Earliest activation time is a good predictor of successful ablation of idiopathic outflow tract ventricular arrhythmias

BackgroundIn idiopathic outflow tract ventricular arrhythmias (OT‐VAs), identifying the site with the earliest activation time (EAT) using activation mapping is critical to eliminating the arrhythmogenic focus. However, the optimal EAT for predicting successful radiofrequency catheter ablation (RFCA) has not been established.HypothesisTo evaluate the association between EAT and successful RFCA in idiopathic OT‐VAs and to determine the optimal cut‐off value of EAT for successful ablation.MethodsWe retrospectively analyzed patients undergoing RFCA for idiopathic OT‐VAs at a single center from January 2015 to December 2019.ResultsAcute procedural success was achieved in 168 patients (87.0%). Among these patients, 158 patients (81.9%) were classified in the clinical success group according to the recurrence of clinical VAs during median (Q1, Q3) follow‐up (330 days [182, 808]). EAT was significantly earlier in the clinical success group compared with the recurrence (p = .006) and initial failure (p < .0001) groups. The optimal EAT cut‐off value predicting clinical success was −30 ms in the right ventricular outflow tract (RVOT) with 77.4% sensitivity and 96.4% specificity. In all cases of successful ablation in the left ventricular outflow tract (LVOT), EAT in the RVOT was not earlier than −29 ms.ConclusionsEAT in patients with successful catheter ablation was significantly earlier than that in patients with recurrence and initial failure. EAT earlier than −30 ms could be used as a key predictor of successful catheter ablation as well as an indicator of the need to shift focus from the RVOT to the LVOT.     

起源于左右心室流出道心动过速和早搏的射频导管消融治疗

目的 探讨射频导管消融（RFCA）治疗心室流出道特发性室性心动过速（室速）和室性早搏（室早）的临床效果、心电图及电生理特征。方法 58例患者中室速10例,室早48例。起源于右室流出道（RVOT）43例,左室流出道（LVOT）15例,其中起源于主动脉瓣上Valsalva左冠窦（LSV）12例。5例RVOT室速是在非接触标测系统Ensite3000指导下进行消融的。结果 （1）58例患者中55例成功,3例失败,9例复发。（2）其中1例患者术中出现急性心包压塞。（3）起源心室流出道的室速和室早具有典型的心电图特征,其中Ⅱ、Ⅲ、aVF导联单向R波是流出道室性心律失常的共同特点。（4）V1或V2导联的R波时限指数与R／S波幅指数可作为区别LSV与RVOT室速和室早的有效指标。结论 射频导管消融治疗心室流出道特发性室性心律失常是一种安全、有效的方法。非接触标测系统对于血流动力学不稳定的复杂性室性心律失常的标测与治疗具有重要的意义。     

The use of MitraClip to prevent posttranscatheter aortic valve replacement left ventricular “suicide”

Patients with concomitant severe aortic stenosis (AS) and left ventricular outflow tract (LVOT) obstruction undergoing transcatheter aortic valve replacement (TAVR) are at risk for hemodynamic collapse due to a sudden decrease in afterload causing worsening LVOT obstruction. We present a case of an 88-year-old female with symptomatic, severe AS, and LVOT obstruction with systolic anterior motion (SAM) of the mitral leaflet in whom alcohol septal ablation was contraindicated secondary to a chronic total occlusion of the right coronary artery that filled retrograde via septal collaterals. MitraClip at the time of TAVR was successfully performed to treat SAM with subsequent stabilization of LVOT gradients despite treatment of the patient's AS. This novel approach may represent a feasible option to prevent hemodynamic complications after TAVR in patients with significant LVOT obstruction secondary to SAM and AS.     

Rare complication of ventricular septal defect in three patients following transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is a highly‐effective but technically challenging procedure. Despite improvement in device technology and operator techniques, complications are common and previously unknown procedural‐related complications continue to arise. In this report, we present a case series of three patients with acquired perimembranous ventricular septal defects following transfemoral TAVR with an Edwards SAPIEN prosthesis. © 2013 Wiley Periodicals, Inc.     

经导管主动脉瓣置换术降低主动脉瓣狭窄患者严重室性心律失常发生率

目的:评估主动脉瓣狭窄(AS)患者经导管主动脉瓣置换(TAVR)术前及术后室性心律失常(VAs)发生率。方法:连续收集自2018年1月1日-2019年12月31日在武汉亚洲心脏病医院接受TAVR治疗的症状性重度AS患者81例,排除TAVR术前存在永久起搏器植入病史、术后因并发症植入永久起搏器、术后30 d内死亡、术前无24 h Holter检查结果及失访的患者共14例,最终67例患者纳入分析。TAVR术前及术后1个月行24 h Holter观察VAs的发生情况。VAs分类依据改良的Lown分级系统。结果:TAVR术前VAs Lown分级为1～2级40例(59. 7%),3～4级23例(34. 3%)。TAVR术后1个月,VAs 1～2级人群占比升高,但差异无统计学意义(P 0. 05)。3～4级人群比例显著降低(P 0. 05)。其中,室性心动过速(VT)的发生率从11. 9%下降至7. 5%,但差异无统计学意义(P0. 05)。结论:VAs常见于AS人群中,TAVR术后1个月严重VAs(改良Lown分级3～4级)的患者比例显著降低,可能与瓣膜置换术后左心室功能改善有关。     

Transcatheter ablation through the cardiac veins in a patient with a biventricular device and left ventricular epicardial arrhythmias.

Left ventricular outflow tract (LVOT) may be a source of repeated premature ventricular complexes (PVCs). In symptomatic patients, radiofrequency catheter ablation (RFCA) can be effective, either from endocardial or from epicardial sites. A 50-year-old patient, with dilated cardiomyopathy (DCM) and severe left ventricular (LV) dysfunction, left bundle branch block (LBBB), New York Heart Association (NYHA) class IV, received a biventricular implantable cardioverter/defibrillator (ICD) in 2002. Despite drug therapy, PVCs were frequent (21.019/24 h) including prolonged runs, prompting ICD intervention. Premature ventricular complexes showed an inferior axis morphology, with an R/S ratio in V3>1, suggesting an LVOT origin. Despite the cardiac resynchronization therapy (CRT) device, successful RFCA was performed through the anterior venous branch, with a favourable clinical outcome. To our knowledge, this is the first case describing epicardial RFCA of a PVC focus from cardiac veins in the presence of a CRT device.     

Emergent use of retrograde left ventricular support in patients after transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is currently a therapeutic alternative to open aortic valve replacement for high‐risk patients with severe symptomatic aortic valve stenosis. The procedure is associated with some life‐threatening complications including circulatory collapse which may require temporary hemodynamic support. We describe our experience with the use of the Impella 2.5 system to provide emergent left ventricular support in cases of hemodynamic collapse after TAVR with the Edwards SAPIEN prosthesis.© 2012 Wiley Periodicals, Inc.     

Electrocardiographic characteristics of the variants of idiopathic left ventricular outflow tract ventricular tachyarrhythmias

Background: Despite similar QRS morphology, idiopathic repetitive monomorphic ventricular tachyarrhythmias (VTs) of left ventricular outflow tract (LVOT) are known to have the variants of different adjacent origins, including the aorto-mitral continuity (AMC), anterior site around the mitral annulus (MA), aortic sinus cusps (ASC), and epicardium. However, the electrocardiographic characteristics of those variants previously have not been evaluated fully.
Methods and Results: Based on the mapping site and successful ablation in 45 consecutive patients with LVOT-VTs, we classified them into VTs of AMC (n = 3), MA (n = 8), ASC (n = 32), and epicardial (n = 2) origins. In all patients, we performed activation mapping and an electrocardiographic analysis. All AMC-VTs patients had monophasic R waves in almost all the precordial leads, while those with anterior MA-VTs had an Rs pattern in some precordial leads except for lead V6, and those with ASC-VTs had a variable transitional zone in leads V1–4. There was no S wave in lead V6 in any group except for one patient with anterior MA-VTs. The intrinsicoid deflection time in the AMC-VTs patients and anterior MA-VTs patients was significantly greater than in those with ASC-VTs (P < 0.05). There was no significant difference in the R-wave amplitude in the inferior leads among the groups. Successful radiofrequency catheter ablation (RFCA) was achieved in all patients except for in those with epicardial origin VT.
Conclusions: Despite many morphological similarities, the LVOT-VTs originating from the AMC, anterior MA and ASC could be identified by our proposed electrocardiographic characteristics in order to safely perform RFCA.     

Transcatheter aortic valve replacement thrombosis in patient supported with durable left ventricular assist device

Aortic insufficiency (AI) is a frequent problem after continuous‐flow left ventricular assist device (LVAD) implantation and results in increased morbidity and mortality. Advances in transcatheter aortic valve replacement (TAVR) technology have resulted in this being discussed as a potential option for LVAD patients with AI. While small case series have been published, we report the first case of TAVR thrombosis in an LVAD patient. This case highlights a major diagnostic and management dilemma that should become more present if this strategy becomes more widespread.     

Insights on the pulmonary artery‐derived ventricular arrhythmia

Pulmonary artery‐derived ventricular arrhythmia is gradually being recognized, which in a clinical context is recognized as an arterial ectopic beat. Our study aimed to provide new insights on the epidemiological characteristics, origin site, electrocardiogram (ECG) characteristics, intracardiac electrophysiological characteristics and radiofrequency catheter ablation (RFCA) strategies for pulmonary artery‐derived ventricular arrhythmia. Patients with a distance between the origin site and the pulmonary valve of >10 mm have what is known as pulmonary trunk‐derived ventricular arrhythmia, while patients with a distance between the origin site and the pulmonary valve of ≤10 mm have what is known as pulmonary sinus cusp‐derived ventricular arrhythmia. It is very difficult to differentiate pulmonary artery‐derived ventricular arrhythmia from right ventricular outflow tract‐derived ventricular arrhythmia on ECGs as both share similar anatomical features, but pulmonary artery‐derived ventricular arrhythmia shows obvious intracardiac electrophysiological characteristics. Currently, conclusions based on the epidemiological characteristics of pulmonary artery‐derived ventricular arrhythmia, relationship between the origin site and the pulmonary valve, electrophysiological characteristics, and RFCA strategies are controversial and still need further study.     

Post‐TAVR aortogram: Transform it into a modern tool for prognosis and efficiency

• Video densitometry after aortography can provide objective assessment of aortic regurgitation post‐transcatheter aortic valve replacement (TAVR)
• Contrast density ratio between the left ventricular outflow track and proximal aorta (LVOT‐AR) of >0.17 suggests greater than mild aortic insufficiency and correlates with echo findings
• LVOT‐AR of >0.17 is associated with higher 30‐day and 1‐year mortality

     

导管射频消融治疗特发性室性心动过速的临床应用

目的评价射频消融治疗特发性室速的有效性和安全性.方法收集2002年1月至2005年1月期间在我院进行射频消融的特发性室性心动过速(IVT)患者34例,右室流出道特发性室速(IRVT)采用起搏标测确定消融耙点,左室特发性室速(ILVT)采用激动顺序标测和起搏标测相结合确定消融靶点.结果其中20例起源于左室间隔部和流出道,14例起源于右室流出道;31例即刻成功,3例失败,成功率91.2%.结论射频消融治疗特发性室性心动过速是安全和有效的.     

Percutaneous closure of acute aorto‐right ventricular fistula following transcatheter bicuspid aortic valve replacement

We report a case of acute aorto‐right ventricular fistula following transcatheter bicuspid aortic valve replacement and subsequent percutaneous closure. The diagnosis and treatment of this rare complication is illustrated through multi‐modality imaging. We hypothesize that the patient's heavily calcified bicuspid aortic valve anatomy led to asymmetric deployment of the transcatheter aortic valve replacement (TAVR) prosthesis, traumatizing the right sinus of Valsalva at the distal edge of the TAVR stent and ultimately fistulized to the right ventricle. The patient acutely decompensated with heart failure five days after TAVR and underwent emergent intervention. The aorto‐right ventricular fistula was closed using an 18‐mm septal occluder device with marked clinical recovery. Transcatheter closure is a viable treatment option for acute aorto‐right ventricular fistula. © 2016 Wiley Periodicals, Inc.     

Left ventricular outflow tract tachycardia originating from the right coronary cusp: identification of location of origin by endocardial noncontact activation mapping from the right ventricular outflow tract

Idiopathic left ventricular outflow tract (LVOT) tachycardia has been shown to originate from a supravalvular site in some patients. Considerable attention recently has focused on identifying this variant of LVOT tachycardia on 12-lead ECG. We report the case of 15-year-old boy in whom a noncontact three-dimensional mapping electrode deployed in the right ventricular outflow tract (RVOT) assisted in identifying a supravalvular LVOT tachycardia. Observation of two early breakthrough sites in the RVOT and right ventricular septum suggested a right aortic cusp origin of the tachycardia. Pace mapping in the right aortic cusp identified a successful ablation site.     

Impact of tricuspid regurgitation and right ventricular dysfunction on outcomes after transcatheter aortic valve replacement: A systematic review and meta‐analysis

Far less attention has been paid to the prognostic effect of right‐side heart disease on outcomes after transcatheter aortic valve replacement (TAVR) when compared with the left side. Therefore, we performed a systematic review and meta‐analysis on the impact of tricuspid regurgitation (TR) and right ventricular (RV) dysfunction on outcomes after TAVR. We hypothesized that TR and RV dysfunction may have a deleterious effect on outcomes after TAVR. Article revealing the prognostic effect of TR and RV dysfunction on outcomes after TAVR were being integrated. Random or fixed effect model was adopted in accordance with the heterogeneity. There were nine studies with a total of 6466 patients enrolled after a comprehensive literature search of the MEDLINE/PubMed, EMBASE, ISI Web of Science, and Cochrane databases. The overall analysis revealed that moderate or severe TR at baseline increased all‐cause mortality after TAVR (HR = 1.79, CI 95% 1.52‐2.11, P < 0.001). Both baseline RV dysfunction (HR = 1.53, CI 95% 1.27‐1.83, P < 0.001) and presence of RV dilation (HR = 1.83, CI 95% 1.47‐2.27, P < 0.001) were associated with all‐cause mortality. Both baseline moderate or severe TR and RV dysfunction worsen prognosis after TAVR and careful assessment of right heart function should be done for clinical decision by the heart team before the TAVR procedure.     

Atrioventricular and intraventricular block after transcatheter aortic valve implantation

Aortic stenosis is the most common valvular heart disease in industrialized countries and the most common cause of left ventricular outflow tract (LVOT) obstruction. Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement for intermediate to high-risk surgical candidates with symptomatic severe aortic stenosis. Conduction system abnormalities, including atrioventricular (AV) and intraventricular (IV) block, are the most common complication of TAVR. In this review, we aim to explore the anatomical issues relevant to atrioventricular block, the relevant clinical and procedural aspects, and the management and long-term implications of AV and IV block.     

Catheter ablation of ventricular arrhythmias originating in the vicinity of the His bundle: significance of mapping the aortic sinus cusp.

BACKGROUND: There is a close anatomical relationship between the right coronary cusp (RCC) and noncoronary aortic cusp (NCC) and sites recording His bundle (HB) activation in the right ventricle (RV). OBJECTIVE: The purpose of this study was to examine the electrocardiographic and electrophysiological characteristics of ventricular arrhythmias (VAs) that originate near the HB and their potential as predictors of successful catheter ablation sites. METHODS: We studied 147 consecutive patients undergoing successful catheter ablation of idiopathic VAs originating from the ventricular outflow tract of either ventricle or the HB region. RESULTS: In 13 (9%) patients with an origin in the RCC (n = 5), NCC (n = 1), or RV HB region (n = 7), the local RV activation in the HB region preceded the QRS onset. In two VAs originating from the RCC or NCC, failed radiofrequency applications near the HB region in the RV delayed the near-field ventricular electrogram and separated the far-field electrograms before the QRS onset in the HB region. The QRS transition in the precordial leads did not discriminate between an RV origin near the HB and an NCC or RCC origin. A QS pattern in lead aVL might be helpful for predicting an RCC origin. CONCLUSIONS: VAs originating near the HB have similar electrocardiographic and electrophysiological characteristics, regardless of whether the ablation site is in the RV or aortic sinuses because of the close anatomical relationship of these structures and rapid transseptal conduction. When RV mapping reveals an earliest ventricular activation in the HB region during VAs, mapping in the RCC and NCC should be added to accurately identify the site of origin.     

Lead I R‐wave amplitude to distinguish ventricular arrhythmias with lead V3 transition originating from the left versus right ventricular outflow tract

BackgroundThe electrophysiology algorithm for localizing left or right origins of outflow tract ventricular arrhythmias (OT‐VAs) with lead V₃ transition still needs further investigation in clinical practice.HypothesisLead I R‐wave amplitude is effective in distinguishing the left or right origin of OT‐VAs with lead V₃ transition.MethodsWe measured lead I R‐wave amplitude in 82 OT‐VA patients with lead V₃ transition and a positive complex in lead I who underwent successful catheter ablation from the right ventricular outflow tract (RVOT) and left ventricular outflow tract (LVOT). The optimal R‐wave threshold was identified, compared with the V₂S/V₃R index, transitional zone (TZ) index, and V₂ transition ratio, and validated in a prospective cohort study.ResultsLead I R‐wave amplitude for LVOT origins was significantly higher than that for RVOT origins (0.55 ± 0.13 vs. 0.32 ± 0.15 mV; p < .001). The area under the curve (AUC) for lead I R‐wave amplitude as assessed by receiver operating characteristic (ROC) analysis was 0.926, with a cutoff value of ≥0.45 predicting LVOT origin with 92.9% sensitivity and 88.2% specificity, superior to the V₂S/V₃R index, TZ index, and V₂ transition ratio. VAs in the LVOT group mainly originated from the right coronary cusp (RCC) and left and right coronary cusp junction (L‐RCC). In the prospective study, lead I R‐wave amplitude identified the LVOT origin with 92.3% accuracy.ConclusionLead I R‐wave amplitude provides a useful and simple criterion to identify RCC or L‐RCC origin in OT‐VAs with lead V₃ transition.     

Impact of Left Ventricular Outflow Tract Calcification on Procedural Outcomes After Transcatheter Aortic Valve Replacement

ObjectivesThis study aimed to systematically assess the importance of left ventricular outflow tract (LVOT) calcification on procedural outcomes and device performances with contemporary transcatheter heart valve (THV) systems.BackgroundLVOT calcification has been associated with adverse clinical outcomes after transcatheter aortic valve replacement (TAVR). However, the available evidence is limited to observational data with modest numbers and incomplete assessment of the effect of the different THV systems.MethodsIn a retrospective analysis of a prospective single-center registry, LVOT calcification was assessed in a semiquantitative fashion. Moderate or severe LVOT calcification was documented in the presence of 2 nodules of calcification, or 1 extending >5 mm in any direction, or covering >10 % of the perimeter of the LVOT.ResultsAmong 1,635 patients undergoing TAVR between 2007 and 2018, moderate or severe LVOT calcification was found in 407 (24.9%). Patients with moderate or severe LVOT calcification had significantly higher incidences of annular rupture (2.3% vs. 0.2%; p < 0.001), bailout valve-in-valve implantation (2.9% vs. 0.8%; p = 0.004), and residual aortic regurgitation (11.1% vs. 6.3%; p = 0.002). Balloon-expandable valves conferred a higher risk of annular rupture in the presence of moderate or severe LVOT calcification (4.0% vs. 0.4%; p = 0.002) as compared with the other valve designs. There was no significant interaction of valve design or generation and LVOT calcification with regard to the occurrence of bailout valve-in-valve implantation and residual aortic regurgitation.ConclusionsModerate or severe LVOT calcification confers increased risks of annular rupture, residual aortic regurgitation, and implantation of a second valve. The risk of residual aortic regurgitation is consistent across valve designs and generations. (SWISS TAVI Registry; NCT01368250)     

Subcutaneous implantable cardioverter defibrillator eligibility according to a novel automated screening tool and agreement with the standard manual electrocardiographic morphology tool

Background

Ventricular arrhythmias (VAs) from the left ventricular outflow tract (LVOT) can have multiple exits exhibiting divergent ECG features.

Methods

In a series of 131 patients with VAs with LVOT origin, 10 patients presented with divergent QRS morphologies. Multisite endo- and epicardial mapping of different exit sites was performed.

Results

The earliest ventricular activity of 23 LVOT VAs in 10 patients was detected in the endocardium of the LV in 7 patients, the aortic sinuses of Valsalva (SoV) in 3 patients, the distal coronary sinus in 6 patients, the anterior interventricular vein in 3 patients, and the posterior right ventricular outflow tract (RVOT) in 4 patients. Simultaneous elimination of two divergent QRS morphologies of LVOT VAs by ablation from a single site was achieved in 5 patients (aorto-mitral continuity in 3 patients, SoV and RVOT in each 1 patient) using a mean maximum ablation energy of 46?±?5 W. Sequential ablation from two or three different sites, including trans-pericardial and distal coronary sinus ablation in each 2 patients, led to elimination of the divergent VA QRS morphologies in the other 5 patients. During the follow-up of 28?±?29 months, 4 of the 10 patients had recurrence of at least one LVOT VA. A 43-year-old patient with muscular dystrophy Curschmann-Steinert had recurrence of sustained LVOT VTs and died of sudden cardiac death.

Conclusions

Multisite mapping of different exit sites of LVOT VAs can guide ablation of intramural foci but the recurrence rate after initially successful ablation was high.