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A, Surface 12-lead ECG of normal heart VT. B, Epicardial pace map at successful ablation site on posterolateral left ventricle. This demonstrates a nearly perfect pace map that was better than any endocardial pace map.
Source publication
The epicardial location of an arrhythmia could be responsible for unsuccessful endocardial catheter ablation.
In 48 patients referred after prior unsuccessful endocardial ablation, we considered percutaneous, subxiphoid instrumentation of the pericardial space for mapping and ablation. Thirty patients had ventricular tachycardia (VT), 6 patients ha...
Contexts in source publication
Context 1
... of these 24 VTs could be ablated only from the left coronary cusp, because epicardial lesions could not be delivered owing to interference from the left atrial appendage. Of the 18 remaining epicardial VTs, 17 (94%) were successfully ablated with epicardial lesions (Figures 1 through 3). Successful ablation of these 17 VTs required 31 (range, 1 to 5) epicardial lesions. ...
Context 2
... 9 (38%) of the 24 VTs with an early epicardial site, epicardial pacing could not be achieved because of inability to capture, even with a high stimulation output. For the 15 patients in whom epicardial pace mapping was possible, nearly identical QRS morphology was demonstrated that was never seen with endocardial pace mapping (Figure 1). ...
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Citations
... При наличии правосторонних эпикардиальных ДПЖС иногда используется субксифоидальный доступ для выполнения эпикардиальной аблации, как альтернативный «открытому» хирургическому методу леченипя. Чаще такой метод применяется у пациентов с парасептальными ДПЖС или наличием дивертикула коронарного синуса, что в ряде случаев затрудняет выполнение эндокардиальной аблации [6][7][8][9]. В последние годы с внедрением в клиническую практику видеоторакоскопической техники и минимально инвазивной хирургии появились единичные публикации по их использованию, как эффективного и безопасного подхода, для устранения правосторонних ДПЖС после неудачных эндокардиальных аблаций [10]. ...
The description of the clinical case presents a rare observation of a multi-stage approach to the treatment of right-sided accessory pathway. There are presented the results and features of successful epicardial ablation using a minimally invasive thoracoscopic approach, which made it possible to eliminate accessory pathways for right-sided epicardial localization after failed recurring cataract ablations.
... An important reason for procedural failure in these settings is the deeper extension of the substrate within the endocardium or the involvement of the subepicardium and epicardium. In addition, the presence of epicardial substrates, their density, and distribution is increasingly recognized in several forms of scar-related cardiomyopathies [2][3][4]. Although the epicardial approach to VT ablation increases the success rate, it remains a challenging procedure, requiring peculiar anesthetic management. ...
Background
Epicardial approach to ventricular tachycardia (VT) ablation is mainly performed under general anesthesia (GA). Although catheter manipulation and ablation in the epicardial space could be painful, GA lowers blood pressure and may interfere with arrhythmia induction and mapping, and the use of muscle relaxants precludes identification of the phrenic nerve (PN). Moreover, an anesthesiologist’s presence is required during GA for the whole procedure, which may not always be possible. Therefore, we evaluated the feasibility and safety of epicardial VT ablations performed under conscious sedation using dexmedetomidine in our center.Methods
Between January 2018 and January 2022, all patients who underwent epicardial VT ablation under continuous dexmedetomidine infusion were prospectively included in the study. All patients received premedication 30 min before the epicardial puncture with paracetamol (acetaminophen 10 mg/ml) 1000 mg and ketorolac 30 mg. Sedation protocol included an intravenous bolus of midazolam hydrochloride (0.03–0.05 mg/kg) followed by continuous infusion of dexmedetomidine (0.2–0.7 mcg/kg/h). In addition, an intravenous fentanyl citrate bolus (0.7–1.4 mcg/kg) was given for short-term analgesia, followed by a second dose repeated after 30 to 45 min. Sedation-related complications were defined in case of respiratory failure, severe hypotension, and bradycardia requiring treatment.ResultsSixty-nine patients underwent epicardial or endo-epi VT ablation under conscious sedation and were included in the analysis. The mean age was 65.4 ± 12.1 years; forty-six patients were males (66.6%). All patients had drug-refractory recurrent VT. Forty-seven patients (68.1%) had non-ischemic cardiomyopathy (NICM), 13 patients (18.9%) had ischemic-cardiomyopathy (ICM), and 9 patients (13%) had myocarditis. Standard percutaneous sub-xiphoid access was attempted in all patients. Non-inducibility of any VT was achieved in 82.6% (9/9 myocarditis, 10/13 ICM, 38/47 NICM, n = 57/69 patients), inducibility of non-clinical VT in 13% (3/13 ICM, 6/38 NICM, n = 9/69 patients), and failure in 4.3% (3/38 NICM, n = 3/69 patients). Although we observed procedural-related complications in five patients (7.2%), one transient PN palsy, two pericarditis, and two vascular complications, those were not related to the conscious sedation protocol. No respiratory failure, severe hypotension, or bradycardia requiring treatment has been observed among the patients.Conclusions
Prompt availability of anesthesiology support remains crucial for complex procedures such as epicardial VT ablation. Continuous infusion of dexmedetomidine and administration of midazolam and fentanyl seem to be a safe and effective sedation protocol in patients undergoing epicardial VT ablation.
... Conventional ventricular bipolar substrate voltage parameters were used (dense scar: < 0.5 mV, low voltage: 0.5-1.5 mV, normal > 1.5 mV) [18]. Unipolar lowvoltage was defined as electrogram amplitude < 8.3 mV (LV) [19], and < 5.5 mV (RV) [20]. The chamber mapped was based on the characteristics of the induced or spontaneously occurring VT. ...
Background
Women are under-represented in many key studies and trials examining outcomes of catheter ablation (CA) for ventricular arrhythmias (VA). We compared characteristics between men and women undergoing their first catheter ablation for VA at a single centre over 10 years.
Methods
The clinical, procedural characteristics and outcomes of 287 consecutive patients (male = 182, female = 105), undergoing their first CA at our centre over 10 years were compared according to sex and underlying heart disease.
Results
In the ablation population, women were younger, had fewer co-morbidities, were less likely to have ischemic cardiomyopathy (ICM) and VA storm and were more likely to have idiopathic VA and premature ventricular complexes as the indication for ablation (P < 0.05 for all). Amongst idiopathic and non-ischemic cardiomyopathy (NICM) subgroups, baseline characteristics were similar; amongst ICM, women were younger and had higher numbers of drug failure pre-ablation (P = 0.05). Women were similar to men in all procedural characteristics, acute procedural success and complications, regardless of underlying heart disease. At median follow-up of 666 days, VA-free survival, overall mortality and survival free of death or transplant were comparable in both groups. Sex was not a predictor of these outcomes, after accounting for clinical and procedural characteristics.
Conclusion
Women represented 36% of the real-world population at our centre referred for CA of VA. There are key differences in clinical features of women versus men referred for VA ablation. Despite these differences, VA ablation in women can be accomplished with similar success and complication rates to men, regardless of underlying heart disease.
... In the multicentric study of Della Bella et al. 12 published in 2011, only 38% of the patients received an epicardial ablation as first-line approach. This finding shows how the indication threshold for epicardial ablation has changed in the last decade from a bail-out solution in unsuccessful endocardial ablation [13][14][15] to a direct first-procedure target predominantly in NIDCM. This especially applies to patients with epicardial LGE, which underlines the importance of magnetic resonance imaging for the planning of these procedures. ...
Aims
Epicardial ablation has risen to an essential part of the treatment of ventricular tachycardias (VTs). In this study, we report the efficacy, risks, and current trends of epicardial ablation in structural heart disease as reported in a tertiary single centre over a 12-year period.
Methods and results
Two hundred and thirty-six patients referred for VT ablation underwent a successful epicardial access and were included in the analysis (89% non-ischaemic cardiomyopathy, 90% males, mean age 60 years, mean left ventricular ejection fraction 38.4%). After performing epicardial ablation the clinical VTs were eliminated in 87% of the patients and 71% of the cohort achieved freedom from VT during 22-month follow-up. Twelve patients (5%) suffered major procedure-related complications. Until the end of follow-up 47 (20%) patients died, 9 (4%) underwent a left ventricular assist device implantation and 10 (4%) patients received a heart transplantation. Antiarrhythmic drugs at baseline and during follow-up were independent predictors of VT recurrence. Atrial fibrillation, renal dysfunction, worse New York Heart Association class, and antiarrhythmic drugs at follow-up were associated with worse survival in our cohort.
Conclusion
In this large tertiary single-centre experience, percutaneous epicardial access was feasible in the large majority of the cohort with acceptably low complications rates. A combined endo-/epicardial approach resulted in 87% acute and 71% long-term success. Further studies are needed to clarify the role of routine combined endo-/epicardial ablation in these complex cardiomyopathies.
... Ablation from distal GCV, close to its continuation as the anterior interventricular (AIV), is a highly successful procedure [3], but anatomy of the cardiac venous system may prevent reaching the transition point, even with high-flow saline perfusion, 60 mL/min at a period of 2 min [10]. Percutaneous, pericardial instrumentation for epicardial catheter mapping and ablation of the LVS is feasible, safe, and may be applicable to a variety of cardiac arrhythmias in which standard endocardial ablation techniques have failed [11] unless the operating team is inexperienced in such technique. Omitting all aforementioned challenges, mapping ventricular prepotentials from the LAA via transseptal puncture seems to be comforta b l e a n d f e a s i b l e f o r m o d e r a t e l y e x p e r i e n c e d electrophysiologists. ...
PurposeVentricular arrhythmias originating from the left ventricular summit (LVS) may present with challenges for catheter ablation. Recently, the left atrial appendage (LAA) became a new vantage point for mapping and ablating arrhythmias from that region, but data of possible usefulness is limited.Methods
From September to December 2019, we retrospectively analyzed 48 consecutive patient hearts (20 male; mean age 57.9y ± 11.56) undergoing diagnostic coronary vessel imaging in 64 dual-source computer tomography angiography (CTA). Distances from the LAA to the LVS, LAA shape type, and coronary arteries in the LVS region were measured. Also, we compared the true LVS area from CTA with a calculated formula derived from LVS definition.ResultsThe mean LVS area calculated from the formula was 291.58 mm2 (± 115.5) while the true area calculated from CT was 263.33 mm2 (± 99.49) (p = 0.44). The mean inaccessible area was 133.42 mm2 (± 72.89), accessible 95.67 mm2 (± 72.77). The mean LAA coverage over LVS was 196.08 mm2—which is approximately 75% of LVS size in general. The most common LAA shape was chicken wing (50%); windsock has the highest accessible area coverage on average (80.23%), followed by chicken wing (59.88%), broccoli (47.72%), and cactus (46.98%). The mean distance from LAA to the surface was 5.14 mm (1.5 to 10 mm) and was not correlated with BMI. LAA has a 98% coverage over the point of transition between the great cardiac vein and anterior interventricular vein.Conclusion
Angio-CT assessment of the LAA over the LVS structures may be helpful in decision making before an ablation procedure. LAA appears to be a promising mapping approach in LVS arrhythmias.
... Эпикардиальная локализация дополнительных путей обусловливает 8% длительных и неудачных попыток выполнения аблации [14]. К сожалению, несмотря на улучшение технического оснащения, использование новых поколений катетеров и источников энергии для РЧА, некоторые субстраты аритмии оказываются недоступны с эндокардиальной поверхности [15]. ...
... В 3 случаях выполнена успешная торакоскопическая аблация эпикардиального ДПЖС от ушка правого предсердия к правому желудочку. По результатам эпикардиального картирования в 2 наблюдениях выявлена ранняя эндокардиальная активация, и аблация оказалась успешна исключительно с эндокардиальной поверхности [15]. ...
... В литературе описаны редкие случаи ДПЖС от ушка правого предсердия (УПП) к правому желудочку [15,[38][39][40]. Сложности в выявлении локализации ДПЖС встречаются нередко, а для успешной аблации у таких пациентов может потребоваться воздействие вдали от кольца, в области УПП, которая является местом ранней активации желудочков [16]. ...
... 18 Percutaneous epicardial ablation has been used in pathways far away from the endocardium, such as right atrial appendage to right ventricular pathway. 19,20 All these attempts greatly increase the overall success rate of RAP ablation. ...
Background:
Right-sided accessory pathway (RAP) ablation sometimes is very challenging.
Objective:
Our study aimed to demonstrate an alternative approach to ablation RAPs under the tricuspid valve, especially when the conventional ablation attempts at the atrial side failed.
Methods:
Twelve patients with RAPs were enrolled, 8 of whom had previous failed ablation. With the help of a long sheath, the under-valve approach was attempted in 3 patients during tachycardia, in 2 patients during ventricular pacing, and in 7 patients with sinus rhythm. Three-dimensional electroanatomic mapping was performed in 3 patients during their repeat procedures.
Results:
The acute outcomes of the procedures in all patients were successful. Patients were free of tachycardia or recurrence of accessory pathway conduction during a median 12.5 (range, 7-45) months' follow up. No complications were found during the procedure or the follow-up period.
Conclusions:
Radiofrequency ablation under the tricuspid valve to eliminate RAPs is feasible due to its stable contact and the accurate ablation of the ventricular insertion site. It provides an alternative approach to tough RAP ablation.
... Ablation of ventricular tachycardia remains a challenge due to the inaccessibility of the epicardial wall from the left ventricular chamber. Schweikert et al found 40% of the patients with ventricular tachycardia require additional epicardial ablation [46]. Zenati et al found that peri-cardioscopic approach is suitable for epicardial ablation and interventions [40]. ...
... Epicardial approach to VT ablation is being performed routinely in some institutions with variations in patient selection, approach and strategies related to mapping and ablation. 5,7,8,10,18,19 We studied the acute safety and efficacy of epicardial VT ablations done at our Institute. ...
Background and aim: Epicardial approach to VT ablation increases the success rate of ablation but is not without complications. We studied the safety and efficacy of epicardial VT ablations performed at our institute.
Methods: All patients who underwent epicardial VT ablation at our institute were studied retrospectively. The outcome of VT ablation was among three groups: ischaemic cardiomyopathy (ICM), non-ischaemic cardiomyopathy (NICM) and granulomatous myocarditis (GM). Safety outcomes assessed included all complications considered to be due to pericardial access or epicardial mapping/ablation.
Results: A total of 54 patients (total 119 VTs, mean 2.2 (0.9)) were taken up for ablation procedure through epicardial access. Mean age: 47 (10) years, males: 83%. All patients had drug resistant recurrent VTs. The epicardial procedure was abandoned in three patients due to access issues; percutaneous sub-xiphoid access was employed in 48 and surgical approach in four patients. Complete success was achieved in 59% and partial success in 76%. The outcomes were poor in ICM patients as compared to those with GM and NICM. Overall success rates for all clinical VTs were 89% in GM, 90% in NICM and 67% in ICM. Success rates for epicardial VT ablation were 94%, 85% and 78% respectively for GM, NICM and ICM. Procedure related complications occurred in six patients.
Conclusion: Epicardial ablation for VT offers good immediate outcomes with acceptable safety profile.
... Most centres perform epicardial ablation after a failed endocardial procedure or in cases with epicardial scar on DE-MRI or other imaging studies. [68][69][70] The 12-lead ECG of the clinical VT may also indicate an epicardial origin. 71,72 This approach is usually relatively easy but may be complicated in presence of prior cardiac surgery or 45 pericarditis. ...
L'ablation par radiofréquence constitue un des traitements des tachycardies ventriculaires, en association avec les drogues anti-arythmiques et l’implantation d'un défibrillateur. L’objectif principal de cette thèse est de mieux comprendre le substrat arythmogène non seulement à l’aide d'imagerie cardiaque (IRM et scanner) de haute résolution et de cartographie de haute densité, en utilisant des cathéters multipolaires. Cela nous permettra d'analyser la relation structure-fonction. Nous avons étudié cette relation sur différents types de substrats (ICM, NICM, DAVD, et myocardites). Nous avons ainsi prouvé la supériorité de la cartographie de haute densité obtenue à partir de cathéters multipolaires, comparativement aux données recueillies par l’imagerie, dans l’identification de la cicatrice arythmogène et la détection des LAVA. La deuxième partie de cette thèse concerne l’étude du substrat arythmogène épicardique. Nous avons ainsi décrit la technique de cartographie par voie percutanée antérieure, puis démontré l'efficacité des procédures uniquement avec abord épicardique. La segmentation du nerf phrénique et des artères coronaires ont permis de diminuer le taux de complications théoriquement liés à cet abord. Nous avons poursuivi ce travail avec l’analyse des sites d'intérêt de l'ablation des TV: les LAVA. Après une description de la stratégie d’élimination des LAVA, nous avons tenté de trouver des prédicteurs permettant de localiser les sites de LAVA, à partir des données d'imagerie. Quand l'imagerie montre une cicatrice intraseptale ou intramurale, les LAVA ne peuvent pas être enregistrés avec la cartographie et des alternative techniques d'ablation sont nécessaires comme une ablation bipolaire, l'alcoolisation intra coronaire et l'ablation avec l'aiguille irriguée. Le dernier chapitre est une revue sur le futur de l'imagerie, de la cartographie et de l’ablation des tachycardies ventriculaires. Une meilleure compréhension du substrat arythmogène pourrait améliorer l'efficacité et la sécurité des ablations de tachycardie ventriculaire.
