Advertisement

Value of mapping and ablation of ventricular tachycardia targets within the coronary venous system in patients with nonischemic cardiomyopathy

Published:January 16, 2020DOI:https://doi.org/10.1016/j.hrthm.2020.01.010

      Background

      Patients with nonischemic cardiomyopathy (NICM) often require epicardial ventricular tachycardia (VT) ablation procedures via subxiphoid access. The coronary venous system (CVS) provides limited access to the epicardial space.

      Objective

      The purpose of this study was to determine the value of an approach targeting the CVS in these patients.

      Methods

      In a series of 41 consecutive patients (mean age 59.7 ± 11.5 years; 36 men [88%]; ejection fraction 34.5% ± 13.1%; 269 inducible VTs [6.6 ± 5.0 VTs per patient]) with NICM and VT, mapping and ablation were performed sequentially at the endocardium, then within the CVS, and finally within the pericardial space if required.

      Results

      VT target sites were identified within the CVS in 15 patients and by subxiphoid access to the pericardial space in 8 patients. Ablation within the CVS eliminated VT inducibility in 9 patients without the need for epicardial ablation. Cardiac magnetic resonance imaging demonstrated that the CVS was closer to a scarred area in patients with CVS-related VT target sites than in other patients (mean 3.5 ± 3.9 mm vs 14.3 ± 8.3 mm; P < .001). A cutoff distance of ≤9 mm from the scar (area under the curve 0.91; 95% confidence interval 0.82–0.99; sensitivity 0.78; specificity 0.93) identified patients with vs patients without VT target sites within the CVS.

      Conclusion

      A stepwise approach with mapping/ablation in the endocardium followed by ablation within the CVS can reduce the need for subxiphoid epicardial access in some patients with NICM. Proximity of the scar to the CVS detected by cardiac magnetic resonance imaging can identify the patients most likely to benefit from this approach.

      Keywords

      To read this article in full you will need to make a payment
      Subscribe to Heart Rhythm
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Soejima K.
        • Stevenson W.G.
        • Sapp J.L.
        • Selwyn A.P.
        • Couper G.
        • Epstein L.M.
        Endocardial and epicardial radiofrequency ablation of ventricular tachycardia associated with dilated cardiomyopathy: the importance of low-voltage scars.
        J Am Coll Cardiol. 2004; 43: 1834-1842
        • Liuba I.
        • Frankel D.S.
        • Riley M.P.
        • et al.
        Scar progression in patients with nonischemic cardiomyopathy and ventricular arrhythmias.
        Heart Rhythm. 2014; 11: 755-762
        • Ibrahim E.H.
        • Runge M.
        • Stojanovska J.
        • et al.
        Optimized cardiac magnetic resonance imaging inversion recovery sequence for metal artifact reduction and accurate myocardial scar assessment in patients with cardiac implantable electronic devices.
        World J Radiol. 2018; 10: 100-107
        • Amado L.C.
        • Gerber B.L.
        • Gupta S.N.
        • et al.
        Accurate and objective infarct sizing by contrast-enhanced magnetic resonance imaging in a canine myocardial infarction model.
        J Am Coll Cardiol. 2004; 44: 2383-2389
        • Josephson M.E.
        Clinical Cardiac Electrophysiology: Techniques and Interpretation.
        2nd ed. Lea & Febiger, Philadelphia1993
        • Bogun F.
        • Good E.
        • Reich S.
        • et al.
        Isolated potentials during sinus rhythm and pace-mapping within scars as guides for ablation of post-infarction ventricular tachycardia.
        J Am Coll Cardiol. 2006; 47: 2013-2019
        • Piers S.R.
        • Tao Q.
        • van Huls van Taxis C.F.
        • Schalij M.J.
        • van der Geest R.J.
        • Zeppenfeld K.
        Contrast-enhanced MRI-derived scar patterns and associated ventricular tachycardias in nonischemic cardiomyopathy: implications for the ablation strategy.
        Circ Arrhythm Electrophysiol. 2013; 6: 875-883
        • Neilan T.G.
        • Coelho-Filho O.R.
        • Danik S.B.
        • et al.
        CMR quantification of myocardial scar provides additive prognostic information in nonischemic cardiomyopathy.
        JACC Cardiovasc Imaging. 2013; 6: 944-954
        • Carrigan T.
        • Patel S.
        • Yokokawa M.
        • et al.
        Anatomic relationships between the coronary venous system, surrounding structures, and the site of origin of epicardial ventricular arrhythmias.
        J Cardiovasc Electrophysiol. 2014; 25: 1336-1342
        • Briceno D.F.
        • Enriquez A.
        • Liang J.J.
        • et al.
        Septal coronary venous mapping to guide substrate characterization and ablation of intramural septal ventricular arrhythmia.
        JACC Clin Electrophysiol. 2019; 5: 789-800
        • Liang J.J.
        • Santangeli P.
        • Callans D.J.
        Long-term outcomes of ventricular tachycardia ablation in different types of structural heart disease.
        Arrhythm Electrophysiol Rev. 2015; 4: 177-183
        • Siontis K.C.
        • Kim H.M.
        • Dabbagh G.S.
        • et al.
        Association of preprocedural cardiac magnetic resonance imaging with outcomes of ventricular tachycardia ablation in patients with idiopathic dilated cardiomyopathy.
        Heart Rhythm. 2017; 14: 1487-1493
        • Andreu D.
        • Ortiz-Perez J.T.
        • Boussy T.
        • et al.
        Usefulness of contrast-enhanced cardiac magnetic resonance in identifying the ventricular arrhythmia substrate and the approach needed for ablation.
        Eur Heart J. 2014; 35: 1316-1326
        • Enriquez A.
        • Malavassi F.
        • Saenz L.C.
        • et al.
        How to map and ablate left ventricular summit arrhythmias.
        Heart Rhythm. 2017; 14: 141-148
        • Romero J.
        • Cerrud-Rodriguez R.C.
        • Di Biase L.
        • et al.
        Combined endocardial-epicardial versus endocardial catheter ablation alone for ventricular tachycardia in structural heart disease: a systematic review and meta-analysis.
        JACC Clin Electrophysiol. 2019; 5: 13-24
        • Piers S.R.
        • Leong D.P.
        • van Huls van Taxis C.F.
        • et al.
        Outcome of ventricular tachycardia ablation in patients with nonischemic cardiomyopathy: the impact of noninducibility.
        Circ Arrhythm Electrophysiol. 2013; 6: 513-521