Relation of the Unipolar Low‐Voltage Penumbra Surrounding the Endocardial Low‐Voltage Scar to Ventricular Tachycardia Circuit Sites and Ablation Outcomes in Ischemic Cardiomyopathy

Chopra, Nagesh; Tokuda, Michifumi; Ng, Justin; Reichlin, Tobias; Nof, Eyal; John, Roy M.; Tedrow, Usha B.; Stevenson, William G.

doi:10.1111/jce.12393

Cited by 34 publications

(16 citation statements)

References 23 publications

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“…This 5.5 mV cut-off was shown to predict epicardial involvement in patients with right ventricular cardiomyopathy in patients with no or minimal endocardial bipolar voltage changes; 30 The importance of endocardial unipolar mapping in detecting abnormal substrates deeper to the endocardial recording site, such as intramural and/or epicardial abnormalities, has been replicated in further studies. 35,36 The use of unipolar recordings has been shown to be of particular value in identifying the common midseptal substrate in patients with nonischemic cardiomyopathy. The unipolar cut-off needs to be titrated higher in the LV in the setting of left ventricular hypertrophy (Figure 3).…”

Section: Substrate Mapping: General Considerationsmentioning

confidence: 99%

Substrate mapping for unstable ventricular tachycardia

Santangeli

Marchlinski

2016

Heart Rhythm

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The primary goal of catheter ablation of scar-related ventricular tachycardia (VT) is the interruption of critical areas of slow conduction responsible for the development and maintenance of the reentrant VT circuit. Most patients with scar-related VT present with unstable arrhythmias that are not amenable to interrogation from multiple sites to define the VT circuit based on the intracardiac activation sequence and the response to entrainment mapping. In order to effectively target unstable VTs, a number of ablation approaches have been described with the aim of targeting the abnormal substrate defined with mapping in sinus or paced rhythm. Some of these strategies (eg, late potential and local abnormal ventricular activity ablation or scar homogenization) target the entire abnormal substrate harboring abnormal electrograms, defined with a variety of different criteria. Scar dechanneling, linear ablation through sites matching VT with pacing, and the core isolation approach focus on more discrete regions within the abnormal substrate that have been proven relevant to the clinical and/or inducible arrhythmias by means of physiologic maneuvers, although this does not necessarily translate to fewer radiofrequency lesions to achieve the procedural end-point. Observational studies evaluating different substrate-based ablation techniques have reported fairly uniform arrhythmia-free survivals at short- and mid-term follow-up, although direct comparisons between different techniques are lacking. In this article, we summarize the different state-of-the-art substrate mapping and ablation approaches for targeting unstable VT, with a particular focus on the relative merits and limitations of the described techniques.

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Section: Substrate Mapping: General Considerationsmentioning

confidence: 99%

Substrate mapping for unstable ventricular tachycardia

Santangeli

Marchlinski

2016

Heart Rhythm

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“…We defined as unipolar penumbra area the unipolar scar beyond the bipolar LVA. 15 Further offline analyses were undertaken after segmenting the LV endocardial shell into 17 segments and the LV epicardial shell into 12 segments using the design line tool. 16 Each segment was considered to be analyzable only if fill threshold criteria were met and the predominant bipolar and unipolar voltage type was noted.…”

Section: Voltage Analysismentioning

confidence: 99%

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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“…Reasons include an absence of defined SR targets, an absence of a well-defined scar as in the setting of idiopathic dilated cardiomyopathy, 7 and residual VTs that may be induced even after an otherwise successful substrate modification procedure. 8,9 The feasibility of mechanical circulatory ECMO for Hemodynamic Support of VT Ablation support in this setting is attractive, [10][11][12][13][14] but no consensus on the best strategy has been reached.…”

mentioning

confidence: 99%

Extracorporeal Membrane Oxygenation for Hemodynamic Support of Ventricular Tachycardia Ablation

Baratto

Pappalardo

Olóriz

et al. 2016

Circ: Arrhythmia and Electrophysiology

108

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Background-We report the experience in a cohort of consecutive patients receiving extracorporeal membrane oxygenation during catheter ablation of unstable ventricular tachycardia (VT) at our center. Methods and Results-From 2010 to 2015, extracorporeal membrane oxygenation was initiated in 64 patients (average age: 63±15 years; left ventricular ejection fraction in 27±9%; cardiogenic shock in 23%, and electrical storm in 62% of patients) undergoing 74 unstable VT catheter ablation procedures. At least one VT was terminated in 81% of procedures with baseline inducible VT, and VT noninducibility was achieved in 69%. Acute heart failure occurred in 5 patients: 3 underwent emergency heart transplantation, 1 had left ventricular assist device (LVAD) implantation, and 1 patient eventually died because of subsequent mesenteric ischemia. All other patients were discharged alive. After a median follow-up of 21 months (13-28 months), VT recurrence was 33%; overall survival was 56 out of 64 patients (88%). Extracorporeal membrane oxygenation-supported ablation was the bridge to LVAD in 6.9% and to heart transplantation in 3.5% of patients. VT recurrence was related to ablation success (after 180 days of follow up: 19% when VT was noninducible, 42% if nonclinical VT was inducible, 75% when clinical VT was inducible, and 75% in untested patients, P<0.001). Incidence of all-cause death, heart transplantation, and LVAD was independently related to ablation outcome (at 180 days of follow-up: 9% when noninducibility was achieved, 50% in case of inducible VT, and 75% in untested patients, P<0.001). At multivariable analyses, noninducibility (hazard ratio 0.198; P=0.001) and left ventricular ejection fraction (hazard ratio 0.916; P=0.008) correlated with all-cause death, LVAD, and heart transplantation. Conclusions-Ablation of unstable VTs can be safely supported by extracorporeal membrane oxygenation, which allows rhythm stabilization with low procedure mortality, bridging decompensated patients to permanent LVAD or heart transplantation. Successful ablation is associated with better outcomes than unsuccessful ablation.(Circ Arrhythm Electrophysiol. 2016;9:e004492.

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Relation of the Unipolar Low‐Voltage Penumbra Surrounding the Endocardial Low‐Voltage Scar to Ventricular Tachycardia Circuit Sites and Ablation Outcomes in Ischemic Cardiomyopathy

Cited by 34 publications

References 23 publications

Substrate mapping for unstable ventricular tachycardia

Substrate mapping for unstable ventricular tachycardia

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

Extracorporeal Membrane Oxygenation for Hemodynamic Support of Ventricular Tachycardia Ablation

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