Hybrid surgical vs percutaneous access epicardial ventricular tachycardia ablation

Li, Anthony; Hayase, Justin; Do, Duc; Buch, Éric; Vaseghi, Marmar; Ajijola, Olujimi A.; Macias, Carlos; Krokhaleva, Yuliya; Khakpour, Houman; Boyle, Noel G.; Benharash, Peyman; Biniwale, Reshma; Shivkumar, Kalyanam; Bradfield, Jason S.

doi:10.1016/j.hrthm.2017.11.009

Cited by 32 publications

(25 citation statements)

References 12 publications

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“…Percutaneous epicardial access is limited after LVAD implant by surgical adhesions and the location of the LVAD hardware, though there are published reports of a subxiphoid surgical approach for VT ablation after LVAD placement . Practically, epicardial mapping and ablation would be best performed using standard percutaneous techniques prior to LVAD implant, or concurrent with the implant procedure itself.…”

Section: Discussionmentioning

confidence: 99%

Feasibility and utility of intraoperative epicardial scar characterization during left ventricular assist device implantation

Moss

Oesterle

Raiman

et al. 2018

Cardiovasc electrophysiol

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Introduction: Ventricular arrhythmias (VA) after left ventricular assist device (LVAD) placement are associated with increased morbidity and mortality.We sought to assess epicardial voltage characteristics at the time of LVAD implantation and investigate relationships between scar burden and postimplant VA. Methods and Results: Consecutive patients underwent open chest epicardial electroanatomic mapping immediately before LVAD implantation. Areas of low voltage and sites with local abnormal potentials were identified. Patients were followed prospectively for postimplant VA and clinical outcomes. Between 2015 and 2017, 36 patients underwent high-density intraoperative epicardial voltage mapping; 15 had complete maps suitable for analysis. Mapping required a median of 11.8 (interquartile range [IQR], 8.5-12.7) minutes, with a median of 2650 (IQR, 2139-3191) points sampled per patient. Over a median follow-up of 311 (IQR, 168-469) postoperative days, four patients (27%) experienced sustained VA. Patients with postimplant VA were more likely to have had preimplant implantable cardioverter defibrillator shocks (100% vs 27%; P = 0.03), ventriculartachycardia storm (75% vs 9%; P = 0.03), and lower ejection fraction (13.5 vs 19.0%, P = 0.05). Patients with postimplant VA also had a significantly higher burden of epicardial low bipolar voltage points: 55.4% vs 24.9% of points were less than 0.5 mV (P = 0.01), and 88.9% vs 63.7% of points less than 1.5 mV (P = 0.004).Conclusions: Intraoperative high-density epicardial mapping during LVAD implantation is safe and efficient, facilitating characterization of a potentially arrhythmogenic substrate. An increased burden of the epicardial scar may be associated with a higher incidence of postimplant VA. The role of empiric

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Section: Discussionmentioning

confidence: 99%

Feasibility and utility of intraoperative epicardial scar characterization during left ventricular assist device implantation

Moss

Oesterle

Raiman

et al. 2018

Cardiovasc electrophysiol

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“…This approach might not be possible in patients with pericardial adhesions caused by prior cardiac surgery. In such cases, a hybrid procedure involving surgical access with a subxiphoid pericardial window and a limited anterior or lateral thoracotomy A B Figure 3A, B. Epicardial radiofrequency ablation of the LV apical anterior wall (B) with a surgical ablation pen (Cardioblate, Medtronic Inc.), followed by pace-mapping (A) with a bipolar catheter of 15-mm interelectrode distance connected to an external temporary pacemaker device A B might be a feasible and safe method [4,5]. There is no need to proceed to a full thoracotomy in order to obtain epicardial access, especially if the precordial leads cannot be assessed whilst applying diagnostic manoeuvres.…”

Section: Discussionmentioning

confidence: 99%

Skuteczna ablacja ustawicznego, nasierdziowego częstoskurczu komorowego pod kontrolą ograniczonego mappingu stymulacyjnego w czasie operacji kardiochirugicznej. Strategia z wyboru?

et al. 2018

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Case reportA 59-year-old male with prior anterior myocardial infarction (MI), left ventricular (LV) ejection fraction of 35% and electrical storm despite the use of beta-blocker, lignocaine and amiodarone was transferred to our institution. Incessant ventricular tachycardia (VT) of 430 ms cycle length with left superior axis configuration, negative concordance pattern in the precordial leads and QRS duration of 230 ms was registered ( Figure 1A). His ECG in sinus rhythm was normal ( Figure 1B). The arrhythmia was occasionally terminated with pacing and cardioversion from his implantable cardioverter-defibrillator (ICD), which was immediately restarted afterwards. Although ECG suggested epicardial VT origin, it was decided to perform an endocardial ventricular mapping before proceeding to an epicardial approach. High-density bipolar voltage map (CARTO ® 3, Biosense Webster Inc.) with a Thermocool ® SmartTouch™ catheter introduced into LV through a retrograde approach was acquired initially. Large low-voltage area (LVA) with electrogram amplitude < 1.5 mV limited to the inferobasal wall (29 cm 2 ) and discrete LVA within apical segment of the inferior wall was identified (Figure 2A). An activation map acquired during VT showed the earliest activation of the LV apex, however with entrainment and pace-mapping from multiple endocardial LV sites, not consistent with clinical arrhythmia ( Figure 2B). Suspecting that VT exit site could be located within the right ventricle (RV), a voltage,

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“…Here, surgical epicardial access gained with the assistance of cardiothoracic surgeons may be a safe alternative. 79 Autonomic modulation procedures may be indicated in the setting of ongoing refractory VT. Surgical cardiac sympathetic denervation can significantly reduce the incidence of ICD shocks in refractory VT. 80 Renal denervation has also been shown to prevent VT recurrence in small case series. 59 VT ablation may be used as a bridging procedure to insertion of left ventricular assist devices or cardiac transplant, in which case the procedure and post-operative care should be undertaken with involvement from transplant teams and cardiac surgeons.…”

Section: Further Proceduresmentioning

confidence: 99%

Team Management of the Ventricular Tachycardia Patient

Tang

et al. 2018

Arrhythmia &Amp; Electrophysiology Review

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Ventricular tachycardia is a common arrhythmia in patients with structural heart disease and heart failure, and is now seen more frequently as these patients survive longer with modern therapies. In addition, these patients often have multiple comorbidities. While anti-arrhythmic drug therapy, implantable cardioverter-defibrillator implantation and ventricular tachycardia ablation are the mainstay of therapy, well managed by the cardiac electrophysiologist, there are many other facets in the care of these patients, such as heart failure management, treatment of comorbidities and anaesthetic interventions, where the expertise of other specialists is essential for optimal patient care. A coordinated team approach is therefore essential to achieve the best possible outcomes for these complex patients.

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Hybrid surgical vs percutaneous access epicardial ventricular tachycardia ablation

Cited by 32 publications

References 12 publications

Feasibility and utility of intraoperative epicardial scar characterization during left ventricular assist device implantation

Feasibility and utility of intraoperative epicardial scar characterization during left ventricular assist device implantation

Skuteczna ablacja ustawicznego, nasierdziowego częstoskurczu komorowego pod kontrolą ograniczonego mappingu stymulacyjnego w czasie operacji kardiochirugicznej. Strategia z wyboru?

Team Management of the Ventricular Tachycardia Patient

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