Epicardial Approach Research Articles

Lead Longevity in Pediatric and Congenital Heart Disease Patients: The Impact of Patient Somatic Growth.

Pacemakers and implantable cardioverter-defibrillators in pediatric and congenital heart disease (CHD) patients may be required for decades. In this population, there are sparse data on long-term lead functionality. The aims of this study were to assess pacemaker and defibrillator lead survival in pediatric and CHD patients beyond 10 years after implantation and to identify patient- and lead-related factors associated with earlier lead failure. This was a retrospective study reviewing all patients with a pacemaker or defibrillator who received care at a single large children's hospital during a 30-year timespan. The log-rank test and Cox proportional hazards model were used to identify risk factors associated with earlier lead failure. Data were collected from 952 leads in 396 patients. Overall lead survival was 87% at 10 years, 78% at 15 years, and 69% at 20 years. Male sex, younger patient age, greater somatic growth, left ventricular lead location, and epicardial implantation approach were associated with higher likelihood of lead failure (log-rank test P<0.05). On multivariate analysis, the most significant predictor of lead failure was patient somatic growth≥5cm/year (HR 3.33; 95%CI: 1.78-6.25). The presence of CHD, lead insulation, and lead manufacturer had no impact on lead longevity. Greater patient somatic growth is an important predictor of lead failure. Greater somatic growth may account for the observation in this study (and prior studies) that leads in male patients, younger patients, and implanted via epicardial approach were more likely to fail.

Epicardial ablation in patients with Brugada syndrome: a single centre experience

Abstract Introduction Brugada syndrome (BrS) is a rare disease associated with an increased risk of ventricular fibrillation (VF), ventricular tachycardia (VT), and sudden cardiac death (SCD). The standard prevention of SCD in patients with BrS is the implantation of an implantable cardioverter-defibrillator (ICD), especially in patients who have previously suffered cardiac arrest or arrhythmogenic syncope. Catheter ablation is an effective method to prevent recurrences of VF/VT in these patients. Purpose Retrospective analysis of the results of catheter ablation by epicardial approach and genetic testing in patients with a diagnosis of BrS and repeated adequate ICD interventions. Methods In 2013-2024, catheter ablation by epicardial approach was performed in our centre in 9 patients diagnosed with Brugada syndrome (mean age 41±6 years, nine males, left ventricular ejection fraction 57±4%). All patients had an ICD implanted for secondary prevention of SCD and presented with adequate ICD therapies (mean 9±11 shocks/patient in the last six months before catheter ablation). Before catheter ablation, two patients were treated with quinidine. Patients underwent cardiogenetic testing by next-generation sequencing of 228 genes. Results Type 1 electrocardiogram (ECG) pattern was present at baseline ECG in four (44%) patients; in five (56%) patients, type 1 was induced after ajmaline administration. Genetic testing was performed in seven patients, and only one patient (14%) was found to have a relevant pathogenic mutation in the SCN5A gene. Prior to ablation, sustained VT/VF could be induced by programmed electrical stimulation in three patients (33%). Epicardial ablation was targeted at areas of abnormal electrograms located over the right ventricular outflow tract. No complications were noted. The mean follow-up period was 25±30 months. In one patient (11%), reablation was required to suppress ventricular arrhythmias successfully. After the last ablation, no recurrence of VT/VF was observed in any patient. Conclusions Epicardial ablation is an effective method that leads to the suppression of ventricular arrhythmias in patients with a diagnosis of BrS and repeated ICD interventions. Despite the malignant arrhythmic phenotype, patients in our cohort had a rather low prevalence of signs associated with a high risk of VT/VF, such as spontaneous ECG pattern of BrS, inducibility of VT/VF during electrical programmed stimulation, or the presence of a causative genetic mutation.

Effect of dispersive electrode position (anterior vs. posterior) in epicardial radiofrequency ablation of ventricular wall: A computer simulation study.

An epicardial approach is often used in radiofrequency (RF) catheter ablation to ablate ventricular tachycardia when an endocardial approach fails. Our objective was to analyze the effect of the position of the dispersive patch (DP) on lesion size using computer modeling during epicardial approach. We compared the posterior position (patient's back), commonly used in clinical practice, to the anterior position (patient's chest). The model considered ventricular wall thicknesses between 4 and 8 mm, and electrode insertion depths between .3 and .7 mm. RF pulses were simulated with 20 W of power for 30 s duration. Statistically significant differences (P < .001) were found between both DP positions in terms of baseline impedance, RF current (at 15 s) and thermal lesion size. The anterior position involved lower impedance (130.8 ± 4.7 vs. 146.2 ± 4.9 Ω) and a higher current (401.5 ± 5.6 vs. 377.5 ± 5.1 mA). The anterior position created lesion sizes larger than the posterior position: 8.9 ± 0.4 vs. 8.4 ± 0.4 mm in maximum width, 8.6 ± 0.4 vs. 8.1 ± 0.4 mm in surface width, and 4.5 ± 0.4 vs. 4.3 ± 0.4 mm in depth. Our results suggest that: (1) the redirection of the RF currents due to repositioning the PD has little impact on lesion size and only affects baseline impedance, and (2) the differences in lesion size are only 0.5 mm wider and 0.2 mm deeper for the anterior position, which does not seem to have a clinical impact in the context of VT ablation.

Road-Map to Epicardial Approach for Catheter Ablation of Ventricular Tachycardia in Structural Heart Disease: Results From a 10-Year Tertiary-Center Experience.

Epicardial approach in ventricular tachycardia (VT) ablation is still regarded as a second-step strategy, due to the risk of complications. We evaluated the frequency that epicardial ablation targets were identified and ablation performed following pericardial access compared with unnecessary pericardial access for different VT causes and potential markers of epicardial VT. All VT ablation procedures including epicardial approach over a 10-year period were included. First-line epicardial approach was indicated in arrhythmogenic right ventricular cardiomyopathy (ARVC) and postmyocarditis VT; in patients with idiopathic dilated cardiomyopathy (IDCM) and postmyocardial infarction, indications resulted from available imaging techniques or 12-lead VT morphology. The epicardial approach was considered useful if epicardial ablation was performed after epicardial mapping. Feasibility, complications, and long-term outcome were reported. Four hundred and eighty-eight subjects with a median age of 60 years (interquartile range, 47-65) and of left ventricle ejection fraction 41% (interquartile range, 30-55) underwent 626 epicardial VT ablations. Percutaneous access had a success rate of 92.2% and a complication rate of 3.6%. Overall, epicardial approach was, respectively, indicated to 11.8% of postmyocardial infarction patients, 49.5% in IDCM, 94% in myocarditis, and 90.7% in ARVC. Epicardial ablation at the first ablation attempt was performed in 9.3% of postmyocardial infarction patients, 28.8% in IDCM, 86.5% in myocarditis, and 81.3% in patients with ARVC. In first-line epicardial group, ARVC and myocarditis showed the highest odds for epicardial ablation (OR, 4.057 [95% CI, 1.299-8.937]; P=0.007; OR, 3.971 [95% CI, 1.376-11.465]; P=0.005, respectively). IDCM independently predicted unnecessary epicardial approach (OR, 2.7 [95% CI, 1.7-4.3]; P<0.001). After a follow-up of 41 months (interquartile range, 19-64), patients with IDCM experienced higher rate of recurrences and mortality compared with other causes. Epicardial approach is integral part of ablation armamentarium regardless of the VT cause, with high feasibility and low complication rate in experienced centers. Our data support its use at first ablation attempt in VTs related to ARVC and myocarditis.

Epicardial catheter ablation of ventricular tachycardia in patients of acm - from a university hospital report in switzerland

Abstract Background Arrhythmogenic left ventricular cardiomyopathy (ALVC) as a subtype of arrhythmogenic cardiomyopathy (ACM) is increasingly being recognized. Cardiac magnetic resonance (CMR) has emerged as the primary imaging modality for the diagnosis of ACM. In patients with right-dominant ACM (ARVC) and recurrent sustained ventricular tachycardia (VT), endocardial +/-epicardial ablation yields good clinical outcomes in the long-term. However, studies on VT ablation in ACM with LV involvement are scarce. Purpose We sought to investigate clinical outcomes of VT ablation in ACM patients with LV involvement. Methods The study included patients from the Zurich ACM Registry who met 2020 "Padua Criteria" for ACM and underwent VT ablation between January 2018 and July 2023. Epicardial ablation was performed in patients with recurrent sustained VT despite endocardial ablation, those lacking and endocardial substrate or if the ECG of the VT / substrate on CMR was suggestive of an epicardial origin. Catheter ablation was guided by activation/entrainment mapping for mappable VT, and pace mapping/voltage mapping during sinus rhythm for unmappable VT. Consecutive follow-up of all patients was performed according to our protocol. Results Twenty-one ACM patients underwent n=24 VT ablation procedures. Of those 20 patients, 6 patients (30%) had LV involvement on CMR. Eight (33%) patients underwent epicardial +/- endocardial ablation. Among patients receiving epicardial ablation, 3 patients (38%) had LV involvement. These three underwent a single ablation procedure, which was epicardial only. Total follow-up was 30 months (range 4-43). Three-month sustained VT/VF recurrence rates were 12% in the ACM group with LV involvement vs 25% in ACM without LV involvement. All patients with sustained VT/VF recurrence underwent repeat ablation via an epicardial approach within 3 months and were free of sustained VT/VF thereafter during a median follow-up of 12 months. One-year recurrence rate did not differ between ACM patients with LV involvement vs. without LV involvement (7.7% vs 8.3%, P＝0.117). Seven out of eight epicardial ablations achieved freedom from VT/VF after one-year follow-up. One ARVC patient with previous endocardial ablation had recurrent VT one month after epicardial ablation, which was free of VT after Flecainide combined with beta-blocker. No significant differences were found in the use of beta-blockers and antiarrhythmic drugs between both groups (ACM with LV involvement vs. without LV involvement) at baseline and during one-year follow-up. Conclusions Single or adjuvant epicardial substrate ablation of VT in arrhythmogenic cardiomyopathy is promising in terms of postprocedural VT free survival, especially in patients with left ventricular involvement demonstrated by CMR.Figure 1Figure 2

In-hospital mortality following catheter ablation procedures in Germany: insights from the VARY project

Abstract Background The number of catheter ablation (CA) procedures has increased significantly over the last decade. 102,737 CA have been performed in Germany in 2021. Although CA of different types of arrhythmias is generally considered to be safe, serious complications, including in-hospital death, may occur. There is a paucity of real-world national healthcare data in Germany. Aim To investigate the overall in-hospital mortality in patients undergoing any type of CA procedure in Germany and to identify variables associated with in-hospital mortality. Methods According to the German law German hospitals are obliged to provide a dataset including case data, diagnosis based on the ICD-10-GM, operational and procedural codes to the Institute for hospital remuneration system (InEK) every year. The VARY project aims at analyzing and monitoring these data to report the real world scenario on patients undergoing CA in Germany. As of now, 22 German centers were contacted by the Institute for Myocardial Infarction Research (IHF). Their Data between 2019 and 2023 provided from seven of those centers were used for this analysis. Datasets from ten centers are pending. Five centers were not able to provide their data. The project is supported by the German Heart Foundation. Results A total 21,028 patients underwent inpatient CA. 49 patients (69.4% males) died in-hospital following a CA procedure resulting in an overall in-hospital mortality rate of 0.23%. A percutaneous epicardial ablation approach was used in 6.1% of the patients who died (Group A) compared to 0.3% in the surviving patients (Group B). Radiofrequency ablation was used in 83.7% vs. 72.6%, cryoablation in 10.2% vs 27.1%. Patients who died were older compared to those who survived (mean age: 66.7 ± 14.6 vs. 62.0 ± 14.4 years, p &amp;lt;0.01) and had more comorbidities such as diabetes (19/49 (38.8.%) vs. 2274/20,979 (10.8%), p &amp;lt;0,01), chronic obstructive pulmonary disease (5/49 (10.2%) vs. 555/20,979 (2.6%), p &amp;lt; 0,01) and heart failure (39/49 (79.6%) vs. 5116/20,979 (24.4%), p &amp;lt;0.01). There was no difference with regards to gender between the two groups. The most common arrhythmia in both groups was atrial fibrillation with 67.3% and 75.3% (p &amp;lt; 0.01). Cardiac arrest was observed in 44.9% of patients in group A compared to only 0.3% in group B. The median hospital stay was longer in group A (19.0 (IQR 8.0; 42.0) vs. 2.0 (IQR 1.0; 3.0), p &amp;lt; 0.01). 46/49 (93.9%) patients who died were treated on an intensive care unit for a median time of 13.5 days (IQR 3.8; 33.8) compared to 1272/20,979 (6.1%) (p &amp;lt; 0.01) in group B. A cardiac implantable electronic device implantation or revision was performed in 18.4% patients in group A (4 defibrillator implantations, 2 pacemaker implantations, 5 revisions) compared to 2.9% in group B (survivors). Conclusion Inpatient catheter ablation procedures in Germany are associated with a very low in-hospital mortality comparable to data reported from the US.

A propensity score matched comparison of pulsed field versus hybrid ablation in patients with long standing persistent atrial fibrillation

Abstract Introduction On one hand pulsed-field ablation (PFA) has shown favourable data in terms of safety and efficiency for pulmonary veins isolation (PVI). One the other hand, hybrid ablation results in better outcomes in patients with persistent atrial fibrillation (AF), as it combines a thoracoscopic epicardial and transvenous endocardial approach in a single procedure. Purpose Aim of this study was to to compare 1-year follow-up data of patients with long standing persistent AF undergoing PVI and posterior wall isolation using PFA, and hybrid AF ablation. Methods Consecutive patients with long standing persistent AF undergoing a first PVI with PFA at our institution were included. For comparison, patients with long standing persistent AF undergoing a first PVI with hybrid ablation were selected using a 1:1 nearest neighbor propensity score matching. Hybrid AF ablation was performed in a one-step procedure: (i) thoracoscopic ablation followed by (ii) endocardial mapping and eventual ablation. All patients received PVI and posterior wall isolation in both group. Additional lesions were performed based on clinical indication and physician judgement. The primary endpoint was recurrence of atrial tachyarrhythmia after 12 months of follow-up (with a blanking period of 3 months). Results A total of 130 patients with persistent AF underwent hybrid ablation and 72 patients underwent PFA. 85 patients (age:67.5±9.7 years, 68.2% males, CHA2DS2-VASc: 2.5±1.3) with long standing persistent AF underwent their first AF ablation (PFA N= 39; Hybrid N = 46). After a 1-year follow-up, freedom from atrial tachyarrhythmia recurrence was 74.4% with PFA and 71.7% with hybrid ablation (p = 0.786). After propensity score matching, a total of 39 matched pairs of PFA and hybrid first AF ablation remained. The result remained unchanged and no significant difference was observed between treatment cohorts after matching (Figure 1, p=0.039). Conclusion In a propensity score matched analysis of patients with long standing persistent AF, freedom from any atrial tachyarrhythmia 1 year after AF ablation using PFA was favourable and at least as good as with hybrid ablation.

Dual operator percutaneous epicardial access to minimize needle pericardial dwell time: A modified SAFER epicardial approach

The sustained apnea for epicardial access with right ventriculography technique (SAFER epicardial approach) has been previously shown to be effective and safe (1). However, it requires a brief period of unprotected needle dwell time within the pericardium while the operator switches the contrast syringe for a guidewire. This transition period, though brief, raises concerns regarding the potential risk of inadvertent perforation of the right ventricular (RV) wall given the systolic-diastolic excursion of the heart and/or the possibility of losing epicardial access. In an effort to limit the unprotected needle dwell time in the pericardium, we describe the dual operator modified SAFER epicardial approach.

ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY AND CARDIAC SARCOIDOSIS: THE GREY ZONE

Abstract Cardiac sarcoidosis (CS) is a rare multisystem disorder characterized by granulomatous infiltration of the myocardium, whose clinical manifestations can be extremely heterogeneus. We report the case of a 47–year–old man with a previous diagnosis of arrhythmogenic right ventricular cardiomyopathy (ARVD). In history he had a marked arrhythmic pattern with multiple episodes of sustained ventricular arrhythmias, biventricular disfunction (LVEF 37%, RVEF 32%) and extensive biventricular transmural late–gadolinium enhancement (greater than 50%) at cardiac RMN. At EKG epsilon wave mainly seen in precordial leads. In November 2022 he was implanted with bicameral defibrillator and in March 2023 he underwent ablation procedure for ventricular tachycardia with RF with endo–epicardial approach. In May 2023 he arrived at our Centre for acute decompensated heart failure. At restored hemodynamic stability, screening for the possible inclusion in transplant list was started. Right heart catheterization (RHC) showed low cardiac index with no pulmonary hypertension. Chest CT unexpectedly showed the presence of multiple micronodules with perilymphatic distribution with confluent appearance compatible with pulmonary sarcoidosis. In consideration of this result, the transplant program was temporarily postponed and investigations for possible cardiac involvement of an inflammatory nature were started. 18F–FDG PET–CT showed pulmonary, splenic, lymphonodal and especially cardiac uptake in the mid–distal segment of the lateral wall of the left ventricle and in the inferior–apical site suspicious for inflammatory pathology. Unfortunately, both lymphonodal and cardiac biopsies were inconclusive because of insufficient material. Nevertheless, the clinical scenario satisfied the Japanese criteria for possible CS; therefore, treatment with prednisone 1 mg/kg was started and a 18F–FDG PET–CT was planned after 3 months of steroid therapy. CS can disguise as a phenocopy of arrhythmogenic right ventricular cardiomyopathy because of several common characteristics, especially arrhythmic presentation. Due to these similarities, a careful overall evaluation of each patient with ARVD is mandatory as several transplant centers have reported cases of CS in explanted heart with a pretransplant misdiagnosis of ARVD or dilated cardiomiopathy. Performing a chest CT in all ARVD patients as part of transplant screening may be considered.

Rate of Change of Initial Intrinsicoid Deflection Predicts Endocardial Versus Epicardial Ventricular Tachycardia

BackgroundAssessment of origin of ventricular tachycardias (VTs) arising from epicardial vs endocardial sites are largely challenged by the available criteria and etiology of cardiomyopathy. Current electrocardiographic (ECG) criteria based on 12-lead ECG have varying sensitivity and specificity based on site of origin and etiology of cardiomyopathy. ObjectivesThis study sought to test the hypothesis that epicardial VT has a slower initial rate of depolarization than endocardial VT. MethodsWe developed a method that takes advantage of the fact that electrical conduction is faster through the cardiac conduction system than the myocardium, and that the conduction system is primarily an endocardial structure. The technique calculated the rate of change in the initial VT depolarization from a signal-averaged 12-lead ECG. We hypothesized that the rate of change of depolarization in endocardial VT would be faster than epicardial. We assessed by applying this technique among 26 patients with VT in nonischemic cardiomyopathy patients. ResultsWhen comparing patients with VTs ablated using epicardial and endocardial approaches, the rate of change of depolarization was found to be significantly slower in epicardial (6.3 ± 3.1 mV/s vs 11.4 ± 3.7 mV/s; P < 0.05). Statistical significance was found when averaging all 12 ECG leads and the limb leads, but not the precordial leads. Follow up analysis by calculation of a receiver-operating characteristic curve demonstrated that this analysis provides a strong prediction if a VT is epicardial in origin (AUC range 0.72-0.88). Slower rate of change of depolarization had high sensitivity and specificity for prediction of epicardial VT. ConclusionsThis study demonstrates that depolarization rate analysis is a potential technique to predict if a VT is epicardial in nature.

Difference between endocardial and epicardial application of pulsed fields for targeting Epicardial Ganglia: An in-silico modelling study

BackgroundPulsed Field Ablation (PFA) has recently been proposed as a non-thermal energy to treat atrial fibrillation by selective ablation of ganglionated plexi (GP) embedded in epicardial fat. While some of PFA-technologies use an endocardial approach, others use epicardial access with promising pre-clinical results. However, as each technology uses a different and sometimes proprietary pulse application protocol, the comparation between endocardial vs. epicardial approach is almost impossible in experimental terms. For this reason, our study, based on a computational model, allows a direct comparison of electric field distribution and thermal-side effects of both approaches under equal conditions in terms of electrode design, pulse protocol and anatomical characteristics of the tissues involved. Methods2D computational models with axial symmetry were built for endocardial and epicardial approaches. Atrial (1.5−2.5 mm) and fat (1−5 mm) thicknesses were varied to simulate a representative sample of what happens during PFA ablation for different applied voltage values (1000, 1500 and 2000 V) and number of pulses (30 and 50). ResultsThe epicardial approach was superior for capturing greater volumes of fat when the applied voltage was increased: 231 mm3/kV with the epicardial approach vs. 182 mm3/kV with the endocardial approach. In relation to collateral damage to the myocardium, the epicardial approach considerably spares the myocardium, unlike what happens with the endocardial approach. Although the epicardial approach caused much more thermal damage in the fat, there is not a significant difference between the approaches in terms of size of thermal damage in the myocardium. ConclusionsOur results suggest that epicardial PFA ablation of GPs is more effective than an endocardial approach. The proximity and directionality of the electric field deposited using an epicardial approach are key to ensuring that higher electric field strengths and increased temperatures are obtained within the epicardial fat, thus contributing to selective ablation of the GPs with minimal myocardial damage.

Transvenous endocardial pacing with SelectSecure™ 3830 lead in pediatric patients: case series of two infants and a literature review

BackgroundThe SelectSecure™ 3830 lead is an innovative, lumenless, and thin active fixed lead with a nonretractable screw-in tip and a diameter of 4.1 Fr, making it the thinnest pacing lead available. Its high anti-extrusion properties and durability have shown favorable outcomes in cardiac pacing, especially in pediatric patients. The superfine design and easy implantation of the lead have rendered it a preferred choice in children, particularly in cases of congenital heart disease.Case presentationThis case series presents two infant patients who underwent transvenous endocardial pacing using the SelectSecure™ 3830 lead, along with a comprehensive literature review on the topic. The study followed the patients for 5 years and 3 years, respectively, and observed stable pacing parameters, indicating a positive therapeutic outcome and safety.This article discusses the optimal age and body shape for transvenous lead implantation in infants and highlights the advantages and disadvantages of endocardial and epicardial pacing approaches. Although endocardial pacing offers several benefits such as minimal trauma, short hospital stay, and longer battery life, it may not be suitable for intracardiac shunts, and venous occlusion remains a concern. On the other hand, epicardial pacing may be considered for children with challenging endocardial access but comes with higher risk of lead failure and coronary artery compression.This study emphasizes the importance of careful follow-up in pediatric patients with pacing, as lead failure can occur in young patients owing to growth and development, leading to syncope and battery depletion. The article also underscores the significance of selecting the appropriate pacing location to minimize the impact of cardiac function, with right ventricular septal pacing emerging as a preferable option.ConclusionsThe SelectSecure™ 3830 lead presents a promising solution for transvenous endocardial pacing in pediatric patients with high degree atrioventricular block and bradycardia, ensuring safe and effective pacing as they grow and develop.

Feasibility of carbon dioxide insufflation and impact on epicardial approach utilization for ventricular tachycardia ablation in a midvolume referral center

BackgroundEpicardial access is often crucial for successful ventricular tachycardia (VT) ablation, but it is often burdened by significant procedural risk. Intentional coronary vein exit and intrapericardial CO2 insufflation (EpiCO2) can facilitate subxiphoid pericardial access. ObjectiveThis prospective study aimed to assess procedural feasibility, safety, and impact of the introduction of intrapericardial CO2 insufflation for epicardial access in a referral center for VT ablation. MethodsAll consecutive patients treated with epicardial VT ablation between November 2022 and January 2024 with the EpiCO2 technique at Pisa University Hospital were prospectively enrolled and compared in terms of feasibility, efficiency, and safety with a local retrospective cohort of patients treated with subxiphoid dry puncture between July 2018 and October 2022. ResultsTwenty-two consecutive patients (90.9% male; mean age, 54.3 years) underwent VT ablation with EpiCO2 during the study period. Epicardial access was achieved in all patients; median time from coronary sinus (CS) cannulation to epicardial access was 33 minutes. Intentional vein exit was successful in all cases, whereas CO2 insufflation was not feasible in 1 patient. There were no major complications and no significant bleeding. Since EpiCO2 introduction, epicardial approach utilization increased from 17.8% to 40% of all VT procedures. Comparison with 20 standard dry approach epicardial ablations showed no significant differences in terms of total procedural duration (322.5 [interquartile range, 296.75–363.75] minutes vs 359 [interquartile range, 323–409] minutes; P = .08). ConclusionIn our single-center experience, EpiCO2 was feasible and safe and led to significant increase in procedural volume without affecting total procedural time compared with standard dry puncture.

Efficacy and Safety of Epicardial Access on Uninterrupted Anticoagulation Using the SAFER Epicardial Approach

Efficacy and Safety of Epicardial Access on Uninterrupted Anticoagulation Using the SAFER Epicardial Approach

Catheter ablation of ventricular arrhythmias in arrhythmogenic cardiomyopathy - comparison of different approaches and results of genetic testing

Abstract Introduction Arrhythmogenic cardiomyopathy (ACM) is a disease characterized by fatty-fibrous remodeling of the myocardium and a high risk of ventricular tachycardia (VT). Catheter ablation is an effective method that prevents VT recurrences. Although the arrhythmogenic substrate in ACM is located dominantly in the epicardium, in some patients VT can be effectively suppressed only by endocardial ablation. Purpose Retrospective analysis of catheter ablation results of VT in patients with ACM and right ventricular involvement. Methods Between 2001-2021, catheter ablation of VT was performed in 51 patients (mean age 43±18 years, 9 women) with a clinical diagnosis of ACM and right ventricular involvement. Pathogenic/likely pathogenic mutation was detected during the genetic testing in 80% of patients. Repeated ablation procedures were necessary to suppress VT (a total of 1.9±1.3 procedures/patient). According to the approach, patients were divided into three groups: A - endocardial ablation only (n=20); B - endocardial ablation first, followed by epicardial approach (n=15); C- primary epicardial approach (n=16). Results The primary epicardial approach (group C) compared to the endocardial approach (group A+B) was associated with better VT free survival (Figure 1, p&amp;lt;0.02) and significantly fewer procedures needed to suppress arrhythmia recurrences (1.1±0.2 vs 2.3±1.5 procedures/patient; p&amp;lt;0.005). Patients in whom an endocardial approach (group A) was sufficient to control arrhythmias were significantly older than patients in whom an epicardial approach (group B) had to be used (52.9±15.1 vs 36.0±16.0 years; p&amp;lt;0.001). The frequency of pathogenic mutations did not differ among groups (A - 83% vs B - 71% vs C - 86%; p=n.s.). The most commonly found mutation was in the gene for plakophilin 2 (51% of all patients). Conclusion Epicardial VT ablation in ACM patients with right ventricular involvement leads to the most effective control of arrhythmias. Endocardial ablation alone may be sufficient to control VT in older patients. The identification of a pathogenic/likely pathogenic mutation does not seem to be relevant for choice of ablation approach.Figure 1

Abstract 12128: Catheter Ablation Outperforms Implantable Cardioverter Defibrillator Therapy in Improving Arrhythmic Outcomes of Brugada Syndrome

Background: Brugada syndrome (BrS) is characterized by ventricular arrhythmias that pose a significant risk to affected individuals. While ICD therapy is the primary treatment, it does not prevent VF episodes. Catheter ablation (CA) has shown promise in improving arrhythmic outcomes. This study aims to compare the efficacy of CA with ICD therapy in symptomatic BrS patients. Methods: A total of 49 symptomatic BrS patients were enrolled, with 21 patients undergoing CA and 28 patients receiving ICD therapy. Substrate modification techniques, including endocardial and epicardial approaches, were utilized along with VF-triggering PVC ablation strategies. The primary outcomes assessed were the occurrence of VF episodes and sudden cardiac death during the follow-up period. Results: The study population had a mean age of 44.3±10.4 years, with 44 patients (89.8%) being male. Among the participants, 40 (81.6%) exhibited the typical type 1 BrS electrocardiogram pattern, and 12 (24.5%) had a positive SCN5A mutation. VF-triggering PVCs were successfully ablated in 3 patients (14.3%), while VF substrates were eliminated in 18 patients (85.7%). Epicardial ablation was performed in 14 patients (66.7%). During a median follow-up of 46.2 (15.6-68.8) months, the primary outcomes occurred more frequently in the ICD group compared to the CA group (4.8% vs. 57.1%, Log-rank P = 0.006). Conclusion: Our findings suggest that CA is a more effective therapy for improving arrhythmic outcomes in symptomatic BrS patients compared to ICD implantation. These results highlight the potential of CA as a first-line therapeutic approach for managing symptomatic BrS.

Outcomes of catheter ablation in high-risk patients with Brugada syndrome refusing an implantable cardioverter defibrillator implantation.

The aim of this study was to investigate the outcomes of catheter ablation (CA) in preventing arrhythmic events among patients with symptomatic Brugada syndrome (BrS) who declined implantable cardioverter defibrillator (ICD) implantation. A total of 40 patients with symptomatic BrS were included in the study, of which 18 refused ICD implantation and underwent CA, while 22 patients received ICD implantation. The study employed substrate modification (including endocardial and epicardial approaches) and ventricular fibrillation (VF)-triggering pre-mature ventricular contraction (PVC) ablation strategies. The primary outcomes were a composite endpoint consisting of episodes of VF and sudden cardiac death during the follow-up period. The study population had a mean age of 43.8 ± 9.6 years, with 36 (90.0%) of them being male. All patients exhibited the typical Type 1 BrS electrocardiogram pattern, and 16 (40.0%) were carriers of an SCN5A mutation. The Shanghai risk scores were comparable between the CA and the ICD groups (7.05 ± 0.80 vs. 6.71 ± 0.86, P = 0.351). Ventricular fibrillation-triggering PVCs were ablated in 3 patients (16.7%), while VF substrates were ablated in 15 patients (83.3%). Epicardial ablation was performed in 12 patients (66.7%). During a median follow-up of 46.2 (17.5-73.7) months, the primary outcomes occurred more frequently in the ICD group than in the CA group (5.6 vs. 54.5%, Log-rank P = 0.012). Catheter ablation is an effective alternative therapy for improving arrhythmic outcomes in patients with symptomatic BrS who decline ICD implantation. Our findings support the consideration of CA as an alternative treatment option in this population.

Combination of percutaneous left appendage epicardial ligation and endo-epicardial atrial fibrillation ablation.

Atrial fibrillation (AF) is the main cause of cardioembolic stroke. In high-bleeding-risk patients, long-life anticoagulation therapy is not permitted, and left atrial appendage (LAA) closure may be considered. LAA is also a critical substrate for AF. Epicardial LAA occlusion has several advantages: LAA ligation results in a favorable electrical and structural atrial remodeling, which decreases AF recurrence. Endocardial ablation alone is not efficient for all patients, and new evidence shows better outcomes in patients affected by persistent AF after a combined hybrid endo-epicardial ablation. Considering the synergic potential of these techniques, in this case series, they were both combined in a single procedure. We describe the treatment of 5 patients referred for refractory AF ablation and LAA closure. All patients had high thrombotic and previous major hemorrhage, with relative contraindication to life-long therapy with anticoagulation. A combined procedure of LAA ligation and endo-epicardial ablation was scheduled with short-term anticoagulation. LAA closure was performed with an epicardial approach using the LARIAT system. Then, LA mapping and ablation were performed, endocardially and then epicardially.All procedures were concluded without complications.At follow-up, in all patients, transesophageal echocardiography showed the complete occlusion of the LAA; therefore, anticoagulation therapy was interrupted. All patients were asymptomatic, and in the sinus rhythm, no hemorrhage or ischemic events occurred. The combination of percutaneous LAA ligation and endo-epicardial ablation was revealed to be feasible and safe and might represent a new approach for the treatment of refractory AF in patients with indication of LAA occlusion.

The Strengths and Weaknesses of Left Atrial Appendage Ligation or Exclusion (LARIAT, AtriaClip, Surgical Suture)

Left atrial appendage (LAA) epicardial exclusion has been associated with addressing 2 potential deleterious consequences attributed to the LAA, namely, thrombus formation and an arrhythmogenic contributor in advanced forms of atrial fibrillation. With more than 60 years of history, the surgical exclusion of the LAA has been firmly established. Numerous approaches have been used for surgical LAA exclusion including surgical resections, suture ligation, cutting and non-cutting staples, and surgical clips. Additionally, a percutaneous epicardial LAA ligation approach has been developed. A discussion of the various epicardial LAA exclusion approaches and their efficacy will be discussed, along with the salient beneficial affects on LAA thrombus formation, LAA electrical isolation and neuroendocrine homeostasis.

Sex differences in catheter ablation for ventricular tachycardia in structural heart disease: a single center 10-years experience

Abstract Funding Acknowledgements Type of funding sources: None. Background Women are underrepresented in studies concerning ventricular tachycardia (VT) catheter ablation (CA). Different etiologies and type of structural heart diseases (SHD) are well established in women; nonetheless conflicting results about efficacy and safety of CA in women have been reported. Purpose To evaluate acute and long-term outcome of VT CA in SHD in women compared to men in a high-volume tertiary Center. Methods All consecutive procedures were included from January 2010 to December 2021. Clinical characteristics, VT etiologies and procedure data of female patients were compared to male population. Catheter ablation was performed according to standard protocol in our center. In mappable VTs, the reentry circuit was characterized, and ablation aimed at VT interruption during radiofrequency (RF); otherwise, a substrate modification approach aiming at late potentials abolition or ablation at sites of slow conduction during sinus rhythm was performed. Following ablation, prevention of any VT inducibility and substrate modification was considered ablation endpoint. Acute results, complications, and VT recurrences during follow up were analyzed comparing the two groups. Results Among 1608 overall VT CA procedures, 141 procedures were performed in 117 women. Female were younger, with less comorbidities, less ischemic VT etiology and higher left ventricular ejection fraction (LVEF) as compared to men (Table 1). They were also less likely ICD carriers. No significant differences were found with regards to: epicardial approach (39.7% vs 35.3%, p=0.68); VT inducibility at baseline (57.4% vs 67.6%, p=0.14), VT termination during RF (87.6% vs 77.6%, p=0.51), and prevention of any VT inducibility at the programmed electrical stimulation (PES) after ablation (79.5% vs 78.1%, p=0.7). Major complications occurred in 4.9% of females as compared to 4.3% of male patients. At median follow-up of 25 months, VT recurrences occurred in 24.7% of female population and 27.5% of male group (p=0.42). Cumulative VT-free survival was comparable in both groups (Figure 2). Conclusions Women with SHD have favorable acute and long-term outcome of VT ablation, despite a high prevalence of non-ischemic etiologies. VT recurrence rate and procedure safety is comparable to male patients, suggesting that catheter ablation can be offered as an effective treatment to women with refractory ventricular arrhythmias.