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Improving Safety of Epicardial Ventricular Tachycardia Ablation Using the Scar Dechanneling Technique and the Integration of Anatomy, Scar Components, and Coronary Arteries Into the Navigation System

2012; Lippincott Williams & Wilkins; Volume: 125; Issue: 11 Linguagem: Inglês

10.1161/circulationaha.111.087858

1524-4539

Juan Fernández‐Armenta, Antonio Berruezo, Jose T. Ortiz‐Pérez, Lluı́s Mont, David Andreu, Csaba Herczku, Tim Boussy, Josép Brugada,

Cardiac electrophysiology and arrhythmias

HomeCirculationVol. 125, No. 11Improving Safety of Epicardial Ventricular Tachycardia Ablation Using the Scar Dechanneling Technique and the Integration of Anatomy, Scar Components, and Coronary Arteries Into the Navigation System Free AccessBrief ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessBrief ReportPDF/EPUBImproving Safety of Epicardial Ventricular Tachycardia Ablation Using the Scar Dechanneling Technique and the Integration of Anatomy, Scar Components, and Coronary Arteries Into the Navigation System Juan Fernández-Armenta, MD, Antonio Berruezo, MD, PhD, Jose T. Ortiz-Pérez, MD, PhD, Lluis Mont, MD, PhD, David Andreu, MSc, Csaba Herczku, MD, Tim Boussy, MD and Josep Brugada, MD, PhD Juan Fernández-ArmentaJuan Fernández-Armenta From the Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic, Universitat de Barcelona and IDIBAPS (Institut d'Investigacions Biomèdiques August Pi i Sunyer), Barcelona, Catalonia, Spain. , Antonio BerruezoAntonio Berruezo From the Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic, Universitat de Barcelona and IDIBAPS (Institut d'Investigacions Biomèdiques August Pi i Sunyer), Barcelona, Catalonia, Spain. , Jose T. Ortiz-PérezJose T. Ortiz-Pérez From the Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic, Universitat de Barcelona and IDIBAPS (Institut d'Investigacions Biomèdiques August Pi i Sunyer), Barcelona, Catalonia, Spain. , Lluis MontLluis Mont From the Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic, Universitat de Barcelona and IDIBAPS (Institut d'Investigacions Biomèdiques August Pi i Sunyer), Barcelona, Catalonia, Spain. , David AndreuDavid Andreu From the Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic, Universitat de Barcelona and IDIBAPS (Institut d'Investigacions Biomèdiques August Pi i Sunyer), Barcelona, Catalonia, Spain. , Csaba HerczkuCsaba Herczku From the Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic, Universitat de Barcelona and IDIBAPS (Institut d'Investigacions Biomèdiques August Pi i Sunyer), Barcelona, Catalonia, Spain. , Tim BoussyTim Boussy From the Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic, Universitat de Barcelona and IDIBAPS (Institut d'Investigacions Biomèdiques August Pi i Sunyer), Barcelona, Catalonia, Spain. and Josep BrugadaJosep Brugada From the Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clínic, Universitat de Barcelona and IDIBAPS (Institut d'Investigacions Biomèdiques August Pi i Sunyer), Barcelona, Catalonia, Spain. Originally published20 Mar 2012https://doi.org/10.1161/CIRCULATIONAHA.111.087858Circulation. 2012;125:e466–e468A 54-year-old patient with a nonischemic cardiomyopathy, mild left ventricular dysfunction, and a nonsyncopal ventricular tachycardia was admitted for an ablation procedure. Preprocedural contrast-enhanced cardiac magnetic resonance (ce-CMR) was performed with a 3T clinical scanner (Magnetom Trio, Siemens Healthcare, Erlangen, Germany). A free-breathing 3-dimensional navigator and electrocardiographically gated inversion-recovery gradient-echo sequence was applied in the axial orientation, starting 5 minutes after an intravenous injection of 0.2 mmol/kg gadodiamide. Image acquisition parameters were set to allow a true isotropic 1.2×1.2×1.2-mm spatial resolution, and the acquisition time was targeted below 9 minutes to permit simultaneous evaluation of the coronary tree and myocardial enhancement. To minimize motion artifacts, the acquisition window was selected with a high-temporal-resolution 4-chamber cine view. The patient was instructed to maintain shallow and steady breathing during the acquisition. The full volume was reconstructed in the left ventricular short-axis orientation, and the resulting images were processed with self-customized software (TCTK [Tissue Characterization Tool Kit], Barcelona, Spain). An algorithm based on the pixel signal intensity was applied to characterize the hyperenhanced area as scar core or border zone. The processed images were imported into the CARTO system (Biosense Webster, Diamond Bar, CA). The study showed a subepicardial hyperenhancement in the anterolateral left ventricular wall (Figure 1A).Download figureDownload PowerPointFigure 1. A, Basal short-axis view of the contrast-enhanced cardiovascular magnetic resonance (ce-CMR). There is a subepicardial distribution of the hyperenhancement in the lateral wall (white arrow) that turns midmyocardial in the anterior wall (yellow arrow). B, Volume-rendered image of the ascending aorta and the coronary arteries derived from ce-CMR and visualized with the CARTO system. C, Left lateral view of the left ventricular epicardial voltage map. Normal tissue is coded in purple (>1.5 mV). Heterogeneous green (border zone) and red (core) areas of low voltage are visible in the basal aspect of the lateral wall. Blue dots indicate electrograms with isolated delayed components; red dots, ablation points. D, Three-dimensional ce-CMR reconstruction of the ventricles (right ventricle in blue, left in yellow), coronary arteries (gray), and scar tissue (border zone in green, core in red). Lack of perfect concordance between the ce-CMR–derived scar and the epicardial bipolar map (especially in the most anterior part) is explained by the presence of normal tissue interposed between the scar and the epicardial surface, as depicted in panel A (yellow arrow).An electroanatomic map of the right and left ventricles was obtained and merged with the ce-CMR 3-dimensional volume-rendered reconstruction, which included cardiac chambers, coronary vessels, and characterized scar tissue (core and border zone; Figures 1B and 1D). The left ventricular endocardial voltage map showed no low-voltage areas or abnormal bipolar electrograms. The left ventricular epicardial voltage map showed a lateral and basal low-voltage area coincident with the scar location obtained from the ce-CMR (Figure 1C). Electrograms with isolated delayed components (E-IDCs) were present in the epicardial scar area, but also in areas with normal voltage range.A potential complication of epicardial radiofrequency ablation is damage to coronary vessels. Using the described acquisition protocol, it is possible to obtain the distribution of the scar and epicardial coronary arteries together with the anatomy of the cardiac chambers from the 3T ce-CMR. Registration with the electroanatomic map provides a real-time localization of the arteries. In this case, E-IDCs were present just over an oblique marginal artery (Figure 2). The E-IDCs had an activation sequence from the edge to the center of the scar (Figure 2). Therefore, radiofrequency applications were delivered at the edge of the scar, over E-IDCs with the shortest isolated delayed component lateness (ie, entrance of late potential channels during sinus rhythm; Figure 2, electrogram A), as described previously.1 Finally, a remap was obtained to establish complete elimination of E-IDCs, including those over the coronary artery (Figure 3).Download figureDownload PowerPointFigure 2. Three-dimensional contrast-enhanced cardiovascular magnetic resonance (3D ce-CMR) reconstruction ventricles, arteries, and scar components merged with the electroanatomic map. The 3D ce-CMR–derived scar is not visible because it is located below the epicardial bipolar map. Bipolar electrograms over the oblique marginal artery showed an isolated delayed component (blue dot, electrogram B). The activation sequence of the isolated component (arrow and electrograms A, B, C, and D) began at the edge of the scar; radiofrequency applications were therefore directed to this location (black dot, electrogram A). Blue dots indicate electrograms with isolated delayed components; black dots, targeted electrograms; and red dots, ablation points.Download figureDownload PowerPointFigure 3. Epicardial voltage map merged with 3-dimensional contrast-enhanced cardiovascular magnetic resonance of ventricles, arteries, and scar components. Electrogram with isolated delayed component (arrow) over the coronary artery is shown (upper panel). After epicardial radiofrequency application at the edge of the scar (entrance of late potential channel), an epicardial remap was performed (lower panel), which showed no isolated delayed component (asterisk).Prior reports showed that myocardial scar obtained by ce-CMR can be characterized and imported into a navigation system, which facilitates mapping and ablation.2,3 Coronary anatomy display into the CARTO system, obtained from computed tomography, improves the safety of epicardial ablation, avoiding the need for a coronary angiogram during the procedure.4 The present case shows how progress in the acquisition protocols and ce-CMR image postprocessing allows acquisition of not only the anatomy and scar components but also the distribution of the main coronary arteries to guide ventricular tachycardia ablation.Areas of E-ICDs have been related to critical reentry isthmuses and targeted for ventricular tachycardia substrate ablation. By analyzing the activation sequence of E-ICDs during sinus rhythm, it is possible to identify the late potential channel entrance into the scar.1 Targeting the conducting channel entrance during ablation reduces the extent of radiofrequency application, which improves the safety of epicardial ablation.1 The present case reveals how this ablation technique (scar dechanneling) can eliminate multiple remote E-ICDs that would otherwise be eliminated by applying radiofrequency just over the coronary arteries.DisclosuresNone.FootnotesCorrespondence to Antonio Berruezo, MD, PhD, Arrhythmia Section, Cardiology Department, Thorax Institute, Hospital Clinic, C/Villarroel 170, 08036 Barcelona, Spain. E-mail [email protected]ub.esReferences1. Berruezo A, Fernández-Armenta J, Mont L, Zeljko HM, Andreu D, Herczku C, Boussy T, Tolosana JM, Arbelo E, Brugada J. Combined endocardial and epicardial catheter ablation in arrhythmogenic right ventricular dysplasia incorporating scar dechanneling technique. Circ Arrhythm Electrophysiol. 2012; 5:111–121.LinkGoogle Scholar2. Desjardins B, Crawford T, Good E, Oral H, Chugh A, Pelosi F, Morady F, Bogun F. Infarct architecture and characteristics on delayed enhanced magnetic resonance imaging and electroanatomic mapping in patients with postinfarction ventricular arrhythmia. Heart Rhythm. 2009; 6:644–651.CrossrefMedlineGoogle Scholar3. Andreu D, Berruezo A, Ortiz-Perez JT, Silva E, Mont L, Borras R, de Caralt TM, Perea RJ, Fernández-Armenta J, Zeljko H, Brugada J. Integration of 3D electroanatomic maps and magnetic resonance scar characterization into the navigation system to guide ventricular tachycardia ablation. Circ Arrhythm Electrophysiol. 2011; 4:674–683.LinkGoogle Scholar4. Zeppenfeld K, Tops LF, Bax JJ, Schalij MJ. Epicardial radiofrequency catheter ablation of ventricular tachycardia in the vicinity of coronary arteries is facilitated by fusion of 3-dimensional electroanatomical mapping with multislice computed tomography. Circulation. 2006; 114:e51–e52.LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Sun A, Piccini J and Daubert J (2019) New High-Density and Automated Mapping Systems Cardiac Mapping, 10.1002/9781119152637.ch16, (197-210) Andreu D, Fernández-Armenta J, Acosta J, Penela D, Jáuregui B, Soto-Iglesias D, Syrovnev V, Arbelo E, Tolosana J and Berruezo A (2018) A QRS axis–based algorithm to identify the origin of scar-related ventricular tachycardia in the 17-segment American Heart Association model, Heart Rhythm, 10.1016/j.hrthm.2018.06.013, 15:10, (1491-1497), Online publication date: 1-Oct-2018. Shinbane J and Saxon L (2018) Virtual medicine: Utilization of the advanced cardiac imaging patient avatar for procedural planning and facilitation, Journal of Cardiovascular Computed Tomography, 10.1016/j.jcct.2017.11.004, 12:1, (16-27), Online publication date: 1-Jan-2018. Briceño D, Romero J, Gianni C, Mohanty S, Villablanca P, Natale A and Di Biase L (2017) Substrate Ablation of Ventricular Tachycardia: Late Potentials, Scar Dechanneling, Local Abnormal Ventricular Activities, Core Isolation, and Homogenization, Cardiac Electrophysiology Clinics, 10.1016/j.ccep.2016.10.014, 9:1, (81-91), Online publication date: 1-Mar-2017. Fernández-Armenta J, Penela D, Acosta J, Andreu D and Berruezo A (2015) Approach to Ablation of Unmappable Ventricular Arrhythmias, Cardiac Electrophysiology Clinics, 10.1016/j.ccep.2015.05.011, 7:3, (527-537), Online publication date: 1-Sep-2015. Berruezo A, Fernández-Armenta J, Andreu D, Penela D, Herczku C, Evertz R, Cipolletta L, Acosta J, Borràs R, Arbelo E, Tolosana J, Brugada J and Mont L (2015) Scar Dechanneling, Circulation: Arrhythmia and Electrophysiology, 8:2, (326-336), Online publication date: 1-Apr-2015. Berruezo A and Fernandez-Armenta J (2014) Lines, circles, channels, and clouds: looking for the best design for substrate-guided ablation of ventricular tachycardia, Europace, 10.1093/europace/euu030, 16:7, (943-945), Online publication date: 1-Jul-2014. Andreu D, Ortiz-Pérez J, Boussy T, Fernández-Armenta J, de Caralt T, Perea R, Prat-González S, Mont L, Brugada J and Berruezo A (2014) Usefulness of contrast-enhanced cardiac magnetic resonance in identifying the ventricular arrhythmia substrate and the approach needed for ablation, European Heart Journal, 10.1093/eurheartj/eht510, 35:20, (1316-1326), Online publication date: 21-May-2014., Online publication date: 21-May-2014. Berruezo A, Fernández-Armenta J and Brugada J (2014) Letter by Berruezo et al Regarding Article, "Impact of Local Ablation on Interconnected Channels Within Ventricular Scar: Mechanistic Implications for Substrate Modification", Circulation: Arrhythmia and Electrophysiology, 7:2, (362-362), Online publication date: 1-Apr-2014. Neven K, Fernández-Armenta J, Andreu D and Berruezo A (2014) Epicardial Ablation: Prevention of Phrenic Nerve Damage by Pericardial Injection of Saline and the Use of a Steerable Sheath, Indian Pacing and Electrophysiology Journal, 10.1016/S0972-6292(16)30735-5, 14:2, (87-93), Online publication date: 1-Mar-2014. de Groot J and Deneke T (2013) Epicardial mapping and ablation of arrhythmias: is magnetic navigation the answer we have been waiting for?, Netherlands Heart Journal, 10.1007/s12471-013-0446-3, 21:9, (389-390), Online publication date: 1-Sep-2013. Fernández-Armenta J, Berruezo A, Andreu D, Camara O, Silva E, Serra L, Barbarito V, Carotenutto L, Evertz R, Ortiz-Pérez J, De Caralt T, Perea R, Sitges M, Mont L, Frangi A and Brugada J (2013) Three-Dimensional Architecture of Scar and Conducting Channels Based on High Resolution ce-CMR, Circulation: Arrhythmia and Electrophysiology, 6:3, (528-537), Online publication date: 1-Jun-2013. (2012) European Perspectives, Circulation, 126:16, (f91-f96), Online publication date: 16-Oct-2012. March 20, 2012Vol 125, Issue 11 Advertisement Article InformationMetrics © 2012 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.111.087858PMID: 22431889 Originally publishedMarch 20, 2012 PDF download Advertisement SubjectsElectrophysiology