Percutaneous Epicardial Ablation Research Articles

The NICE guidelines for percutaneous epicardial catheter ablation of ventricular tachycardia: symptomatic of a guideline-obsessed health service?

Although the risk of sudden death associated with ventricular arrhythmia in patients with structural heart disease is significantly reduced by the use of implantable cardioverter defibrillators (ICDs) these devices do...

Abstract 5690: Idiopathic Catecholamine-sensitive Epicardial Ventricular Tachycardia At The Crux Of The Heart

Idiopathic ventricular tachycardia (VT) has been described from the epicardial surface of the left ventricle (LV), usually near the summit of the LV in the outflow tract. Ablation of these VTs may be possible by delivery of energy within the coronary venous system or directly on the epicardial surface. We describe a distinct syndrome of focal epicardial VT induced by catecholamine infusion that arises from the crux of the heart. Among 340 cases of idiopathic VT referred for catheter ablation, 4 patients were identified with a clinical syndrome of catecholamine sensitive VT that was mapped to the epicardial surface at the crux of the heart. There were 3 males and 1 female (age 31–79 yrs, mean 58). VT was sustained in all patients and associated with syncope or near syncope in 3 of 4 pts. The LVEF was >0.55 in 3 pts and mildly depressed (0.45) in 1 pt. In all pts VT could be induced with programmed stimulation or burst pacing from the right ventricular apex but required the infusion of isoproterenol for induction in 3. The VT was very rapid with a mean cycle length of 264 msec. The surface ECG during VT demonstrated a left superior axis QRS morphology in all pts, with an abrupt precordial tansition from V1 to V2 in 3 pts and R waves across the precordium in one. The precordial maximal deflection index was > 0.55 in all pts (mean 0.67). The site of earliest activation during intracardiac mapping occurred at the crux of the heart with activation in the middle cardiac vein or proximal coronary sinus recorded 20 –50 msec (mean −38 msec) prior to the onset of the surface QRS. Catheter ablation with irrigated RF was attempted within the middle cardiac vein or proximal coronary sinus in all pts and was successful in 1. In 2 of 3 remaining pts, percutaneous epicardial RF ablation was attempted and was successful. Simultaneous coronary angiography demonstrated the site of earliest activation within 5–10 mm of the proximal posterior descending coronary artery (PDA). There was no acute narrowing of the PDA in any pt following ablation. Idiopathic VT may arise from the epicardial surface at the crux of the heart in close proximity to the PDA. This syndrome can result in very rapid, catecholamine sensitive VT, and may require careful attention to the PDA during ablation.

Idiopathic focal epicardial ventricular tachycardia originating from the crux of the heart

Idiopathic ventricular tachycardia (VT) can arise from the epicardium, usually near the summit of the left ventricle (LV). The purpose of this study was to describe a distinct syndrome of epicardial VT that arises from the crux of the heart. Among 340 patients with idiopathic VT referred for ablation, four were identified with VT that was mapped to the epicardium at the crux. VT was sustained in all patients and was associated with syncope or presyncope in three. Rapid VT (mean cycle length 264 ms) was induced with programmed stimulation or burst pacing from the ventricle but required isoproterenol infusion in three. ECG during VT demonstrated a left superior axis QRS morphology with a precordial maximal deflection index >or=0.55 in all patients (mean 0.61). Intracardiac mapping revealed earliest activation in the middle cardiac vein or proximal coronary sinus at the crux in all patients. Irrigated radiofrequency ablation in the middle cardiac vein or proximal coronary sinus was attempted in all patients and successfully abolished VT in one. Percutaneous epicardial radiofrequency ablation was attempted in 2 of 3 remaining patients and successfully abolished VT in both. Simultaneous coronary angiography demonstrated the site of earliest activation within 5 to 10 mm of the proximal posterior descending coronary artery, with no acute narrowing of that artery following ablation. Idiopathic VT may arise by a focal mechanism from the epicardium at the crux in close proximity to the posterior descending coronary artery. This syndrome can result in rapid, catecholamine-sensitive VT and requires careful attention to the posterior descending coronary artery during ablation.

Percutaneous Pericardial Instrumentation for Catheter Ablation of Focal Atrial Tachycardias Arising from the Left Atrial Appendage

Focal atrial tachycardias originating from the left atrial appendage present unique anatomic challenges for successful ablation. We describe the role of minimally invasive percutaneous epicardial mapping and ablation in the management of two patients with ectopic atrial tachycardias arising from the left atrial appendage following failure of a conventional endocardial approach to achieve cure.

Experimental Efficacy of Pericardial Instillation of Anti‐inflammatory Agents during Percutaneous Epicardial Catheter Ablation to Prevent Postprocedure Pericarditis

Pericarditis is a potential complication of catheter-based percutaneous epicardial mapping and ablation. This study evaluates the efficacy and safety of intrapericardial instillation of anti-inflammatory agents after pericardial mapping and ablation in a porcine model of postprocedural pericarditis. Twenty-five healthy swine underwent epicardial mapping and ablation after transthoracic subxyphoid puncture. After 60 minutes of continuous catheter manipulation in the pericardial space, radiofrequency energy was delivered in a linear fashion to the epicardial surfaces of both atria. The animals were randomly divided to receive the anti-inflammatory agents, Hyaluronic Acid and Triamcinolone, or control. Fourteen days after ablation, the hearts were excised and the degree of pericardial reaction/adhesions scored. The severity was uniformly graded 4 (intense) in all control animals and was characterized by intense adhesion between the parietal and the visceral pericardium obscuring tissue planes and epicardial anatomy. Hyaluronic Acid provided a mild benefit (score 3.0 +/- 0.9), but 2 mg/kg of Triamcinolone significantly attenuated the inflammatory effect (all animals uniformly scored 1.0). In a porcine model of ablation-related pericarditis, intrapericardial instillation of 2 mg/kg of intermediate-acting corticosteroids effectively prevents post-procedure inflammatory adhesion formation.

Percutaneous epicardial ablation of atrial fibrillation

E a T p f d u h t i a v l s d d a f w t o f 8 ( u t d t g d c d ntroduction atheter ablation of arrhythmias has revolutionized the clincal practice of cardiac electrophysiology (EP). Several arhythmias can now be cured with a high degree of success n the outpatient setting. In addition to this, catheter-based echniques are now being widely used for the management f atrial fibrillation. The standard approach to catheter blation is from the endocardial aspect of the heart. Reently, percutaneous epicardial mapping has been develped and is routinely being used in several EP laboratories round the world. Epicardial mapping and ablation was nitially used for the management of ventricular tachycaria. Subsequently, this technique has been used successully for the management of accessory pathways, atrial rrhythmias, and atrial fibrillation. Epicardial mapping nd ablation has proven to be safe and effective and s associated with a low risk of complications based on he available data from the institutional experiences reorted at the Heart Rhythm meeting in 2007. The meaningul success rates seen with surgical approaches for the anagement of atrial fibrillation (especially stand-alone rocedures) have prompted a need for the assessment of picardial mapping and ablation of atrial arrhythmias in the P lab. This viewpoint article will review key aspects of the picardial approach as it relates to the management of atrial rrhythmias, highlight the current limitations, and reflect on he future prospects of this approach.

Percutaneous Epicardial Catheter Ablation Opens Another Chapter in the Catheter‐Based Ablation for Atrial Fibrillation

Over the past two decades, no other story in cardiology has received as much attention as the nonpharmacological treatment of cardiac arrhythmias, catheter-based ablation. The story began to unfold with the development of the catheterbased radiofrequency (RF) ablation of accessory pathways, proven to be the first nonsurgical curative treatment in cardiology.1,2 Shortly thereafter, electrophysiologists realized they could perform ablations to cure a variety of supraventricular tachycardia (SVT) easily and effectively, yielding spectacular outcomes that had rarely been witnessed with other treatment modalities. What followed is quite remarkable. Professionals from several disciplines (i.e., basic and clinical scientists, engineers, and health care providers)—from various industries to academia—formed the vanguard of interventional electrophysiology. The ensemble of new talents and intellects helped create new catheters, mapping systems, and a variety of tools and technologies that facilitated ablation procedures. These advances dramatically transformed the field of clinical electrophysiology—from the sedate specialty that merely carried out diagnostic electrophysiologic studies or antiarrhythmic drug testing—to an exciting and dynamic discipline that provided effective treatment for SVT via its interventional approach. Fortunately, the story did not end with SVT ablation, but continued for all types of cardiac arrhythmias. At present, most tachyarrhythmias can be reproducibly ablated with great success. For example, patients with typical cavotricuspid isthmus-dependent atrial flutter can now be ablated in 1 hour or less with a success rate of over 95% and a very low likelihood of complications. One by one, many arrhythmias joined the long list of tachycardias that use catheter ablation as the first-line treatment. However, finding the best way to ablate atrial fibrillation (AF), “the mother of all arrhythmias,” remains a major challenge—the Holy Grail for the electrophysiologist! Just as the Knight Templar faced daunting tasks when searching for the grail, so has the electrophysiologist dealt with many obstacles when ablating AF. First, the electrophysiologic mechanisms underlying human AF remain unclear and are likely to be somewhat different from patient to patient (i.e., paroxysmal to persistent). The seminal work by Haissaguerre et al.3 clearly establishes the important role of pulmonary veins (PVs) as triggering and perpetuating AF. As

Hybrid Epicardial and Endocardial Ablation of Persistent or Permanent Atrial Fibrillation: A New Approach for Difficult Cases

Although percutaneous epicardial catheter ablation (PECA) has been used for the management of epicardial ventricular tachycardia, the use of PECA for atrial fibrillation (AF) has not yet been reported. To evaluate the efficacy and feasibility of a hybrid PECA and endocardial ablation for AF. We performed PECA for AF in five patients (48.6 +/- 8.1 years old, all male, four redo ablation procedures of persistent AF with a risk of pulmonary vein (PV) stenosis, one de novo ablation of permanent [AF]) after an endocardial AF ablation guided by PV potentials and 3D mapping (NavX). Utilizing an open irrigation tip catheter, a left atrial (LA) linear ablation from the roof to the perimitral isthmus or localized ablation at the junction between the LA appendage and left-sided PVs or ligament of Marshall (LOM) was performed. PECA of AF was successful in all patients with an ablation time of <15 minutes. The left-sided PV potentials were eliminated by PECA in all patients. Bidirectional block of the perimitral line was achieved in two of two patients and a left inferior PV tachycardia with conduction block to the LA was observed during the ablation in the area of the LOM in one patient. A hemopericardium developed in one patient, but was controlled successfully. During 8.0 +/- 6.3 months of follow-up, all patients have remained in sinus rhythm (four patients without antiarrhythmic drugs). A hybrid PECA of AF is feasible and effective in patients with redo-AF ablation procedures and at risk for left-sided PV stenosis or who are resistant to endocardial linear ablation.

Percutaneous epicardial ablation reverses ventricular tachycardia mediated cardiomyopathy

We report on the case of an 18-year-old girl with asymptomatic incessant ventricular tachycardia. Initial attempts at endocardial ablation failed and she was monitored until her cardiac function deteriorated. A percutaneous epicardial approach with electroanatomical mapping was then used which successfully terminated the tachycardia. Left ventricular size and function subsequently returned to normal. This case demonstrates that percutaneous epicardial ablation of ventricular tachycardia is safe and feasible in young patients and highlights the importance of recognising this at an early stage.

Percutaneous Epicardial Mapping and Ablation of a Posteroseptal Accessory Pathway

A 20-year-old man with no past medical history experienced a syncopal episode. He was found to be pulseless, and cardiopulmonary resuscitation was initiated. When emergency medical service arrived, rhythm strip showed an irregular wide-complex tachycardia consistent with preexcited atrial fibrillation with cycle length as short as 180 ms (333 beats per minute) (Figure 1A). He was defibrillated successfully into sinus rhythm. A 12-lead ECG showed sinus rhythm with PR interval of 110 ms, delta waves and pseudo-infarct pattern in the inferior leads consistent with a posteroseptal accessory pathway (Figure 1B). He was referred to us for an electrophysiology study. Figure 1. A, Rhythm strip of patient during the cardiac arrest, showing irregular wide-complex tachycardia very suggestive of preexcited atrial fibrillation. B, 12-lead ECG after resuscitation. The short PR interval, delta wave and pseudo-infarct pattern in the inferior leads are consistent with the presence of a manifest accessory pathway (Wolff-Parkinson-White Syndrome). During the procedure, extensive mapping in the right atrium, the coronary sinus (CS) and its branches, and the left atrium (via transseptal approach) was performed. A CS angiogram showed the presence of a diverticulum. The area of earliest ventricular …