DOI: 10.1161/CIRCEP.114.002377
Percutaneous Epicardial Ablation of Ventricular Arrhythmias Arising from the Left Ventricular Summit: Outcomes and ECG Correlates of Success
Running title: Santangeli et al.; Epicardial ablation of LV summit VTs
Pasquale Santangeli, MD1; Francis E. Marchlinski, MD1; Erica S. Zado, PA-C1; D1; Da Davi David vidd S. vi S Frankel, Fran Fr anke an kell, MD1; ke Daniel Benhayon, MD1; Mathew D. Hutchinson, MD1; David Lin, MD in C. Garcia, Garc Ga rcia rc iaa, MD1; Michael P. Riley, MD, PhD1; Gregory E. Supple, MD1; Fermin Rupa Bala, ala ala la, M MD D1; B Benoit enoit Desjardins, Desjjardins,, MD, PhD2; David D vid J. Call Da Callans, lllans, MD1; Sanjay Dixit, M MD1
1
Electrophysiology h ol hysiol olog o y Se og S Section, ctio ct io on, n, Cardiovascular Car ardi diov ovas a cu ulaar Di Division, ivi v siion on,, 2De Department Depa p rtme pa rttme ment nt ooff Ra Radi Radiology, diiol diol olog ogy, og y,, H Hospital ospi os p tal of the pi University Univ Un iver iv ersi er sity si ty ooff Pe Penn Pennsylvania, nnsy nn sylv sy lvan lv ania an ia,, Ph ia Phil Philadelphia, ilad il adel ad elph el phia ph ia,, PA ia A
Correspondence: Sanjay Dixit, MD Hospital of the University of Pennsylvania 9 Founders Pavilion – Cardiology 3400 Spruce St. Philadelphia, PA, 19104 Tel: 215-615-4337 Fax: 215-662-2879 E-mail: [email protected]
Journal Subject Code: [5] Arrhythmias, clinical electrophysiology, drugs
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DOI: 10.1161/CIRCEP.114.002377
Abstract: Background - Percutaneous epicardial ablation of ventricular arrhythmias (VAs) arising from the left ventricular summit (LVS) is limited by the presence of major coronary vessels and epicardial fat. We report the outcomes of percutaneous epicardial mapping and ablation of VAs arising from the LVS, and the ECG features associated with successful ablation. Methods and Results - Between January 2003 and December 2012 a total of 23 consecutive patients (49 ± 14 years, 39% males) with VAs arising from the LVS underwent percutaneous epicardial instrumentation for mapping and ablation due to unsuccessful ablation from the coronary venous system and multiple endocardial LV/RV sites. Successful epicardial ablation p was achieved in 5 (22%) patients. In the remaining 18 (78%) cases, ablation for bllat atio ionn was io was aborted abor ab ortte or ted fo ted o either close proximity to major coronary arteries or poor energy delivery over epicardial ery ove verr ep ve epic iccar ardi dial di al ffat. at The Q-wave amplitude >1.85 mplitude mpli litu li tu ude d ratio rat atio i in in aVL/aVR was higher in n th thee successful gro group, oup u , with a ratio of >1. present in 4 (80%) patients group unsuccessful group (880%) patie ents in n the the h successful suuccceesssfu ful grou ouup vs. vs. 2 (11%) (11% (1 1% %) in i the the un nsuc u cess uc ssfu ss full gr fu rou oupp (P (P = 0.008). Thee rratio R/S V1 group, patients ati t o of R / wave /S wavee iin nV 1 wass greater grreater eateer iinn tthe he ssuccessful ucceessfuul grou uc ou up, w with i h 4 (80%) it (80% 0%) pa patie tie in the successful sful group gro r upp having havin ng a R/S ratio ratio of >2 in ra n V1 V1 vs. v . 5 (28%) vs (28% (2 8%)) in the 8% h unsuccessful he unsuc uccess uc s ful group ss g oup (P gr ( = 0.056). None the V1, n of th ne he pa ppatients tien ti ents en t in in the h successful successful f l group groupp had had d an iinitial nitia i l “q” “ ” wave “q w ve iin wa n lead dV 1 as 1, opposed to 6 (33%) ECG (33 33%) %) iinn the the unsuccessful unsu un succ cces essf sffull group. gro roup up.. The The presence pres pr esen ence cee ooff at lleast east ea stt ttwo wo ooff th the he th tthree reee EC re criteria above predicted successful ablation with 100% sensitivity and 72% specificity. Conclusions - Epicardial instrumentation for mapping and ablation of VAs arising from the LVS is successful only in a minority of patients due to close proximity to major coronary arteries and/or epicardial fat. A Q-wave ratio of >1.85 in aVL/aVR, a R/S ratio of >2 in V1, and absence of “q” waves in lead V1 help identify appropriate candidates for epicardial ablation.
Key words: catheter ablation, epicardial, mapping, ventricular tachycardia, left ventricular summit
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DOI: 10.1161/CIRCEP.114.002377
Introduction The left ventricular summit (LVS) is a common site of origin of idiopathic ventricular arrhythmias (VAs).1 According to the initial description by McAlpine,2 the LVS is a triangular portion of the epicardial left ventricular outflow tract (LVOT) bounded by the bifurcation between the left anterior descending and the left circumflex coronary arteries, and transected laterally by the great cardiac vein (GCV) at its junction with the anterior interventricular vein (AIV).2 Given the proximity to major coronary vessels and the presence of a thick layer of epicardial fat in this location,1, 2 catheter ablation of VAs originating from rom the LVS with ha percutaneous epicardial approach is challenging; in many cases, ablation on fr from om adjacent adj djac acen entt st stru structures r such as thee left leeft coronary cor oron o aryy ccusp, on usp, the GCV-AIV junct junction, tio ionn, the endocardial endocar a dial al aspect of basal LV (immediately ely below the aaortic el orticc valve), valv ve), and/or an nd/or or thee sep septal ptaal RV RV outflow oouutfllow w trac tract ct at at its lleftmost e tm ef tmoost as aspe aspect e is 3-55 an effectivee alte alternative teern rnat atiive appr at approach proach h to aachieve chi ch hieve ssuccess. u cess.3uc However, H owev ow ever, wh ev when ablat ablation atio at io on off L LVS VS V VA A from
these alternative n native llocations lo catiionns iiss unsuccessful unsuccessful, l, an ep epicardial picardi diall app di approach pproachh mi pp migh might igh ghtt be b consid considered. derred ed.11,, 6 IIn this study, we report rtt tthe he outcomes o ttcomes off percutaneous perc ttaneo a s epicardial ic diall mapping pii and ndd ablation blati tio off VAs VAs originating from the LVS, and the electrocardiographic (ECG) features predicting successful ablation.
Methods The study design was retrospective and included consecutive patients with VAs originating from the LVS who underwent percutaneous epicardial instrumentation for mapping and ablation following unsuccessful attempt at the same from the coronary venous system, cusp region, and adjacent endocardial LV/RV sites. According to prior studies,1 the LVS was defined as the triangular portion of the epicardial LVOT with the apex at the bifurcation between the left anterior descending and the circumflex coronary arteries and the base formed by an arc 3 Downloaded from http://circep.ahajournals.org/ at Tulane University on January 31, 2015
DOI: 10.1161/CIRCEP.114.002377
connecting the first septal perforator branch of the left anterior descending coronary artery with the circumflex coronary artery (Figure 1). The LVS is bisected by the GCV in two regions, one closer to the apex of the triangle (i.e., inaccessible area), and one at the base of the triangle (i.e., accessible area). All the anatomical definitions were based on orthogonal fluoroscopy, intracardiac echocardiography and intraprocedural coronary angiography. All patients had failed treatment with at least 1 antiarrhythmic drug and/or atrioventricular nodal blocking agents; these were discontinued for at least five half-lives before the procedure. All patients signed a written informed consent according ngg to institutional guidelines of the University of Pennsylvania Health System. The baseline line ccharacteristics haraccte hara terist riistic iccs including the ECG h age, he agee, sex, ag sex e , nature naature of the clinical arrhythmia, arrhyth hmi m a, and 12-lead 12-leead E CG of the VAs were recorded. Electrophysiological study ablation y log ysiol ogic ical ic c st tud dy and and d catheter cat atthe heter ab bla lati tion ti Patients presented electrophysiology Conscious esented d to th the he ccardiac ardia di c el lecttropphy h siiolloggy laboratory labborattory y in th the he fa fast fasting sttingg state. sttatte. C Consciou onsc on scciou sedation was approach. as used sed d as the the preferred fe ed d approach h General G all anesthesia sth thesii with iith th an iinhaled nhhalledd anesthetic theti tic (typically sevoflurane) was used for obtaining pericardial access and during epicardial mapping and ablation. Atrial and/or ventricular burst pacing with and without intravenous isoproterenol (up to 12 μg/min) was used to provoke the VAs in case of suppression after general anesthesia induction. Catheters were positioned in the heart using fluoroscopic guidance. A 6-Fr quadripolar catheter with 5-mm interelectrode distance (Bard Inc., Delran, New Jersey) was placed at the RV apex. A 7-Fr decapolar catheter with 5-mm electrodes and 2-mm interelectrode distance was advanced to the coronary sinus and at the GCV-AIV junction. A deflectable 8-Fr mapping/ablation catheter that had a 3.5-mm irrigated tip and a 2-mm ring electrode separated by 1 mm (Thermocool, Biosense Webster, Diamond Bar, California) was advanced to the RV
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DOI: 10.1161/CIRCEP.114.002377
(transvenous approach), LV (retrograde aortic approach), coronary venous system and epicardial space for mapping. Access to the pericardial space and epicardium was obtained using the approach described by Sosa et al.7 A 64-element phased-array ICE catheter (AcuNav, Acuson, Mountain View, California) was used to assist catheter manipulation, assess distance from the ostium of the left main coronary artery, monitor radiofrequency energy delivery, tissue-catheter contact, and complications. In addition, ICE was used together with the three-dimensional electroanatomic mapping system to define the anatomical details of structures adjacent to the epicardial LVS. During mapping in the LV and coronary cusp region, intravenous hep heparin parrin w was used to achieve an activated clotting tiPHRIVHFRQGV The site off origi origin giin off tthe gin h V he VA A wa w was a d bas ased as ed oon n de ddetailed taailed activation and pace m a ping. In par ap rticu ula l r, during activation determined based mapping. particular, mapping, the he lo llocal cal activa activation atiion ti time ime w was as co cconsistently nsiistent nttly m measured easu sure su red from re om th the he on onset nseet off th the he eelectrogram lecctrrogg o ositive e orr negative neg egati tive deflection) defl f ecti tion ti on)) of the on the distal distall bipole bipoole of bi of the the mapping m ppin ma i g catheter cath ca theter to th to the th (earliest positive s of the set th he QRS QRS complex comp plex in i anyy off the th he 122 ECG ECG G leads. leadds. Activation Acti tivati tioon times ti tiimes were re measured meass earliest onset by 2 independent endent dentt observers obser bs ers and ndd ddispla displayed ispll edd on a three th three-dimensional dimensional di io l el electroanatomic l tr tomii map (CARTOTM, Biosense Webster, Diamond Bar, California) as well as the EP recording system (PruckaTM, GE, Houston, TX). Pace-map match was visually judged by 2 observers, with each of the 12 ECG leads assessed for the QRS vector and major notching or deflections from baseline. An ideal match required identical QRS complexes between the paced beats and native VA in 12 of 12 ECG leads. Coronary angiography was performed to delineate the ostium and the course of the left coronary artery prior to ablation. Radiofrequency energy was only delivered if the site was >5 mm from a coronary artery. During radiofrequency energy delivery, if a suppression/elimination of VAs occurred within the initial 30 seconds, the application was maintained and carefully titrated for 60 seconds, targeting an impedance drop of 10-15 Ohms
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with a maximum temperature of 45°C and a maximum power of 40 watts. After ablation, atrial and/or ventricular burst pacing with and without intravenous isoproterenol (up to 12 μg/min) was used to assess arrhythmia inducibility. Acute success was defined as inability to induce the clinical VAs (ventricular premature depolarization [VPD] or ventricular tachycardia [VT]) at the end of the procedure and no recurrence during 24 hours of post-procedural hospital ECG monitoring. ECG analysis Detailed ECG analysis was performed off-line on the PruckaTM CardioLab oLab recording g sy system yst steem (GE, Houston, TX) with the recordings displayed at a speed of 100 and d 20 200 00 mm mm/ mm/s. /s. Analysis /s Anal nal alyysi ysi of ECG tracings n sw ngs was a pperformed as erfo er f rm med according to previousl previously sly reported mea sl measurements e suure rements applied to thee outflow tract act region. ac region.8-11 IInn pa particular, artticullar, th the he fo following ollow winng E ECG CG G ffeatures eatu ea urees wer were re as assessed: sseessedd: 1)) QR QRS RS pseud udoo-ddelt ud ltta wave (P ((PdW), dW W), intri ins nsic icoi ic oid id deflection d fl de f eccti tionn time tim me (IDT), (IDT (I DT T), m axiimum deflection ax defflecc duration; 2)) pseudo-delta intrinsicoid maximum 8-12 8 122 index (MDI); D ); DI); ) 833)) R wave waave amp amplitude pli litude d in leads lead ds II, II, II II IIIII and d aV aVF VF (a (and nd ratio io o bbetween etween t R wa w wav wave ave inn lead
II / lead III); ));; 4) Q wave a e amplit amplitude plit lit dde iin n lleads ds aVL VL and ndd aVR VR ((and d ratio ti bbetween bet ett een Q wave a e iin llead ead d aVL / lead aVR); 5) R wave amplitude in leads V1, V2 and V3; 6) S wave amplitude in leads V1, V2, and V3; 7) presence of a QS complex in lead I.12 Three QRS complexes were measured in each patient to confirm reproducibility, and the mean of the values was used. Follow-up Antiarrhythmic drugs were not reinitiated if ablation was acutely successful. Post procedure, patients remained overnight in the hospital under continuous ECG monitoring. Beyond that, patients were followed in the outpatient clinic at our institution, or by their referring physician. Information about symptoms, VA burden using 24-hour Holter or auto-triggered transtelephonic ECG monitoring was assessed 2-6 months after discharge.
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Statistical analysis Descriptive statistics are reported as mean ± SD or median and interquartile range (IQR) for continuous variables, and as absolute frequencies and percentages for categorical variables. Between-group comparisons were performed with the Mann-Whitney U test and Fisher’s exact test as appropriate. The Wilcoxon matched-pairs signed-rank test was used to compare activation mapping and ablation (impedance drops) data (repeated measurements on a single sample). In order to formally assess the degree of interobserver agreement for ECG analysis, two observers independently measured a total of 96 ECG parameters from 6 patients randomlyy selected. selected ed d. Interobserver disagreement was considered present when the timing difference iffereenc ncee exceeded exce ex ceed eded ed 5 ms and the voltage was l age ltag ge difference diff di fffer e ence ce exceeded 0.1 mV. All tests teest stss were 2-sided, 2-sided e , and an nd a P value 1.85 (vs. 2/18 [11%] unsuccessful essful cases, P = 00.008 .000 for .0 comparison). An R-wave to S-wave ratio in lead V1 greater than 2 wass pres present esen entt in i 44/5 /5 ((80%) 80% 80 % patients in thee successful succ su cces e sf es s ull group group compared with 5/188 (28%) ( 8%) cases of (2 o uunsuccessful n uccessful ablation ((P = ns 0.056 for comparison). patients group had initial omparison). None None ooff the he patie i ntts in the ie the successful suc uccess s fuul grou ss oup ha ou ad an initi ial “q”” wave wavve in lead V1 vs.. 6/18 QS 188 [33%] [33% 333%] in in the th unsuccessful unsuccces essful group. gro r up up. A Q S complex comp co mpllex in lead mp leadd I was was pr ppresent esentt iin n3 (60%) successful unsuccessful No significant c full andd 4 ((22%) cessf 22%) 22 % unsuccessf %) ful cases. N o si ign g ifficant di ddifferences fferrences between ff betweeen th the successful and off ttotal ndd unsuccessful ns ccessf sff l groups gro ps were ere detected dett tedd in in terms t ottall QRS QRS duration d ration ti ((147 1477 ± 16 ms 14 vs. 149 ± 26 ms, respectively, P = 0.970), MDI (0.51 ± 0.07 vs. 0.52 ± 0.11, respectively, P = 0.794), IDT (76 ± 5 ms vs. 88 ± 24 ms, respectively, P = 0.079), PdW (44 ± 5 ms vs. 55 ± 12 ms, respectively, P = 0.086), and R-wave ratio in leads II/III (0.79 ± 0.16 vs. 0.93 ± 0.20, respectively, P = 0.248). ECG correlates of successful epicardial ablation The three criteria that were tested to assess the value of the ECG to help identify patients who had successful epicardial ablation were: 1) Q-wave ratio in leads aVL/aVR >1.85, 2) R/S wave ratio in lead V1 >2 and, 3) Lack of initial “q” wave in lead V1. The presence of at least two of these three ECG criteria was associated with successful epicardial ablation with 100% sensitivity
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and 72% specificity. Follow-up After a median follow-up of 36 months (interquartile range 36 months), 3 out of the 5 patients who had successful epicardial ablation were free from any recurrent VAs; one of these patients was maintained on propafenone. Another patient had a reduction in the VPD burden after ablation (from 23% to 7.8% burden on 24-h Holter monitoring) and has remained off antiarrhythmic drug therapy. Finally, one patient had recurrent VT, which was controlled with amiodarone.
Discussion n The present study nt st nt tudy was specifically speecif sp iffical ific a ly ddesigned esig igne ig n d to aassess ne ssesss thee outcomes ouutc t om mes off percutaneous perc rcut rc utan ut neo e us eepicardial pica pi cardd ca mapping and ablation LVS, ECG features nd ab nd abla laati tion on for foor VA VAs or ooriginating ig gin i attin ing fr ffrom om m tthe he L VS,, an VS andd to t evaluate ev vallua uatte th thee EC CG fe eat a ures e associated with w th successful wit succ su cces cc essf es sful sf ul epicardial e ic ep icar ardi ar dial di all ablation. ablat atio at ionn. To io T the the h best bes estt off oour urr kknowledge, n wl no wled edge ed g , ou ge oourr st sstudy udyy iincludes ud ncll the largest po population popu pulaati t on o to to date ddaate te w with itth LVS LVS arrhythmias a rhhythm ar ytthm h ia i s undergoing u ddeerg un goi o ngg percutaneous per e cu cuta taneeou ouss epicardial epic ep i ar ic a di d al a mapping and ablation. The major findings are as follows: 1) the outcome of catheter ablation for LVS arrhythmias from the epicardium is poor, with an acute success rate of 22% and a long-term arrhythmia-free survival of 17%; 2) ECG features including a Q-wave ratio in leads aVL/aVR >1.85, and R/S wave ratio in lead V1 of >2, and the lack of an initial “q” wave in lead V1 may help identify cases where epicardial ablation may have a higher chance of success. Epicardial catheter ablation of VAs from the LVS Catheter ablation of VAs arising from the LVS can be challenging, given the proximity to critical structures such as major coronary vessels and/or inability to deliver effective radiofrequency lesions due to the presence of a thick layer of epicardial fat.1, 9, 13, 14 In many of these cases, radiofrequency delivery from adjacent sites such as the endocardial LV/RV, coronary cusp 11 Downloaded from http://circep.ahajournals.org/ at Tulane University on January 31, 2015
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region or coronary venous system is successful in eliminating the arrhythmias.3-5 In this regard, ICE together with three-dimensional electroanatomic mapping is particularly valuable in defining the anatomical details of structures adjacent to the epicardial LVS; however, in this series, ICE did not enhance ablation success. In a recent study by our group, successful ablation of VAs from the inaccessible LVS area was achieved from the left coronary cusp in 56% of cases.3 Similarly, Yamada et al., who first described the anatomy and electrophysiologic characteristics of arrhythmias arising from the LVS in a series of 27 patients, reported successful ablation from the GCV-AIV region in more than 70% of cases.1 Whenn ablation from ad adjacent dja jacce sites fails, a percutaneous epicardial access for mapping and ablation may be b considered. consi sid idere deredd.11,, 6 Thus blished blish shed sh ed experience exp x erieence with epicardial mapping mappin ingg and ablation in on off L VS arrhythmias is sscant. far, the published LVS For instance, ce, in ce in the studyy by by Yamada Yamaada ett al., only Ya only y 9/27 9/2 27 (33%) (333% 3 ) ppatients atiients und underwent ndder erwent ntt ep eepicardial iccarddiaal n ab nd bla lati tiion which tio whhichh was succ cceessfull iinn 4/9 cc 4/9 / (44%) (444%) cases. case sees.1 IInn our stud study, dy, y iinn about ab boutt ttwo-thirds wo mapping and ablation successful of cases, radiofrequency a freq adiof quencyy de deli delivery l very li y iin n tthe he epi epicardial picarddial llocation pi ocati tion i was ab abortedd ddue ue to pr pproximity oxim imit im itty to o major epicardial coronary vessels. radiofrequency ardial rdi diall coronar essels ell Wh When radiofreq adi dioffr enc ablation abl blati ti was as att attempted tte tedd after aft fte verifying erif rif if safe distance from major coronary vessels, it was successful in eliminating the arrhythmia only in a small subset of these patients. We think this is likely due to the presence of epicardial fat at the tissue-catheter interface,15, 16 although we did not find significant differences in average impedance drops with radiofrequency application in successful versus unsuccessful cases. Prior studies have shown that epicardial fat represents a major limitation to achieving adequate lesions by radiofrequency energy;17 in these cases, a different source of ablation energy, such as cryoablation, may be more efficacious.18 In rare cases, minimally invasive surgical ablation has also been shown to be effective in treating LVS arrhythmias, which were successfully targeted after mobilizing the coronary artery away from the site of cryoablation in the area of interest.19
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However, the degree of incremental benefit with these techniques compared to conventional percutaneous radiofrequency ablation warrants validation in larger studies. None of the patients included in our series underwent cryoablation and/or surgical ablation. ECG features associated with successful epicardial ablation The accessible area of the LVS is located inferiorly and laterally to the GCV, where the anatomical separation between the left anterior descending and circumflex coronary arteries is maximal and there is lower chance of having a thick layer of epicardial fat (Figure 1).20, 21 Indeed, the three ECG features found to be more prevalent in successful ful versus unsucce unsuccessful ess ssfu f cases (i.e., Q-wave ratio aVL/aVR >1.85, R/S ratio in V1 >2, and lackk of “q” “q”” wa “q wave ve iin n V1 V1) V1), ), reflect a more o e lateral ore late la tera eraal site s tee of si of origin of the VAs (dist (distant tan antt from the m midline idline ne and the apex of thee LVS triangle). Acc According Accordingly, ccor cc o dingly,, mo more pa patients atient nts in nt n the thee successful succe ceessfu ful gr group rouup had hadd a QS S pat pattern atttern iinn lead atte leead d I, w which wh h again points t to a more ts mo o lateral lateral t l (and (and epicardial) ep pic icardial al)) or al origin rig igin i off the he V VAs. As.12 T The h llow he ow aablation blation successs from bl the epicardial dial llocation ocatio i n in our series seriies suggests sugg ggests that gg tha h t the th he majority majo jority ity off these th hese VA were orig originating ig gin nat atingg from the inaccessible LVS. activation ssible iblle location ib l ati tion off the th LVS LV S This Thi is is corroborated bo tedd bby tthe he observation obser bs ation ti tthat hatt th the acti ti a times septal to the GCV/AIV were better compared to those lateral to the GCV/AIV. In our study, the presence of at least two of the three ECG criteria was associated with successful epicardial ablation with a 100% sensitivity and 72% specificity. Our findings support the usefulness of ECG analysis to select cases with the greatest chance of success of epicardial ablation in the LVS region. Limitations This was a single-center observational study. The decision to obtain percutaneous epicardial access for mapping/ablation was made by the operator during the procedure after failed ablation attempts from multiple adjacent structures; this may have introduced subjective bias. Although,
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in our series, the epicardial LVS was accessed in all patients without difficulty, in some cases the left atrial appendage may prevent adequate epicardial mapping in the LVS region. Our institution is a tertiary referral centers for the treatment of VAs and so the characteristics of the study population may not be generalized. Given the small number of patients, our findings with respect to ECG correlates of success should be viewed as hypothesis generating only, and deserve to be validated prospectively in a larger and independent sample of patients.
Conclusions In patients manifesting ventricular arrhythmias arising from the LV summit umm mit tthe he ooutcome utco ut come co me ooff epicardial ablatio vessels ablation ionn is io i poor pooor in the majority of cases du duee to proximity too major m jor coronary vesse ma and/or presence epicardial features more leftward sencce of epica se ard r iaal fat. fatt. ECG fa ECG fe eatturres ppointing oinnting to a m orre le left f ward ft rdd / lateral l teera la rall site sit itee of of origin o of the VA in >1.85 R/S >2 V1, i tthis h s location hi lo loca oca cati t on ti o (i.e., (i. i.ee., Q-wave Q wa Qw vee rratio atio io of of >1 >1.8 . 5 in aVL/aVR, .8 aVL VL/a /aaVR VR,, a R/ /S ratio raati t o of o > 2 in V 1, and 1, absence of “q”” w waves V1) help appropriate candidates successful aves av es iin n le lead a V ad 1) ma may y he elp iidentify deent n iffy ap appr p oppri pr riat atee ca at and ndid idat id ates at es ffor or su succ c es cc essf sfful epicardial aablation ablation. b at bl atio on..
Funding Sources: The study was funded in part by the F. Harlan Batrus Research Fund Conflict of Interest Disclosures: None References 1. Yamada T, McElderry HT, Doppalapudi H, Okada T, Murakami Y, Yoshida Y, Yoshida N, Inden Y, Murohara T, Plumb VJ, Kay GN. Idiopathic ventricular arrhythmias originating from the left ventricular summit: anatomic concepts relevant to ablation. Circ Arrhythm Electrophysiol. 2010;3:616-623. 2. McAlpine WA. Heart and Coronary Arteries. New York: Springer-Verlag; 1975. 3. Jauregui Abularach ME, Campos B, Park KM, Tschabrunn CM, Frankel DS, Park RE, Gerstenfeld EP, Mountantonakis S, Garcia FC, Dixit S, Tzou WS, Hutchinson MD, Lin D, Riley
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MP, Cooper JM, Bala R, Callans DJ, Marchlinski FE. Ablation of ventricular arrhythmias arising near the anterior epicardial veins from the left sinus of Valsalva region: ECG features, anatomic distance, and outcome. Heart Rhythm. 2012;9:865-873. 4. Obel OA, d'Avila A, Neuzil P, Saad EB, Ruskin JN, Reddy VY. Ablation of left ventricular epicardial outflow tract tachycardia from the distal great cardiac vein. J Am Coll Cardiol. 2006;48:1813-1817. 5. Frankel DS, Mountantonakis S, Dahu MI, Marchlinski FE. Elimination of ventricular arrhythmias originating from the anterior interventricular vein with ablation in the right ventricular outflow tract. Heart Rhythm. 2014;11:S217. 6. Tanner H, Hindricks G, Schirdewahn P, Kobza R, Dorszewski A, Piorkowski C, Gerds-Li JH, Kottkamp H. Outflow tract tachycardia with R/S transition in lead V3: six different anatomic approaches for successful ablation. J Am Coll Cardiol. 2005;45:418-423. 23. 7. Sosa E, Scanavacca M, d'Avila A, Pilleggi F. A new technique to perform mapping erform rm eepicardial piicard pica rdia dia i l map m a in the electrophysiology laboratory. J Cardiovasc Electrophysiol. 1996;7:531-536. 6;7:531 31 536 8. Tada H, N H, Nogami ogami A, A N Naito a to ai o S, S, Fukazawa Fuka Fu kaza ka zawa za w H, wa H, Horie Hori Ho r e Y, Y K Kubota ubot ub o a S, ot S O Okamoto kamo ka m to oY Y,, Ho H Hoshizaki shhiz shiz i ak ki H Oshima S, Taniguchi epicardial distinct Tanniguchi K. Left Ta Left ventricular ventrric icular ar epi picarddial outflow outflo ou low lo w tract t actt tachycardia: tr tachyc ycarrdi dia: a nnew e dist ew tinc subgroup of Circ 2001;65:723-730. of outflow outf ou t low tract tracct tachycardia. tr tach hycarrdi dia. a Jp Jpn C ircc J. J. 20 001;6 ;6 65: 5 77223-73 730. 73 9. Daniels DV, Lu Morton Santucci Akar Green A,, Wi Wilber DJ. DV,, L u YY YY, Mo M rtton o JJB, B S B, antu ucc c i PA PA, Ak A arr JJG, G, G reen re en A Wilb lb lber ber e D J. IIdiopathic J. diop di o at op athi hc epicardial left l ventricular ventriicula larr tachycardia la tach hyc y ardi d a originating orig igiinatin ig i g remote t from from the th he sinus siinuus off Valsalva: Vallsalv l a: electrophysiological s siological l characteristics, cha hara raact cter eris er isti is tics ti ics cs, catheter cath ca thet th eter et e aablation, er blat bl a io at ion, n aand n, ndd iidentification dent de n if nt ificcat atio io ion on from frrom the the 12-lead 12-lead electrocardiogram. Circulation. 2006;113:1659-1666. diogram Ci di l tii 2006;113:1659 2006 20 06;113 113:165 16599 1666 1666 10. Berruezo A, Mont L, Nava S, Chueca E, Bartholomay E, Brugada J. Electrocardiographic recognition of the epicardial origin of ventricular tachycardias. Circulation. 2004;109:18421847. 11. Ito S, Tada H, Naito S, Kurosaki K, Ueda M, Hoshizaki H, Miyamori I, Oshima S, Taniguchi K, Nogami A. Development and validation of an ECG algorithm for identifying the optimal ablation site for idiopathic ventricular outflow tract tachycardia. J Cardiovasc Electrophysiol. 2003;14:1280-1286. 12. Valles E, Bazan V, Marchlinski FE. ECG criteria to identify epicardial ventricular tachycardia in nonischemic cardiomyopathy. Circ Arrhythm Electrophysiol. 2010;3:63-71. 13. Kumagai K, Fukuda K, Wakayama Y, Sugai Y, Hirose M, Yamaguchi N, Takase K, Yamauchi Y, Takahashi A, Aonuma K, Shimokawa H. Electrocardiographic characteristics of the variants of idiopathic left ventricular outflow tract ventricular tachyarrhythmias. J Cardiovasc Electrophysiol. 2008;19:495-501.
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14. Yamada T, McElderry HT, Okada T, Murakami Y, Doppalapudi H, Yoshida N, Yoshida Y, Inden Y, Murohara T, Epstein AE, Plumb VJ, Kay GN. Idiopathic left ventricular arrhythmias originating adjacent to the left aortic sinus of valsalva: electrophysiological rationale for the surface electrocardiogram. J Cardiovasc Electrophysiol. 2010;21:170-176. 15. Cano O, Hutchinson M, Lin D, Garcia F, Zado E, Bala R, Riley M, Cooper J, Dixit S, Gerstenfeld E, Callans D, Marchlinski FE. Electroanatomic substrate and ablation outcome for suspected epicardial ventricular tachycardia in left ventricular nonischemic cardiomyopathy. J Am Coll Cardiol. 2009;54:799-808. 16. Dixit S, Narula N, Callans DJ, Marchlinski FE. Electroanatomic mapping of human heart: epicardial fat can mimic scar. J Cardiovasc Electrophysiol. 2003;14:1128. 17. d'Avila A, Houghtaling C, Gutierrez P, Vragovic O, Ruskin JN, Josephson ME, Reddy VY. Catheter ablation of ventricular epicardial tissue: a comparison of standard cooled-tip dard and cooled-ti tiip radiofrequency energy. Circulation. 2004;109:2363-2369. 18. Di Biase L, Al-Ahamad A, Santangeli P, Hsia HH, Sanchez J, Bai R R, Ba Bailey S, Ho Horton ail iley ey S Hort rton rt on R, Gallinghouse Yang usee GJ, GJ, J Burkhardt Bur u kh khar ardt DJ, Lakkireddy D, Yan ar ang Y, Badhwarr N, S an Scheinman cheinman M, Tung R, Dello Russo Casella and so o A, A, Pelargonio Pelargo goni go niio G, C nio aselllaa M, as M, Tomassoni Toma To mass ma s onni G, Shivkumar Shi hivk v um umar ar K, K, Natale Nata tale ale A. A. Safe Sa Safety afe fety ty y an outcomes of tachyarrhythmias: from multicenter of ccryoablation ryoablationn for vventricular entrric icular ar ta achhyaarrrhytthmia ias: ia s:: rresults esulltss fro om a m ultiicen e te ter experience.. Heart Hear He a t Rhythm. Rh hyt y hm m. 2011;8:968-974. 20011;8 8:9 968 6 -99744. 19. Mulpuru minimally-invasive r SK, ru SK K, Feld Feld GK, GK, K Madani Mad adan anii M, an M Sawhney Saw awhn hney hn ey NS. NS. A novel, novvel e , mi m nima ni maall llyy-in yinva in vaasiv ivee surgical s rg su gic i al approach for ablation originating o abl or blatiion of vventricular bl entriicullar ttachycardia achy hycarddia hy i ori igi ginattingg near the th he proximal prox pr o imall left lefft anterior an nte teri rior ri descendingg coronary artery. Electrophysiol. y ar arte t ry te ry.. Circ Circ Ci rcc Arrhythm Arr rrhy hyyth thm hm Elec E El lec ectr trop tr ophy op hysi hy siol si ol.. 2012;5:e95-97. ol 2012 20 12;5 12 ;5:e ;5 5:ee95 95-9 -97. -9 7. 7. 20. Desjardins B, Morady F, Bogun F. Effect of epicardial fat on electroanatomical mapping and epicardial catheter ablation. J Am Coll Cardiol. 2010;56:1320-1327. 21. Yamada T, Doppalapudi H, McElderry HT, Okada T, Murakami Y, Inden Y, Yoshida Y, Kaneko S, Yoshida N, Murohara T, Epstein AE, Plumb VJ, Kay GN. Idiopathic ventricular arrhythmias originating from the papillary muscles in the left ventricle: prevalence, electrocardiographic and electrophysiological characteristics, and results of the radiofrequency catheter ablation. J Cardiovasc Electrophysiol. 2010;21:62-69.
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Table 1: Clinical characteristics of the patients included in the study
Variable
Overall (N=23)
Successful Abl. (N=5)
Unsuccessful Abl. (N=18)
P value*
Age, years
50 ± 14
50 ± 12
50 ± 15
0.911
9 (39)
1 (20)
8 (44)
0.611
55 ± 14
65 ± 4
53 ± 14
0.021
Sustained VT, n (%)
7 (30)
2 (40)
5 (28)
0.621
Non-sustained VT, n (%)
5 (22)
3 (60)
2 (11)
0.048
Frequent VPDs, n (%)
11 (48)
0 (0)
11 (61)
0.037
Male sex, n (%) LVEF, % Predominant Presenting Arrhythmia i ia
*Comparison between successful and unsuccessful ablation (Abl.) cases. N = number; LVEF = left ventricular ejection fraction; VT = ventricular tachycardia; VPDs = ventricular premature depolarizations.
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Table 2: ECG characteristics in the successful and unsuccessful ablation cases Successful Abl. (N=5)
Unsuccessful Abl. (N=18)
P value*
RBBB morphology, n (%)
4 (80)
9 (50)
0.339
LBBB morphology, n (%)
1 (20)
9 (50)
0.339
QS in lead I, n (%)
3 (60)
4 (22)
0.142
Initial “q” in V1, n (%)
0 (0)
6 (33)
0.272
QRSd
147 ± 16
149 ± 26
0.970
PdW
44 ± 5
55 ± 12 12
0.086 0.08 0. 08
IDT
76 ± 5
88 ± 24 24
00.079 0. 07 07
MDI
0.51 ± 0.07
0.52 ± 0.11 0 11
00.794 79
R in II
1.25 255 ± 0.522
11.51 .51 5 ± 00.38 51 .338
00.456 .4
R in III
1.599 ± 0.61
1.688 ± 00.46 .446
0.823 0.82 2
R in aVF F
11.33 1. 33 ± 00.59 .59 59
11.57 .57 57 ± 0.411
00.433 .44
Ratio R in III/III I//II IIII
0.79 0. 799 ± 00.16 .166 .1
0.93 00. .93 ± 00.20 . 0 .2
00.248 .244
Q in aVL L
1..03 ± 00.41 1.03 .441 .41
00.91 0. .91 91 ± 00.29 .299 .2
0.391 0.3 9
Q in aVR R
00.46 46 ± 00.23 23
00.71 71 ± 00.22 22
00.052 0
Ratio Q in aVL/aVR
2.63 ± 1.31
1.39 ± 0.58
0.017
4 (80)
2 (11)
0.008
R in V1
0.51 ± 0.32
0.40 ± 0.32
0.331
R in V2
0.97 ± 0.54
0.77 ± 0.63
0.296
R in V3
1.86 ± 0.83
1.45 ± 0.71
0.456
S in V1
0.18 ± 0.16
0.47 ± 0.36
0.057
S in V2
0.65 ± 0.50
0.90 ± 0.67
0.551
S in V3
0.40 ± 0.12
0.55 ± 0.49
0.970
Ratio R/S in V1
5.98 ± 5.85
1.81 ± 2.23
0.100
4 (80)
5 (28)
0.056
2.28 ± 1.47
2.34 ± 3.23
0.456
Variable Qualitative findings
Duration (ms)
Limb leadss (mV) (mV mV))
Ratio Q in aVL/aVR >1.85, n (%) Precordial leads (mV)
Ratio R/S in V1 >2, n (%) Ratio R/S in V2
*Comparison between successful and unsuccessful ablation (Abl.) cases. RBBB/LBBB = right/left bundle branch block; QRSd = QRS duration; PdW = pseudo-delta wave; IDT = intrinsicoid deflection time; MDI = maximum deflection index.
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Figure Legends:
Figure 1: Computer tomographic image depicting the anatomy of the left ventricular summit (LVS). The LVS is a triangular region of the LV epicardium with the apex at the bifurcation between the left anterior descending (LAD) and left circumflex (LCx) coronary arteries, and the base formed by an arc connecting the first septal perforator branch (SP) of the LAD with the LCx (white dotted line and arrows). The LVS is bisected by the great cardiac vein (GCV) which separates it into two regions: 1) closer to the apex of the triangle (blue dotted line)) and, 2) 2) a more lateral towards the base of the triangle (yellow dotted line). The formerr is le lless ss aaccessible cces cc essi siiblle fo ffor o catheter ablation lattio ionn in i tthe h eepicardial he picardial aspect due to proximity pi prox oxim ox i ity to coronary im coronnaryy arteries arteries and/or the presence off th thicker epicardial main artery; hicker layerr ooff epi picard pi rddial fa ffat. t. LM LM = lleft eftt m ain in coronary coorron onar ary ar ar rteery y; AIV V = anterior anteriior an interventricular c cular vvein. einn. ei
Figure 2: Fl Flow-chart study, Flo chart hartt displa ddisplaying ispll ing in the th selection lecti tio process off the the patients ati tientt iincluded incl ncll dded ed d iin the th st t d and the acute and long-term outcomes with epicardial (EPI) mapping and ablation. *Epicardial access was obtained after failure of ablation from adjacent sites including the left ventricular and right ventricular endocardial outflow tracts, the coronary venous system, and coronary cusp region. N = number; RF = radiofrequency; LAD = left anterior descending coronary artery; LCx = left circumflex coronary artery.
Figure 3: Comparison of ECG measurements in a sample patient with successful epicardial (EPI) ablation and in one with unsuccessful ablation.
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Figure 4: Comparison of 12-lead ECG of the successful and unsuccessful epicardial ablation groups.
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Percutaneous Epicardial Ablation of Ventricular Arrhythmias Arising from the Left Ventricular Summit: Outcomes and ECG Correlates of Success Pasquale Santangeli, Francis E. Marchlinski, Erica S. Zado, Daniel Benhayon, Mathew D. Hutchinson, David Lin, David S. Frankel, Michael P. Riley, Gregory E. Supple, Fermin C. Garcia, Rupa Bala, Benoit Desjardins, David J. Callans and Sanjay Dixit Circ Arrhythm Electrophysiol. published online January 30, 2015; Circulation: Arrhythmia and Electrophysiology is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2015 American Heart Association, Inc. All rights reserved. Print ISSN: 1941-3149. Online ISSN: 1941-3084
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circep.ahajournals.org/content/early/2015/01/30/CIRCEP.114.002377
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Percutaneous Epicardial Ablation of Ventricular Arrhythmias Arising from the Left Ventricular Summit: Outcomes and ECG Correlates of Success
Running title: Santangeli et al.; Epicardial ablation of LV summit VTs
Pasquale Santangeli, MD1; Francis E. Marchlinski, MD1; Erica S. Zado, PA-C1; D1; Da Davi David vidd S. vi S Frankel, Fran Fr anke an kell, MD1; ke Daniel Benhayon, MD1; Mathew D. Hutchinson, MD1; David Lin, MD in C. Garcia, Garc Ga rcia rc iaa, MD1; Michael P. Riley, MD, PhD1; Gregory E. Supple, MD1; Fermin Rupa Bala, ala ala la, M MD D1; B Benoit enoit Desjardins, Desjjardins,, MD, PhD2; David D vid J. Call Da Callans, lllans, MD1; Sanjay Dixit, M MD1
1
Electrophysiology h ol hysiol olog o y Se og S Section, ctio ct io on, n, Cardiovascular Car ardi diov ovas a cu ulaar Di Division, ivi v siion on,, 2De Department Depa p rtme pa rttme ment nt ooff Ra Radi Radiology, diiol diol olog ogy, og y,, H Hospital ospi os p tal of the pi University Univ Un iver iv ersi er sity si ty ooff Pe Penn Pennsylvania, nnsy nn sylv sy lvan lv ania an ia,, Ph ia Phil Philadelphia, ilad il adel ad elph el phia ph ia,, PA ia A
Correspondence: Sanjay Dixit, MD Hospital of the University of Pennsylvania 9 Founders Pavilion – Cardiology 3400 Spruce St. Philadelphia, PA, 19104 Tel: 215-615-4337 Fax: 215-662-2879 E-mail: [email protected]
Journal Subject Code: [5] Arrhythmias, clinical electrophysiology, drugs
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Abstract: Background - Percutaneous epicardial ablation of ventricular arrhythmias (VAs) arising from the left ventricular summit (LVS) is limited by the presence of major coronary vessels and epicardial fat. We report the outcomes of percutaneous epicardial mapping and ablation of VAs arising from the LVS, and the ECG features associated with successful ablation. Methods and Results - Between January 2003 and December 2012 a total of 23 consecutive patients (49 ± 14 years, 39% males) with VAs arising from the LVS underwent percutaneous epicardial instrumentation for mapping and ablation due to unsuccessful ablation from the coronary venous system and multiple endocardial LV/RV sites. Successful epicardial ablation p was achieved in 5 (22%) patients. In the remaining 18 (78%) cases, ablation for bllat atio ionn was io was aborted abor ab ortte or ted fo ted o either close proximity to major coronary arteries or poor energy delivery over epicardial ery ove verr ep ve epic iccar ardi dial di al ffat. at The Q-wave amplitude >1.85 mplitude mpli litu li tu ude d ratio rat atio i in in aVL/aVR was higher in n th thee successful gro group, oup u , with a ratio of >1. present in 4 (80%) patients group unsuccessful group (880%) patie ents in n the the h successful suuccceesssfu ful grou ouup vs. vs. 2 (11%) (11% (1 1% %) in i the the un nsuc u cess uc ssfu ss full gr fu rou oupp (P (P = 0.008). Thee rratio R/S V1 group, patients ati t o of R / wave /S wavee iin nV 1 wass greater grreater eateer iinn tthe he ssuccessful ucceessfuul grou uc ou up, w with i h 4 (80%) it (80% 0%) pa patie tie in the successful sful group gro r upp having havin ng a R/S ratio ratio of >2 in ra n V1 V1 vs. v . 5 (28%) vs (28% (2 8%)) in the 8% h unsuccessful he unsuc uccess uc s ful group ss g oup (P gr ( = 0.056). None the V1, n of th ne he pa ppatients tien ti ents en t in in the h successful successful f l group groupp had had d an iinitial nitia i l “q” “ ” wave “q w ve iin wa n lead dV 1 as 1, opposed to 6 (33%) ECG (33 33%) %) iinn the the unsuccessful unsu un succ cces essf sffull group. gro roup up.. The The presence pres pr esen ence cee ooff at lleast east ea stt ttwo wo ooff th the he th tthree reee EC re criteria above predicted successful ablation with 100% sensitivity and 72% specificity. Conclusions - Epicardial instrumentation for mapping and ablation of VAs arising from the LVS is successful only in a minority of patients due to close proximity to major coronary arteries and/or epicardial fat. A Q-wave ratio of >1.85 in aVL/aVR, a R/S ratio of >2 in V1, and absence of “q” waves in lead V1 help identify appropriate candidates for epicardial ablation.
Key words: catheter ablation, epicardial, mapping, ventricular tachycardia, left ventricular summit
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Introduction The left ventricular summit (LVS) is a common site of origin of idiopathic ventricular arrhythmias (VAs).1 According to the initial description by McAlpine,2 the LVS is a triangular portion of the epicardial left ventricular outflow tract (LVOT) bounded by the bifurcation between the left anterior descending and the left circumflex coronary arteries, and transected laterally by the great cardiac vein (GCV) at its junction with the anterior interventricular vein (AIV).2 Given the proximity to major coronary vessels and the presence of a thick layer of epicardial fat in this location,1, 2 catheter ablation of VAs originating from rom the LVS with ha percutaneous epicardial approach is challenging; in many cases, ablation on fr from om adjacent adj djac acen entt st stru structures r such as thee left leeft coronary cor oron o aryy ccusp, on usp, the GCV-AIV junct junction, tio ionn, the endocardial endocar a dial al aspect of basal LV (immediately ely below the aaortic el orticc valve), valv ve), and/or an nd/or or thee sep septal ptaal RV RV outflow oouutfllow w trac tract ct at at its lleftmost e tm ef tmoost as aspe aspect e is 3-55 an effectivee alte alternative teern rnat atiive appr at approach proach h to aachieve chi ch hieve ssuccess. u cess.3uc However, H owev ow ever, wh ev when ablat ablation atio at io on off L LVS VS V VA A from
these alternative n native llocations lo catiionns iiss unsuccessful unsuccessful, l, an ep epicardial picardi diall app di approach pproachh mi pp migh might igh ghtt be b consid considered. derred ed.11,, 6 IIn this study, we report rtt tthe he outcomes o ttcomes off percutaneous perc ttaneo a s epicardial ic diall mapping pii and ndd ablation blati tio off VAs VAs originating from the LVS, and the electrocardiographic (ECG) features predicting successful ablation.
Methods The study design was retrospective and included consecutive patients with VAs originating from the LVS who underwent percutaneous epicardial instrumentation for mapping and ablation following unsuccessful attempt at the same from the coronary venous system, cusp region, and adjacent endocardial LV/RV sites. According to prior studies,1 the LVS was defined as the triangular portion of the epicardial LVOT with the apex at the bifurcation between the left anterior descending and the circumflex coronary arteries and the base formed by an arc 3 Downloaded from http://circep.ahajournals.org/ at Tulane University on January 31, 2015
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connecting the first septal perforator branch of the left anterior descending coronary artery with the circumflex coronary artery (Figure 1). The LVS is bisected by the GCV in two regions, one closer to the apex of the triangle (i.e., inaccessible area), and one at the base of the triangle (i.e., accessible area). All the anatomical definitions were based on orthogonal fluoroscopy, intracardiac echocardiography and intraprocedural coronary angiography. All patients had failed treatment with at least 1 antiarrhythmic drug and/or atrioventricular nodal blocking agents; these were discontinued for at least five half-lives before the procedure. All patients signed a written informed consent according ngg to institutional guidelines of the University of Pennsylvania Health System. The baseline line ccharacteristics haraccte hara terist riistic iccs including the ECG h age, he agee, sex, ag sex e , nature naature of the clinical arrhythmia, arrhyth hmi m a, and 12-lead 12-leead E CG of the VAs were recorded. Electrophysiological study ablation y log ysiol ogic ical ic c st tud dy and and d catheter cat atthe heter ab bla lati tion ti Patients presented electrophysiology Conscious esented d to th the he ccardiac ardia di c el lecttropphy h siiolloggy laboratory labborattory y in th the he fa fast fasting sttingg state. sttatte. C Consciou onsc on scciou sedation was approach. as used sed d as the the preferred fe ed d approach h General G all anesthesia sth thesii with iith th an iinhaled nhhalledd anesthetic theti tic (typically sevoflurane) was used for obtaining pericardial access and during epicardial mapping and ablation. Atrial and/or ventricular burst pacing with and without intravenous isoproterenol (up to 12 μg/min) was used to provoke the VAs in case of suppression after general anesthesia induction. Catheters were positioned in the heart using fluoroscopic guidance. A 6-Fr quadripolar catheter with 5-mm interelectrode distance (Bard Inc., Delran, New Jersey) was placed at the RV apex. A 7-Fr decapolar catheter with 5-mm electrodes and 2-mm interelectrode distance was advanced to the coronary sinus and at the GCV-AIV junction. A deflectable 8-Fr mapping/ablation catheter that had a 3.5-mm irrigated tip and a 2-mm ring electrode separated by 1 mm (Thermocool, Biosense Webster, Diamond Bar, California) was advanced to the RV
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(transvenous approach), LV (retrograde aortic approach), coronary venous system and epicardial space for mapping. Access to the pericardial space and epicardium was obtained using the approach described by Sosa et al.7 A 64-element phased-array ICE catheter (AcuNav, Acuson, Mountain View, California) was used to assist catheter manipulation, assess distance from the ostium of the left main coronary artery, monitor radiofrequency energy delivery, tissue-catheter contact, and complications. In addition, ICE was used together with the three-dimensional electroanatomic mapping system to define the anatomical details of structures adjacent to the epicardial LVS. During mapping in the LV and coronary cusp region, intravenous hep heparin parrin w was used to achieve an activated clotting tiPHRIVHFRQGV The site off origi origin giin off tthe gin h V he VA A wa w was a d bas ased as ed oon n de ddetailed taailed activation and pace m a ping. In par ap rticu ula l r, during activation determined based mapping. particular, mapping, the he lo llocal cal activa activation atiion ti time ime w was as co cconsistently nsiistent nttly m measured easu sure su red from re om th the he on onset nseet off th the he eelectrogram lecctrrogg o ositive e orr negative neg egati tive deflection) defl f ecti tion ti on)) of the on the distal distall bipole bipoole of bi of the the mapping m ppin ma i g catheter cath ca theter to th to the th (earliest positive s of the set th he QRS QRS complex comp plex in i anyy off the th he 122 ECG ECG G leads. leadds. Activation Acti tivati tioon times ti tiimes were re measured meass earliest onset by 2 independent endent dentt observers obser bs ers and ndd ddispla displayed ispll edd on a three th three-dimensional dimensional di io l el electroanatomic l tr tomii map (CARTOTM, Biosense Webster, Diamond Bar, California) as well as the EP recording system (PruckaTM, GE, Houston, TX). Pace-map match was visually judged by 2 observers, with each of the 12 ECG leads assessed for the QRS vector and major notching or deflections from baseline. An ideal match required identical QRS complexes between the paced beats and native VA in 12 of 12 ECG leads. Coronary angiography was performed to delineate the ostium and the course of the left coronary artery prior to ablation. Radiofrequency energy was only delivered if the site was >5 mm from a coronary artery. During radiofrequency energy delivery, if a suppression/elimination of VAs occurred within the initial 30 seconds, the application was maintained and carefully titrated for 60 seconds, targeting an impedance drop of 10-15 Ohms
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with a maximum temperature of 45°C and a maximum power of 40 watts. After ablation, atrial and/or ventricular burst pacing with and without intravenous isoproterenol (up to 12 μg/min) was used to assess arrhythmia inducibility. Acute success was defined as inability to induce the clinical VAs (ventricular premature depolarization [VPD] or ventricular tachycardia [VT]) at the end of the procedure and no recurrence during 24 hours of post-procedural hospital ECG monitoring. ECG analysis Detailed ECG analysis was performed off-line on the PruckaTM CardioLab oLab recording g sy system yst steem (GE, Houston, TX) with the recordings displayed at a speed of 100 and d 20 200 00 mm mm/ mm/s. /s. Analysis /s Anal nal alyysi ysi of ECG tracings n sw ngs was a pperformed as erfo er f rm med according to previousl previously sly reported mea sl measurements e suure rements applied to thee outflow tract act region. ac region.8-11 IInn pa particular, artticullar, th the he fo following ollow winng E ECG CG G ffeatures eatu ea urees wer were re as assessed: sseessedd: 1)) QR QRS RS pseud udoo-ddelt ud ltta wave (P ((PdW), dW W), intri ins nsic icoi ic oid id deflection d fl de f eccti tionn time tim me (IDT), (IDT (I DT T), m axiimum deflection ax defflecc duration; 2)) pseudo-delta intrinsicoid maximum 8-12 8 122 index (MDI); D ); DI); ) 833)) R wave waave amp amplitude pli litude d in leads lead ds II, II, II II IIIII and d aV aVF VF (a (and nd ratio io o bbetween etween t R wa w wav wave ave inn lead
II / lead III); ));; 4) Q wave a e amplit amplitude plit lit dde iin n lleads ds aVL VL and ndd aVR VR ((and d ratio ti bbetween bet ett een Q wave a e iin llead ead d aVL / lead aVR); 5) R wave amplitude in leads V1, V2 and V3; 6) S wave amplitude in leads V1, V2, and V3; 7) presence of a QS complex in lead I.12 Three QRS complexes were measured in each patient to confirm reproducibility, and the mean of the values was used. Follow-up Antiarrhythmic drugs were not reinitiated if ablation was acutely successful. Post procedure, patients remained overnight in the hospital under continuous ECG monitoring. Beyond that, patients were followed in the outpatient clinic at our institution, or by their referring physician. Information about symptoms, VA burden using 24-hour Holter or auto-triggered transtelephonic ECG monitoring was assessed 2-6 months after discharge.
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Statistical analysis Descriptive statistics are reported as mean ± SD or median and interquartile range (IQR) for continuous variables, and as absolute frequencies and percentages for categorical variables. Between-group comparisons were performed with the Mann-Whitney U test and Fisher’s exact test as appropriate. The Wilcoxon matched-pairs signed-rank test was used to compare activation mapping and ablation (impedance drops) data (repeated measurements on a single sample). In order to formally assess the degree of interobserver agreement for ECG analysis, two observers independently measured a total of 96 ECG parameters from 6 patients randomlyy selected. selected ed d. Interobserver disagreement was considered present when the timing difference iffereenc ncee exceeded exce ex ceed eded ed 5 ms and the voltage was l age ltag ge difference diff di fffer e ence ce exceeded 0.1 mV. All tests teest stss were 2-sided, 2-sided e , and an nd a P value 1.85 (vs. 2/18 [11%] unsuccessful essful cases, P = 00.008 .000 for .0 comparison). An R-wave to S-wave ratio in lead V1 greater than 2 wass pres present esen entt in i 44/5 /5 ((80%) 80% 80 % patients in thee successful succ su cces e sf es s ull group group compared with 5/188 (28%) ( 8%) cases of (2 o uunsuccessful n uccessful ablation ((P = ns 0.056 for comparison). patients group had initial omparison). None None ooff the he patie i ntts in the ie the successful suc uccess s fuul grou ss oup ha ou ad an initi ial “q”” wave wavve in lead V1 vs.. 6/18 QS 188 [33%] [33% 333%] in in the th unsuccessful unsuccces essful group. gro r up up. A Q S complex comp co mpllex in lead mp leadd I was was pr ppresent esentt iin n3 (60%) successful unsuccessful No significant c full andd 4 ((22%) cessf 22%) 22 % unsuccessf %) ful cases. N o si ign g ifficant di ddifferences fferrences between ff betweeen th the successful and off ttotal ndd unsuccessful ns ccessf sff l groups gro ps were ere detected dett tedd in in terms t ottall QRS QRS duration d ration ti ((147 1477 ± 16 ms 14 vs. 149 ± 26 ms, respectively, P = 0.970), MDI (0.51 ± 0.07 vs. 0.52 ± 0.11, respectively, P = 0.794), IDT (76 ± 5 ms vs. 88 ± 24 ms, respectively, P = 0.079), PdW (44 ± 5 ms vs. 55 ± 12 ms, respectively, P = 0.086), and R-wave ratio in leads II/III (0.79 ± 0.16 vs. 0.93 ± 0.20, respectively, P = 0.248). ECG correlates of successful epicardial ablation The three criteria that were tested to assess the value of the ECG to help identify patients who had successful epicardial ablation were: 1) Q-wave ratio in leads aVL/aVR >1.85, 2) R/S wave ratio in lead V1 >2 and, 3) Lack of initial “q” wave in lead V1. The presence of at least two of these three ECG criteria was associated with successful epicardial ablation with 100% sensitivity
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and 72% specificity. Follow-up After a median follow-up of 36 months (interquartile range 36 months), 3 out of the 5 patients who had successful epicardial ablation were free from any recurrent VAs; one of these patients was maintained on propafenone. Another patient had a reduction in the VPD burden after ablation (from 23% to 7.8% burden on 24-h Holter monitoring) and has remained off antiarrhythmic drug therapy. Finally, one patient had recurrent VT, which was controlled with amiodarone.
Discussion n The present study nt st nt tudy was specifically speecif sp iffical ific a ly ddesigned esig igne ig n d to aassess ne ssesss thee outcomes ouutc t om mes off percutaneous perc rcut rc utan ut neo e us eepicardial pica pi cardd ca mapping and ablation LVS, ECG features nd ab nd abla laati tion on for foor VA VAs or ooriginating ig gin i attin ing fr ffrom om m tthe he L VS,, an VS andd to t evaluate ev vallua uatte th thee EC CG fe eat a ures e associated with w th successful wit succ su cces cc essf es sful sf ul epicardial e ic ep icar ardi ar dial di all ablation. ablat atio at ionn. To io T the the h best bes estt off oour urr kknowledge, n wl no wled edge ed g , ou ge oourr st sstudy udyy iincludes ud ncll the largest po population popu pulaati t on o to to date ddaate te w with itth LVS LVS arrhythmias a rhhythm ar ytthm h ia i s undergoing u ddeerg un goi o ngg percutaneous per e cu cuta taneeou ouss epicardial epic ep i ar ic a di d al a mapping and ablation. The major findings are as follows: 1) the outcome of catheter ablation for LVS arrhythmias from the epicardium is poor, with an acute success rate of 22% and a long-term arrhythmia-free survival of 17%; 2) ECG features including a Q-wave ratio in leads aVL/aVR >1.85, and R/S wave ratio in lead V1 of >2, and the lack of an initial “q” wave in lead V1 may help identify cases where epicardial ablation may have a higher chance of success. Epicardial catheter ablation of VAs from the LVS Catheter ablation of VAs arising from the LVS can be challenging, given the proximity to critical structures such as major coronary vessels and/or inability to deliver effective radiofrequency lesions due to the presence of a thick layer of epicardial fat.1, 9, 13, 14 In many of these cases, radiofrequency delivery from adjacent sites such as the endocardial LV/RV, coronary cusp 11 Downloaded from http://circep.ahajournals.org/ at Tulane University on January 31, 2015
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region or coronary venous system is successful in eliminating the arrhythmias.3-5 In this regard, ICE together with three-dimensional electroanatomic mapping is particularly valuable in defining the anatomical details of structures adjacent to the epicardial LVS; however, in this series, ICE did not enhance ablation success. In a recent study by our group, successful ablation of VAs from the inaccessible LVS area was achieved from the left coronary cusp in 56% of cases.3 Similarly, Yamada et al., who first described the anatomy and electrophysiologic characteristics of arrhythmias arising from the LVS in a series of 27 patients, reported successful ablation from the GCV-AIV region in more than 70% of cases.1 Whenn ablation from ad adjacent dja jacce sites fails, a percutaneous epicardial access for mapping and ablation may be b considered. consi sid idere deredd.11,, 6 Thus blished blish shed sh ed experience exp x erieence with epicardial mapping mappin ingg and ablation in on off L VS arrhythmias is sscant. far, the published LVS For instance, ce, in ce in the studyy by by Yamada Yamaada ett al., only Ya only y 9/27 9/2 27 (33%) (333% 3 ) ppatients atiients und underwent ndder erwent ntt ep eepicardial iccarddiaal n ab nd bla lati tiion which tio whhichh was succ cceessfull iinn 4/9 cc 4/9 / (44%) (444%) cases. case sees.1 IInn our stud study, dy, y iinn about ab boutt ttwo-thirds wo mapping and ablation successful of cases, radiofrequency a freq adiof quencyy de deli delivery l very li y iin n tthe he epi epicardial picarddial llocation pi ocati tion i was ab abortedd ddue ue to pr pproximity oxim imit im itty to o major epicardial coronary vessels. radiofrequency ardial rdi diall coronar essels ell Wh When radiofreq adi dioffr enc ablation abl blati ti was as att attempted tte tedd after aft fte verifying erif rif if safe distance from major coronary vessels, it was successful in eliminating the arrhythmia only in a small subset of these patients. We think this is likely due to the presence of epicardial fat at the tissue-catheter interface,15, 16 although we did not find significant differences in average impedance drops with radiofrequency application in successful versus unsuccessful cases. Prior studies have shown that epicardial fat represents a major limitation to achieving adequate lesions by radiofrequency energy;17 in these cases, a different source of ablation energy, such as cryoablation, may be more efficacious.18 In rare cases, minimally invasive surgical ablation has also been shown to be effective in treating LVS arrhythmias, which were successfully targeted after mobilizing the coronary artery away from the site of cryoablation in the area of interest.19
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However, the degree of incremental benefit with these techniques compared to conventional percutaneous radiofrequency ablation warrants validation in larger studies. None of the patients included in our series underwent cryoablation and/or surgical ablation. ECG features associated with successful epicardial ablation The accessible area of the LVS is located inferiorly and laterally to the GCV, where the anatomical separation between the left anterior descending and circumflex coronary arteries is maximal and there is lower chance of having a thick layer of epicardial fat (Figure 1).20, 21 Indeed, the three ECG features found to be more prevalent in successful ful versus unsucce unsuccessful ess ssfu f cases (i.e., Q-wave ratio aVL/aVR >1.85, R/S ratio in V1 >2, and lackk of “q” “q”” wa “q wave ve iin n V1 V1) V1), ), reflect a more o e lateral ore late la tera eraal site s tee of si of origin of the VAs (dist (distant tan antt from the m midline idline ne and the apex of thee LVS triangle). Acc According Accordingly, ccor cc o dingly,, mo more pa patients atient nts in nt n the thee successful succe ceessfu ful gr group rouup had hadd a QS S pat pattern atttern iinn lead atte leead d I, w which wh h again points t to a more ts mo o lateral lateral t l (and (and epicardial) ep pic icardial al)) or al origin rig igin i off the he V VAs. As.12 T The h llow he ow aablation blation successs from bl the epicardial dial llocation ocatio i n in our series seriies suggests sugg ggests that gg tha h t the th he majority majo jority ity off these th hese VA were orig originating ig gin nat atingg from the inaccessible LVS. activation ssible iblle location ib l ati tion off the th LVS LV S This Thi is is corroborated bo tedd bby tthe he observation obser bs ation ti tthat hatt th the acti ti a times septal to the GCV/AIV were better compared to those lateral to the GCV/AIV. In our study, the presence of at least two of the three ECG criteria was associated with successful epicardial ablation with a 100% sensitivity and 72% specificity. Our findings support the usefulness of ECG analysis to select cases with the greatest chance of success of epicardial ablation in the LVS region. Limitations This was a single-center observational study. The decision to obtain percutaneous epicardial access for mapping/ablation was made by the operator during the procedure after failed ablation attempts from multiple adjacent structures; this may have introduced subjective bias. Although,
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in our series, the epicardial LVS was accessed in all patients without difficulty, in some cases the left atrial appendage may prevent adequate epicardial mapping in the LVS region. Our institution is a tertiary referral centers for the treatment of VAs and so the characteristics of the study population may not be generalized. Given the small number of patients, our findings with respect to ECG correlates of success should be viewed as hypothesis generating only, and deserve to be validated prospectively in a larger and independent sample of patients.
Conclusions In patients manifesting ventricular arrhythmias arising from the LV summit umm mit tthe he ooutcome utco ut come co me ooff epicardial ablatio vessels ablation ionn is io i poor pooor in the majority of cases du duee to proximity too major m jor coronary vesse ma and/or presence epicardial features more leftward sencce of epica se ard r iaal fat. fatt. ECG fa ECG fe eatturres ppointing oinnting to a m orre le left f ward ft rdd / lateral l teera la rall site sit itee of of origin o of the VA in >1.85 R/S >2 V1, i tthis h s location hi lo loca oca cati t on ti o (i.e., (i. i.ee., Q-wave Q wa Qw vee rratio atio io of of >1 >1.8 . 5 in aVL/aVR, .8 aVL VL/a /aaVR VR,, a R/ /S ratio raati t o of o > 2 in V 1, and 1, absence of “q”” w waves V1) help appropriate candidates successful aves av es iin n le lead a V ad 1) ma may y he elp iidentify deent n iffy ap appr p oppri pr riat atee ca at and ndid idat id ates at es ffor or su succ c es cc essf sfful epicardial aablation ablation. b at bl atio on..
Funding Sources: The study was funded in part by the F. Harlan Batrus Research Fund Conflict of Interest Disclosures: None References 1. Yamada T, McElderry HT, Doppalapudi H, Okada T, Murakami Y, Yoshida Y, Yoshida N, Inden Y, Murohara T, Plumb VJ, Kay GN. Idiopathic ventricular arrhythmias originating from the left ventricular summit: anatomic concepts relevant to ablation. Circ Arrhythm Electrophysiol. 2010;3:616-623. 2. McAlpine WA. Heart and Coronary Arteries. New York: Springer-Verlag; 1975. 3. Jauregui Abularach ME, Campos B, Park KM, Tschabrunn CM, Frankel DS, Park RE, Gerstenfeld EP, Mountantonakis S, Garcia FC, Dixit S, Tzou WS, Hutchinson MD, Lin D, Riley
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MP, Cooper JM, Bala R, Callans DJ, Marchlinski FE. Ablation of ventricular arrhythmias arising near the anterior epicardial veins from the left sinus of Valsalva region: ECG features, anatomic distance, and outcome. Heart Rhythm. 2012;9:865-873. 4. Obel OA, d'Avila A, Neuzil P, Saad EB, Ruskin JN, Reddy VY. Ablation of left ventricular epicardial outflow tract tachycardia from the distal great cardiac vein. J Am Coll Cardiol. 2006;48:1813-1817. 5. Frankel DS, Mountantonakis S, Dahu MI, Marchlinski FE. Elimination of ventricular arrhythmias originating from the anterior interventricular vein with ablation in the right ventricular outflow tract. Heart Rhythm. 2014;11:S217. 6. Tanner H, Hindricks G, Schirdewahn P, Kobza R, Dorszewski A, Piorkowski C, Gerds-Li JH, Kottkamp H. Outflow tract tachycardia with R/S transition in lead V3: six different anatomic approaches for successful ablation. J Am Coll Cardiol. 2005;45:418-423. 23. 7. Sosa E, Scanavacca M, d'Avila A, Pilleggi F. A new technique to perform mapping erform rm eepicardial piicard pica rdia dia i l map m a in the electrophysiology laboratory. J Cardiovasc Electrophysiol. 1996;7:531-536. 6;7:531 31 536 8. Tada H, N H, Nogami ogami A, A N Naito a to ai o S, S, Fukazawa Fuka Fu kaza ka zawa za w H, wa H, Horie Hori Ho r e Y, Y K Kubota ubot ub o a S, ot S O Okamoto kamo ka m to oY Y,, Ho H Hoshizaki shhiz shiz i ak ki H Oshima S, Taniguchi epicardial distinct Tanniguchi K. Left Ta Left ventricular ventrric icular ar epi picarddial outflow outflo ou low lo w tract t actt tachycardia: tr tachyc ycarrdi dia: a nnew e dist ew tinc subgroup of Circ 2001;65:723-730. of outflow outf ou t low tract tracct tachycardia. tr tach hycarrdi dia. a Jp Jpn C ircc J. J. 20 001;6 ;6 65: 5 77223-73 730. 73 9. Daniels DV, Lu Morton Santucci Akar Green A,, Wi Wilber DJ. DV,, L u YY YY, Mo M rtton o JJB, B S B, antu ucc c i PA PA, Ak A arr JJG, G, G reen re en A Wilb lb lber ber e D J. IIdiopathic J. diop di o at op athi hc epicardial left l ventricular ventriicula larr tachycardia la tach hyc y ardi d a originating orig igiinatin ig i g remote t from from the th he sinus siinuus off Valsalva: Vallsalv l a: electrophysiological s siological l characteristics, cha hara raact cter eris er isti is tics ti ics cs, catheter cath ca thet th eter et e aablation, er blat bl a io at ion, n aand n, ndd iidentification dent de n if nt ificcat atio io ion on from frrom the the 12-lead 12-lead electrocardiogram. Circulation. 2006;113:1659-1666. diogram Ci di l tii 2006;113:1659 2006 20 06;113 113:165 16599 1666 1666 10. Berruezo A, Mont L, Nava S, Chueca E, Bartholomay E, Brugada J. Electrocardiographic recognition of the epicardial origin of ventricular tachycardias. Circulation. 2004;109:18421847. 11. Ito S, Tada H, Naito S, Kurosaki K, Ueda M, Hoshizaki H, Miyamori I, Oshima S, Taniguchi K, Nogami A. Development and validation of an ECG algorithm for identifying the optimal ablation site for idiopathic ventricular outflow tract tachycardia. J Cardiovasc Electrophysiol. 2003;14:1280-1286. 12. Valles E, Bazan V, Marchlinski FE. ECG criteria to identify epicardial ventricular tachycardia in nonischemic cardiomyopathy. Circ Arrhythm Electrophysiol. 2010;3:63-71. 13. Kumagai K, Fukuda K, Wakayama Y, Sugai Y, Hirose M, Yamaguchi N, Takase K, Yamauchi Y, Takahashi A, Aonuma K, Shimokawa H. Electrocardiographic characteristics of the variants of idiopathic left ventricular outflow tract ventricular tachyarrhythmias. J Cardiovasc Electrophysiol. 2008;19:495-501.
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14. Yamada T, McElderry HT, Okada T, Murakami Y, Doppalapudi H, Yoshida N, Yoshida Y, Inden Y, Murohara T, Epstein AE, Plumb VJ, Kay GN. Idiopathic left ventricular arrhythmias originating adjacent to the left aortic sinus of valsalva: electrophysiological rationale for the surface electrocardiogram. J Cardiovasc Electrophysiol. 2010;21:170-176. 15. Cano O, Hutchinson M, Lin D, Garcia F, Zado E, Bala R, Riley M, Cooper J, Dixit S, Gerstenfeld E, Callans D, Marchlinski FE. Electroanatomic substrate and ablation outcome for suspected epicardial ventricular tachycardia in left ventricular nonischemic cardiomyopathy. J Am Coll Cardiol. 2009;54:799-808. 16. Dixit S, Narula N, Callans DJ, Marchlinski FE. Electroanatomic mapping of human heart: epicardial fat can mimic scar. J Cardiovasc Electrophysiol. 2003;14:1128. 17. d'Avila A, Houghtaling C, Gutierrez P, Vragovic O, Ruskin JN, Josephson ME, Reddy VY. Catheter ablation of ventricular epicardial tissue: a comparison of standard cooled-tip dard and cooled-ti tiip radiofrequency energy. Circulation. 2004;109:2363-2369. 18. Di Biase L, Al-Ahamad A, Santangeli P, Hsia HH, Sanchez J, Bai R R, Ba Bailey S, Ho Horton ail iley ey S Hort rton rt on R, Gallinghouse Yang usee GJ, GJ, J Burkhardt Bur u kh khar ardt DJ, Lakkireddy D, Yan ar ang Y, Badhwarr N, S an Scheinman cheinman M, Tung R, Dello Russo Casella and so o A, A, Pelargonio Pelargo goni go niio G, C nio aselllaa M, as M, Tomassoni Toma To mass ma s onni G, Shivkumar Shi hivk v um umar ar K, K, Natale Nata tale ale A. A. Safe Sa Safety afe fety ty y an outcomes of tachyarrhythmias: from multicenter of ccryoablation ryoablationn for vventricular entrric icular ar ta achhyaarrrhytthmia ias: ia s:: rresults esulltss fro om a m ultiicen e te ter experience.. Heart Hear He a t Rhythm. Rh hyt y hm m. 2011;8:968-974. 20011;8 8:9 968 6 -99744. 19. Mulpuru minimally-invasive r SK, ru SK K, Feld Feld GK, GK, K Madani Mad adan anii M, an M Sawhney Saw awhn hney hn ey NS. NS. A novel, novvel e , mi m nima ni maall llyy-in yinva in vaasiv ivee surgical s rg su gic i al approach for ablation originating o abl or blatiion of vventricular bl entriicullar ttachycardia achy hycarddia hy i ori igi ginattingg near the th he proximal prox pr o imall left lefft anterior an nte teri rior ri descendingg coronary artery. Electrophysiol. y ar arte t ry te ry.. Circ Circ Ci rcc Arrhythm Arr rrhy hyyth thm hm Elec E El lec ectr trop tr ophy op hysi hy siol si ol.. 2012;5:e95-97. ol 2012 20 12;5 12 ;5:e ;5 5:ee95 95-9 -97. -9 7. 7. 20. Desjardins B, Morady F, Bogun F. Effect of epicardial fat on electroanatomical mapping and epicardial catheter ablation. J Am Coll Cardiol. 2010;56:1320-1327. 21. Yamada T, Doppalapudi H, McElderry HT, Okada T, Murakami Y, Inden Y, Yoshida Y, Kaneko S, Yoshida N, Murohara T, Epstein AE, Plumb VJ, Kay GN. Idiopathic ventricular arrhythmias originating from the papillary muscles in the left ventricle: prevalence, electrocardiographic and electrophysiological characteristics, and results of the radiofrequency catheter ablation. J Cardiovasc Electrophysiol. 2010;21:62-69.
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Table 1: Clinical characteristics of the patients included in the study
Variable
Overall (N=23)
Successful Abl. (N=5)
Unsuccessful Abl. (N=18)
P value*
Age, years
50 ± 14
50 ± 12
50 ± 15
0.911
9 (39)
1 (20)
8 (44)
0.611
55 ± 14
65 ± 4
53 ± 14
0.021
Sustained VT, n (%)
7 (30)
2 (40)
5 (28)
0.621
Non-sustained VT, n (%)
5 (22)
3 (60)
2 (11)
0.048
Frequent VPDs, n (%)
11 (48)
0 (0)
11 (61)
0.037
Male sex, n (%) LVEF, % Predominant Presenting Arrhythmia i ia
*Comparison between successful and unsuccessful ablation (Abl.) cases. N = number; LVEF = left ventricular ejection fraction; VT = ventricular tachycardia; VPDs = ventricular premature depolarizations.
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Table 2: ECG characteristics in the successful and unsuccessful ablation cases Successful Abl. (N=5)
Unsuccessful Abl. (N=18)
P value*
RBBB morphology, n (%)
4 (80)
9 (50)
0.339
LBBB morphology, n (%)
1 (20)
9 (50)
0.339
QS in lead I, n (%)
3 (60)
4 (22)
0.142
Initial “q” in V1, n (%)
0 (0)
6 (33)
0.272
QRSd
147 ± 16
149 ± 26
0.970
PdW
44 ± 5
55 ± 12 12
0.086 0.08 0. 08
IDT
76 ± 5
88 ± 24 24
00.079 0. 07 07
MDI
0.51 ± 0.07
0.52 ± 0.11 0 11
00.794 79
R in II
1.25 255 ± 0.522
11.51 .51 5 ± 00.38 51 .338
00.456 .4
R in III
1.599 ± 0.61
1.688 ± 00.46 .446
0.823 0.82 2
R in aVF F
11.33 1. 33 ± 00.59 .59 59
11.57 .57 57 ± 0.411
00.433 .44
Ratio R in III/III I//II IIII
0.79 0. 799 ± 00.16 .166 .1
0.93 00. .93 ± 00.20 . 0 .2
00.248 .244
Q in aVL L
1..03 ± 00.41 1.03 .441 .41
00.91 0. .91 91 ± 00.29 .299 .2
0.391 0.3 9
Q in aVR R
00.46 46 ± 00.23 23
00.71 71 ± 00.22 22
00.052 0
Ratio Q in aVL/aVR
2.63 ± 1.31
1.39 ± 0.58
0.017
4 (80)
2 (11)
0.008
R in V1
0.51 ± 0.32
0.40 ± 0.32
0.331
R in V2
0.97 ± 0.54
0.77 ± 0.63
0.296
R in V3
1.86 ± 0.83
1.45 ± 0.71
0.456
S in V1
0.18 ± 0.16
0.47 ± 0.36
0.057
S in V2
0.65 ± 0.50
0.90 ± 0.67
0.551
S in V3
0.40 ± 0.12
0.55 ± 0.49
0.970
Ratio R/S in V1
5.98 ± 5.85
1.81 ± 2.23
0.100
4 (80)
5 (28)
0.056
2.28 ± 1.47
2.34 ± 3.23
0.456
Variable Qualitative findings
Duration (ms)
Limb leadss (mV) (mV mV))
Ratio Q in aVL/aVR >1.85, n (%) Precordial leads (mV)
Ratio R/S in V1 >2, n (%) Ratio R/S in V2
*Comparison between successful and unsuccessful ablation (Abl.) cases. RBBB/LBBB = right/left bundle branch block; QRSd = QRS duration; PdW = pseudo-delta wave; IDT = intrinsicoid deflection time; MDI = maximum deflection index.
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Figure Legends:
Figure 1: Computer tomographic image depicting the anatomy of the left ventricular summit (LVS). The LVS is a triangular region of the LV epicardium with the apex at the bifurcation between the left anterior descending (LAD) and left circumflex (LCx) coronary arteries, and the base formed by an arc connecting the first septal perforator branch (SP) of the LAD with the LCx (white dotted line and arrows). The LVS is bisected by the great cardiac vein (GCV) which separates it into two regions: 1) closer to the apex of the triangle (blue dotted line)) and, 2) 2) a more lateral towards the base of the triangle (yellow dotted line). The formerr is le lless ss aaccessible cces cc essi siiblle fo ffor o catheter ablation lattio ionn in i tthe h eepicardial he picardial aspect due to proximity pi prox oxim ox i ity to coronary im coronnaryy arteries arteries and/or the presence off th thicker epicardial main artery; hicker layerr ooff epi picard pi rddial fa ffat. t. LM LM = lleft eftt m ain in coronary coorron onar ary ar ar rteery y; AIV V = anterior anteriior an interventricular c cular vvein. einn. ei
Figure 2: Fl Flow-chart study, Flo chart hartt displa ddisplaying ispll ing in the th selection lecti tio process off the the patients ati tientt iincluded incl ncll dded ed d iin the th st t d and the acute and long-term outcomes with epicardial (EPI) mapping and ablation. *Epicardial access was obtained after failure of ablation from adjacent sites including the left ventricular and right ventricular endocardial outflow tracts, the coronary venous system, and coronary cusp region. N = number; RF = radiofrequency; LAD = left anterior descending coronary artery; LCx = left circumflex coronary artery.
Figure 3: Comparison of ECG measurements in a sample patient with successful epicardial (EPI) ablation and in one with unsuccessful ablation.
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DOI: 10.1161/CIRCEP.114.002377
Figure 4: Comparison of 12-lead ECG of the successful and unsuccessful epicardial ablation groups.
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Percutaneous Epicardial Ablation of Ventricular Arrhythmias Arising from the Left Ventricular Summit: Outcomes and ECG Correlates of Success Pasquale Santangeli, Francis E. Marchlinski, Erica S. Zado, Daniel Benhayon, Mathew D. Hutchinson, David Lin, David S. Frankel, Michael P. Riley, Gregory E. Supple, Fermin C. Garcia, Rupa Bala, Benoit Desjardins, David J. Callans and Sanjay Dixit Circ Arrhythm Electrophysiol. published online January 30, 2015; Circulation: Arrhythmia and Electrophysiology is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2015 American Heart Association, Inc. All rights reserved. Print ISSN: 1941-3149. Online ISSN: 1941-3084
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