CLINICAL RESEARCH: ELECTROPHYSIOLOGY
Endocardial and epicardial radiofrequency ablation of ventricular tachycardia associated with dilated cardiomyopathy
The importance of low-voltage scars
Kyoko Soejima, MD*,*,
William G. Stevenson, MD*,
John L. Sapp, MD*,
Andrew P. Selwyn, MD*,
Gregory Couper, MD and
Laurence M. Epstein, MD*
* Cardiovascular Division, Department of Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
Manuscript received September 29, 2003;
revised manuscript received December 9, 2003,
accepted January 5, 2004.
* Reprint requests and correspondence: Dr. Kyoko Soejima, Cardiovascular Division, Department of Internal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, Massachusetts 02115, USA.
ksoejima{at}bics.bwh.harvard.edu
OBJECTIVES: The purpose of this study was to evaluate the occurrence, locations, and relationship of ventricular tachycardia (VT) to low-voltage areas in dilated cardiomyopathy (DCM).
BACKGROUND: The substrate causing monomorphic VT after infarction is characterized by regions of low-voltage (<1.5 mV) scar on electroanatomic maps. The substrate causing VT associated with DCM is less well defined.
METHODS: A total of 28 patients were studied with endocardial (26 patients) and epicardial (8 patients) electroanatomic mapping. The VT circuits were defined by entrainment or pace mapping.
RESULTS: Ventricular tachycardia was due to focal VT in 5, bundle-branch re-entry in 2, and myocardial re-entry in 22 patients (both focal and re-entry VTs in 1 patient). All patients with myocardial re-entry had endocardial (20 of 20 patients) and/or epicardial (7 of 7 patients mapped) scar. Most (63%) endocardial scars were adjacent to a valve annulus. Of the 19 VT circuit isthmuses identified, 12 were associated with an endocardial scar and 7 with an epicardial scar. All myocardial re-entrant VTs were abolished in 12 of 22 patients, and inducible VT was modified in 4 patients. During follow-up of 334 ± 280 days, 54% of patients with myocardial re-entry were free of VT despite frequent episodes before ablation.
CONCLUSIONS: The VTs in DCM are most commonly the result of myocardial re-entry associated with scar. Scars are often adjacent to a valve annulus, deep in the endocardium, and can be greater in extent on the epicardium than on the endocardium. The use of epicardial mapping and radiofrequency is likely to improve success.
|
Abbreviations and Acronyms
| | DCM | = dilated cardiomyopathy | | ICD | = implantable cardioverter-defibrillator | | LV | = left ventricle/ventricular | | RF | = radiofrequency | | RV | = right ventricle/ventricular | | S-QRS | = stimulus to QRS interval | | VT | = ventricular tachycardia |
|
This article has been cited by other articles:
|
|
|
|
 
O. Cano, M. Hutchinson, D. Lin, F. Garcia, E. Zado, R. Bala, M. Riley, J. Cooper, S. Dixit, E. Gerstenfeld, et al.
Electroanatomic substrate and ablation outcome for suspected epicardial ventricular tachycardia in left ventricular nonischemic cardiomyopathy.
J. Am. Coll. Cardiol.,
August 25, 2009;
54(9):
799 - 808.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. Shivkumar and R. Tung
Improving our understanding of epicardial ventricular tachycardia in nonischemic cardiomyopathy.
J. Am. Coll. Cardiol.,
August 25, 2009;
54(9):
809 - 811.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. M. Saba, J. Akella, J. Gammie, R. Poston, A. Johnson, R. E. Hood, T.-M. Dickfeld, and S. R. Shorofsky
The influence of fat thickness on the human epicardial bipolar electrogram characteristics: measurements on patients undergoing open-heart surgery
Europace,
July 1, 2009;
11(7):
949 - 953.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. M. Aliot, W. G. Stevenson, J. M. Almendral-Garrote, F. Bogun, C. H. Calkins, E. Delacretaz, P. D. Bella, G. Hindricks, P. Jais, M. E. Josephson, et al.
EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias: Developed in a partnership with the European Heart Rhythm Association (EHRA), a Registered Branch of the European Society of Cardiology (ESC), and the Heart Rhythm Society (HRS); in collaboration with the American College of Cardiology (ACC) and the American Heart Association (AHA)
Europace,
June 1, 2009;
11(6):
771 - 817.
[Full Text]
[PDF]
|
|
|
|
|
|
|
B. A. Koplan and W. G. Stevenson
Ventricular Tachycardia and Sudden Cardiac Death
Mayo Clin. Proc.,
March 1, 2009;
84(3):
289 - 297.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
F. E. Marchlinski
Ventricular Tachycardia Ablation: Moving Beyond Treatment of Last Resort
Circ Arrhythm Electrophysiol,
August 1, 2008;
1(3):
147 - 149.
[Full Text]
[PDF]
|
|
|
|
|
|
|
F. Sacher, U. B. Tedrow, M. E. Field, J.-M. Raymond, B. A. Koplan, L. M. Epstein, and W. G. Stevenson
Ventricular Tachycardia Ablation: Evolution of Patients and Procedures Over 8 Years
Circ Arrhythm Electrophysiol,
August 1, 2008;
1(3):
153 - 161.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. Carbucicchio, M. Santamaria, N. Trevisi, G. Maccabelli, F. Giraldi, G. Fassini, S. Riva, M. Moltrasio, M. Cireddu, F. Veglia, et al.
Catheter Ablation for the Treatment of Electrical Storm in Patients With Implantable Cardioverter-Defibrillators: Short- and Long-Term Outcomes in a Prospective Single-Center Study
Circulation,
January 29, 2008;
117(4):
462 - 469.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
F. E. Marchlinski
Perivalvular Fibrosis and Monomorphic Ventricular Tachycardia: Toward a Unifying Hypothesis in Nonischemic Cardiomyopathy
Circulation,
October 30, 2007;
116(18):
1998 - 2001.
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. G. Stevenson and K. Soejima
Catheter Ablation for Ventricular Tachycardia
Circulation,
May 29, 2007;
115(21):
2750 - 2760.
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. Maury, B. Leobon, A. Duparc, M. Delay, and M. Galinier
Epicardial catheter ablation of ventricular tachycardia using surgical subxyphoid approach
Europace,
April 1, 2007;
9(4):
212 - 215.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. M. Kramer
The Expanding Prognostic Role of Late Gadolinium Enhanced Cardiac Magnetic Resonance
J. Am. Coll. Cardiol.,
November 21, 2006;
48(10):
1986 - 1987.
[Full Text]
[PDF]
|
|
|
|
|
|
|
Z. Y. Lim, B. Maskara, F. Aguel, R. Emokpae Jr, and L. Tung
Spiral Wave Attachment to Millimeter-Sized Obstacles
Circulation,
November 14, 2006;
114(20):
2113 - 2121.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Nazarian, D. A. Bluemke, A. C. Lardo, M. M. Zviman, S. P. Watkins, T. L. Dickfeld, G. R. Meininger, A. Roguin, H. Calkins, G. F. Tomaselli, et al.
Magnetic Resonance Assessment of the Substrate for Inducible Ventricular Tachycardia in Nonischemic Cardiomyopathy
Circulation,
November 1, 2005;
112(18):
2821 - 2825.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
