Bipolar Radiofrequency Ablation of Ventricular Arrhythmias Originating in the Vicinity of His Bundle
2020; Lippincott Williams & Wilkins; Volume: 13; Issue: 3 Linguagem: Inglês
10.1161/circep.119.008165
ISSN1941-3149
AutoresPiotr Futyma, Kamil Ciąpała, Jarosław Sander, Ryszard Głuszczyk, Marian Futyma, Piotr Kułakowski,
Tópico(s)Atrial Fibrillation Management and Outcomes
ResumoHomeCirculation: Arrhythmia and ElectrophysiologyVol. 13, No. 3Bipolar Radiofrequency Ablation of Ventricular Arrhythmias Originating in the Vicinity of His Bundle Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessReview ArticlePDF/EPUBBipolar Radiofrequency Ablation of Ventricular Arrhythmias Originating in the Vicinity of His Bundle Piotr Futyma, MD, PhD, Kamil Ciąpała, MD, Jarosław Sander, MD, Ryszard Głuszczyk, MD, Marian Futyma, MD, PhD and Piotr Kułakowski, MD, PhD Piotr FutymaPiotr Futyma Correspondence to: Piotr Futyma, MD, PhD, St. Joseph's Heart Rhythm Center, Invasive Cardiology Department, Anny Jagiellonki 17, 35-623, Rzeszów, Poland. Email E-mail Address: [email protected] https://orcid.org/0000-0003-0219-7612 St. Joseph's Heart Rhythm Center, Rzeszów (P.F., K.C., J.S., R.G., M.F., P.K.). , Kamil CiąpałaKamil Ciąpała St. Joseph's Heart Rhythm Center, Rzeszów (P.F., K.C., J.S., R.G., M.F., P.K.). , Jarosław SanderJarosław Sander St. Joseph's Heart Rhythm Center, Rzeszów (P.F., K.C., J.S., R.G., M.F., P.K.). , Ryszard GłuszczykRyszard Głuszczyk St. Joseph's Heart Rhythm Center, Rzeszów (P.F., K.C., J.S., R.G., M.F., P.K.). , Marian FutymaMarian Futyma St. Joseph's Heart Rhythm Center, Rzeszów (P.F., K.C., J.S., R.G., M.F., P.K.). and Piotr KułakowskiPiotr Kułakowski St. Joseph's Heart Rhythm Center, Rzeszów (P.F., K.C., J.S., R.G., M.F., P.K.). Department of Cardiology, Medical Centre for Postgraduate Education, Grochowski Hospital, Warsaw, Poland (P.K.). Originally published16 Feb 2020https://doi.org/10.1161/CIRCEP.119.008165Circulation: Arrhythmia and Electrophysiology. 2020;13:e008165Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: February 17, 2020: Ahead of Print When arrhythmia originates from the His bundle (HB) area, conventional radiofrequency catheter ablation (RFCA) is associated with increased risk of atrioventricular block.1,2 Biophysics of bipolar RFCA (Bi-RFCA) suggest more selective lesion formation.3 It has been shown that Bi-RFCA can be an alternative in case of premature ventricular complex (PVC) or ventricular tachycardia (VT) refractory to standard RF.4 Whether Bi-RFCA can result in safe and effective ablation of PVC/VT originating from the close proximity of HB has not yet been investigated.The data that support the findings of this study are available from the corresponding author upon request. From our single-center bipolar ablation registry, we retrospectively identified patients in whom PVC/VT site of origin was located in close proximity of HB. The study was approved by the Institutional Review Board, and all patients were provided written consent to undergo Bi-RFCA. An open-irrigated ablation catheter (AC; Thermocool, Biosense Webster, Diamond Bar or CoolFlex, St Jude Medical, St Paul) was used for mapping of HB and surrounding sites: tricuspid annulus, proximal coronary sinus or coronary sinus diverticulum, intraventricular septum, outflow tracts, aortic cusps, posterior-superior process, and mitral annulus. This catheter was positioned in the area of earliest PVC/VT activation. A second conventional nonirrigated 4 mm tip catheter (AlCath, Biotronik, Berlin, Germany or Triguy, APT Medical, Shenzen, China) was introduced into the opposite site of earliest endocardial PVC/VT activation. Nonirrigated catheter was connected to a dedicated switch box (Futyma Box, formerly IndiCath, St. Joseph's Heart Rhythm Center, Rzeszów, Poland) to connect tip electrode as an intracardiac return electrode (IRE) to the RF generator (EP Shuttle, Stockert, Freiburg, Germany) instead of dispersive patch and to track IRE temperature as previously described.4 After unfractionated heparin was administered, low-energy bipolar applications between AC and IRE, at generator power settings of 10 W, titrated individually (max 60 W), at AC irrigation of 2 to 30 mL/min, were delivered. Applications were terminated in cases of rapid junctional activity during radiofrequency or if any impairment of retrograde conduction during junctional beats was observed. After ablation, intravenous salbutamol and programmed ventricular stimulation were used to assess arrhythmia inducibility. Follow-up was conducted every 3 months.Continuous variables were compared using 2-tailed Student t test (Microsoft Excel). A P<0.05 was considered statistically significant.Out of consecutive 23 patients who underwent Bi-RFCA at our center between 2016 to 2019, 8 patients had PVC/VT originating in the proximity of HB (2 females, age 60±15 years). ECG characteristics of clinical PVC/VT are presented in Figure [A]. Two patients had more than one parahisian PVC morphology present. All subjects had symptomatic PVCs, 2 had concomitant presyncopal nonsustained VT, and 1 sustained VT. Previous conventional ablation and pharmacological antiarrhythmic treatment consisting of at least one drug failed in all. Clinical and demographic characteristics are presented in the Data Supplement. Mapping of the parahisian area showed that the earliest activation was near the HB in all study patients, and the earliest activation site was used for placement of the AC at the time bipolar ablation. IRE was located at the opposite site according to electro-anatomic relationship (Figure [B] and [C]). Safe distance from HB, represented by the lack of HB signal on the tip of both AC and IRE, was achieved, whereas HB signal at proximal rings of AC/IRE, if present, was acceptable. A total number of 93 bipolar applications (12±10 application/patient) were delivered (mean bipolar RF time 508±565 s, mean power 35±13 W, and mean impedance 163±18 Ω). Bi-RFCA led to acute elimination of PVC/VT in 6 (75%) patients. Transient conduction disturbances occurred in 2 patients and were associated with mechanical compression of conduction system. Two steam pops occurred without consequences. One patient required IRE exchange from 4 mm to 8 mm due to overheating. One patient (number 1), apart from 2 parahisian PVC treated with bipolar approach, underwent ablation of third PVC morphology from MA, which was performed conventionally without problems at the time of Bi-RFCA. In 2 patients (numbers 3 and 4) who experienced PVC/VT recurrence after initial Bi-RFCA, a repeated Bi-RFCA was performed, this time with an open-irrigated catheter used as an IRE. Bi-RFCA led to acute elimination of PVC/VT in both patients. In patient number 4, we used transseptal access for mapping and ablation of LV-posterior-superior process. There were no complications during Bi-RFCA. Detailed procedural characteristics are presented in the Data Supplement. Follow up lasted 11±5 months. There was no VT recurrence, and a 72% PVC burden reduction was achieved (16200±11600 preablation versus 4500±6200 post-ablation PVC/day, P=0.035; Figure [D]). Three patients were on low-dose sotalol (160 mg/day) at the end of follow-up. No atrioventricular block of any degree was observed.Download figureDownload PowerPointFigure. Representative figure of arrhythmia types and clinical scenarios.A, Twelve-lead electrocardiograms of clinical premature ventricular complexes (PVC) and ventricular tachycardia (VT) of study subjects. B, Bipolar radiofrequency catheter ablation (Bi-RFCA) of PVC inferior to His bundle (HB). Left, Example of acceptable recordings from ablation catheter (AC) and intracardiac return electrode (IRE). Notable HB signal is visible only on proximal electrodes of IRE (red field), whereas distal electrodes record no HB signal. A small far-field HB signals on both distal and proximal AC electrodes were acceptable, and Bi-RFCA was successfully delivered without complications. Right, Fluoroscopic image of successful ablation site. C, Bi-RFCA of PVC superior to HB. Left, An example of suboptimal recordings from IRE which was located near the earliest PVC activation site in subaortic region—despite only small far-field signal of HB on AC (green field) located at superior-septal tricuspid anulus (TA), there's a sharp HB signal on IRE (red field) which prevented Bi-RFCA at this site. Right, Fluoroscopic image after optimization of IRE position which was achieved by retracting IRE towards noncoronary cusp (NCC) of aortic valve which allowed safe bipolar application delivery. D, Reduction of premature ventricular complex (PVC) burden after bipolar radiofrequency catheter ablation in individual patients.Small-tip catheters (4, 3, and 5 mm) in Bi-RFCA setting operate at higher impedance values.5 This is probably the reason why Bi-RFCA is associated with more dense lesion core and possibly less collateral damage.3 Obviously, Bi-RFCA may not be a solution for ablation of substrates located directly within HB. However, for substrates close to His, delivering bipolar RF current outside HB (below or above HB) can possibly increase safety. In addition, RF current traveling between 2 tips of electrodes is more condensed at the area of interest (arrhythmia origin) compared with standard RF delivery between ablation electrode and dispersive patch localized at patient's back.To avoid HB injury during Bi-RFCA, following precautions were applied. First of all an exact HB location was carefully determined using 3-dimensional mapping and fluoroscopy. Second, the presence of His signal on AC and IRE was avoided. Third, we started Bi-RFCA at relatively low (10 W) power settings. Fourth, any junctional activity was carefully tracked. Fifth, we terminated bipolar applications in cases of rapid junctional rhythms and any V-A delay. Pacing maneuvers can additionally help to differentiate near-field versus far-field His recordings, and this can improve safety of Bi-RFCA; however, such maneuvers were not performed in this study.Performing Bi-RFCA requires perpendicular orientation of both catheters, which can be challenging and may require assistance of a second electrophysiologist. Visualization of IRE (as a regular 4-pole catheter) using 3-dimensional mapping is possible with the loss of some catheter-specific features such as contact force or 3-dimensional sensor orientation; however, the reading of IRE-tip temperature is possible.5 Simultaneous unipolar ablation can be an alternative, however, its impact on lesion core density and possible impact on reducing collateral damage remain unknown.Bi-RFCA, with a few precautions, can be safely performed in the vicinity of HB, and this approach can be effectively used to treat PVC/VT when standard unipolar RF ablation attempts fail.DisclosuresDr Futyma reports 2 patent applications related with bipolar ablation and creation of bipolar ablation device. The other authors report no conflicts.FootnotesFor Sources of Funding and Disclosures, see page 276The Data Supplement is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCEP.119.008165.Correspondence to: Piotr Futyma, MD, PhD, St. Joseph's Heart Rhythm Center, Invasive Cardiology Department, Anny Jagiellonki 17, 35-623, Rzeszów, Poland. Email piotr.[email protected]comReferences1. Enriquez A, Tapias C, Rodriguez D, Liang J, Marchlinski F, Saenz L, Garcia F. How to map and ablate parahisian ventricular arrhythmias.Heart Rhythm. 2018; 15:1268–1274. doi: 10.1016/j.hrthm.2018.02.028CrossrefMedlineGoogle Scholar2. Yamada T, McElderry HT, Doppalapudi H, Kay GN. Catheter ablation of ventricular arrhythmias originating in the vicinity of the His bundle: significance of mapping the aortic sinus cusp.Heart Rhythm. 2008; 5:37–42. doi: 10.1016/j.hrthm.2007.08.032CrossrefMedlineGoogle Scholar3. Nguyen DT, Zheng L, Zipse MM, Borne RT, Tzou WS, Fleeman B, Sauer WH. Bipolar radiofrequency ablation creates different lesion characteristics compared to simultaneous unipolar ablation.J Cardiovasc Electrophysiol. 2019; 30:2960–2967. doi: 10.1111/jce.14213CrossrefMedlineGoogle Scholar4. Futyma P, Sander J, Ciąpała K, Głuszczyk R, Wysokińska A, Futyma M, Kułakowski P. Bipolar radiofrequency ablation delivered from coronary veins and adjacent endocardium for treatment of refractory left ventricular summit arrhythmias [published online August 11, 2019].J Interv Card Electrophysiol. doi: 10.1007/s10840-019-00609-9. https://link.springer.com/article/10.1007%2Fs10840-019-00609-9.Google Scholar5. Futyma P, Ciąpała K, Głuszczyk R, Sander J, Futyma M, Kułakowski P. Bipolar ablation of refractory atrial and ventricular arrhythmias: importance of temperature values of intracardiac return electrodes.J Cardiovasc Electrophysiol. 2019; 30:1718–1726. doi: 10.1111/jce.14025CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Kahle A, Jungen C, Alken F, Scherschel K, Willems S, Pürerfellner H, Chen S, Eckardt L and Meyer C (2021) Management of ventricular tachycardia in patients with ischaemic cardiomyopathy: contemporary armamentarium, EP Europace, 10.1093/europace/euab274, 24:4, (538-551), Online publication date: 5-Apr-2022. Yue-Chun L, Yuan-Nan L, Jing X, Yang-Qi P, Cheng Z, Yang-Jing X, Jia-Xuan L, Jin L, Jia L and Jia-Feng L (2021) R/S Ratio in Lead III Predicts Successful Ablation of Ventricular Arrhythmias Originating in Para-Hisian Region, JACC: Clinical Electrophysiology, 10.1016/j.jacep.2020.10.012, 7:6, (719-730), Online publication date: 1-Jun-2021. Zhang L, Dong S, Yu H and Chu Y (2021) Ventricular tachycardia originating from the His bundle: A case report, World Journal of Clinical Cases, 10.12998/wjcc.v9.i32.10040, 9:32, (10040-10045), Online publication date: 16-Nov-2021. Yu M, Hou L, Yu H, Ge J, Li P, Guo Z, Huang X, Zhao X, Cao J and Huang S (2021) Electrocardiographic and electrophysiological characteristics of idiopathic ventricular arrhythmias originating from the vicinity of tricuspid annulus, Scientific Reports, 10.1038/s41598-021-88036-7, 11:1, Online publication date: 1-Dec-2021. Liang J and Bogun F (2020) Bipolar ablation for intramural ventricular tachycardia substrate: Ready for prime time?, Heart Rhythm, 10.1016/j.hrthm.2020.04.034, 17:9, (1508-1509), Online publication date: 1-Sep-2020. Futyma P and Kułakowski P (2020) An update to an update on radiofrequency bipolar catheter ablation, Journal of Cardiovascular Electrophysiology, 10.1111/jce.14411, 31:5, (1238-1239), Online publication date: 1-May-2020. Futyma P, Santangeli P, Pürerfellner H, Pothineni N, Głuszczyk R, Ciąpała K, Moroka K, Martinek M, Futyma M, Marchlinski F and Kułakowski P (2020) Anatomic approach with bipolar ablation between the left pulmonic cusp and left ventricular outflow tract for left ventricular summit arrhythmias, Heart Rhythm, 10.1016/j.hrthm.2020.04.029, 17:9, (1519-1527), Online publication date: 1-Sep-2020. Pothineni N, Garcia F and Santangeli P (2021) Radiofrequency Ablation Strategies for Intramural Ventricular Arrhythmias, Methodist DeBakey Cardiovascular Journal, 10.14797/PEYF3776, 17:1, (8) Zhou B, Yu J, Ju W, Li X, Zhang F, Chen H, Li M, Gu K, Xie X, Cheng D, Wang X, Wu Y, Zhou J, Zhang B, Kojodjojo P, Cao K, Yang B and Chen M (2022) Bipolar catheter ablation strategies for outflow tract ventricular arrhythmias refractory to unipolar ablation, Journal of Cardiovascular Electrophysiology, 10.1111/jce.15579 March 2020Vol 13, Issue 3 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.119.008165PMID: 32063033 Originally publishedFebruary 16, 2020 Keywordsventricular tachycardiainventionsHis bundlecatheter ablationPDF download Advertisement SubjectsArrhythmiasCatheter Ablation and Implantable Cardioverter-DefibrillatorElectrophysiology
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