of a catheter with an extendable/ retractable irrigated needle at the tip capable of intramyocardial mapping and ablation. Methods and Results-Sequential consenting patients with recurrent VT underwent ablation with the use of a needletipped catheter. At target sites, the needle was advanced 7 to 9 mm into the myocardium, permitting pacing and recording. Infusion of saline/iodinated contrast mixture excluded perforation and ensured intramyocardial deployment. Further infusion was delivered before and during temperature-controlled radiofrequency energy delivery through the needle. All 8 patients included (6 male; mean age, 54) with a mean left ventricular ejection fraction of 29% were refractory to multiple antiarrhythmic drugs, and 1 to 4 previous catheter ablation attempts (epicardial in 4) had failed.Patients had 1 to 7 (median, 2) VTs present or inducible; 2 were incessant. Some intramyocardial VT mapping was possible in 7 patients. A mean of 22 (limits, 3-48) needle ablation lesions were applied in 8 patients. All patients had at least 1 VT terminated or rendered noninducible. During a median of 12 months follow-up, 4 patients were free of recurrent VT, and 3 patients were improved, but had new VTs occur at some point during follow-up. Two died of the progression of preexisting heart failure without recurrent VT. Complications included tamponade in 1 patient and heart block in 2 patients. Conclusions-Intramyocardial infusion-needle catheter ablation is feasible and permits control of some VTs that have been refractory to conventional catheter ablation therapy, warranting further study. (Circulation. 2013;128:2289-2295.)

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Section: Discussionmentioning

confidence: 99%

“…5 A common limitation is the existence of reentry substrate that is beyond the reach of ablation with the use of standard techniques, [6][7][8] in some cases requiring an open surgical approach. 9 …”

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Initial Human Feasibility of Infusion Needle Catheter Ablation for Refractory Ventricular Tachycardia

et al. 2013

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“…34,35 Success of TCEA depends upon favourable coronary anatomy, with a patent vessel supplying the area of interest. Once a suitable branch is identified, the relationship between the branch and a critical portion of the VT circuit is proven by observing that VT terminates with injection of iced saline or by occlusion of the branch by balloon inflation.…”

Section: Transcoronary Ethanol Ablationmentioning

confidence: 99%

“…In a series from our centre, acute clinical success was obtained in 56 % of patients; all VT recurrences were prevented in 36 % and improved arrhythmia control was achieved in an additional 27 %. 34 The need for this approach is infrequent (1-2 %) and complications include heart block and extension of infarction with further deterioration of LV function. However, in patients with intractable VT unresponsive to traditional ablation techniques, this approach can be life-saving.…”

Section: Transcoronary Ethanol Ablationmentioning

confidence: 99%

Catheter Ablation for Ventricular Arrhythmias

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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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“…Transcoronary ethanol ablation could also be considered. 4 In this case, dehiscence of a portion of the patch allowed access to a critical region for the VT from an LV endocardial approach. Dehiscence of the endocardial patch appears to be a rare postoperative complication after Dor procedure.…”

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Catheter Ablation of Ventricular Tachycardia Beneath an Endoventricular Patch

et al. 2014

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A 70-year-old male with a history of ischemic heart disease with a left ventricular ejection fraction of 35% was referred for ablation to control recurrent episodes of ventricular tachycardia (VT) despite amiodarone therapy and a previous failed catheter ablation attempt. He had undergone coronary artery bypass grafting 20 years ago, and reoperation for mitral valve repair and endoventricular patch reconstruction (Dor procedure) of an anteroapical left ventricular aneurysm 10 years ago.After informed written consent was obtained, catheter mapping and ablation were performed with saline irrigated-tip catheter using electroanatomic mapping (CARTO; Biosense Webster, Diamond Bar, CA). A monomorphic VT with right bundle-branch block morphology in V1 was inducible and hemodynamically tolerated. Intracardiac echocardiography showed a pouch beneath the patch, consistent with dehiscence of a portion of the endoventricular patch, which had been recognized shortly after surgery 10 years previously (Figure 1). No thrombus was evident in the left ventricle (LV) or the pouch. Three-dimensional shells of the LV, the patch, and the apical aneurysmal pouch were separately created using intracardiac echocardiography ( Figure 2). During LV mapping the ablation catheter was observed to enter the LV pouch from a site on its lateral aspect. A site with late potentials during sinus rhythm and presystolic fractionated electrograms during VT was found at the septal aspect of the apical pouch. Entrainment of VT at this site showed minimal fusion and the postpacing interval assessment relative to the tachycardia cycle length, consistent with an area in an outer loop near the exit (Figure 3). VT terminated 4 seconds after initiation of radiofrequency current application at this site. Radiofrequency ablation was applied until pacing at 10-mA 2-ms pulse width no longer captured. After ablation, no sustained VT was inducible by programmed electric stimulation with up to 3 extrastimuli from the right ventricle and LV with or without isoproterenol infusion. The patient has remained free of VT during 1 year of follow-up.When VT occurs in the setting of an anterior LV aneurysm, simple resection of the aneurysm often fails to abolish VT, and resection or ablation that includes the surrounding scarred endocardium is usually effective.1 Surgical left ventricular reconstruction with an endovascular dacron or pericardial patch was described by Dor et al 2 as a method to preserve physiological geometry. It excludes access to the aneurysm and some of the infarct border zone, which may contain the substrate for VT. Ablation of VT can sometimes be achieved at sites along the border of the patch, but if this fails, a surgical approach to reach myocardium beneath the patch may be required.3 Percutaneous epicardial ablation is often not possible because of pericardial adhesions that limit pericardial access, and the VT may originate deep to the epicardium in any case. Transcoronary ethanol ablation could also be considered. 4 In this case, dehiscence of a po...

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Transcoronary Ethanol Ablation for Recurrent Ventricular Tachycardia After Failed Catheter Ablation

Cited by 134 publications

References 21 publications

Initial Human Feasibility of Infusion Needle Catheter Ablation for Refractory Ventricular Tachycardia

Initial Human Feasibility of Infusion Needle Catheter Ablation for Refractory Ventricular Tachycardia

Catheter Ablation for Ventricular Arrhythmias

Catheter Ablation of Ventricular Tachycardia Beneath an Endoventricular Patch

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