KEY TEACHING POINTS
•
The mechanism of ventricular tachycardia in patients with structural heart disease
is most frequently macroreentrant. However, many patients with a myocardial scar have
focal mechanisms and a careful analysis of entrainment can be helpful in determining
the most desirable timing of the successful ablation site.
•
Epicardial ablation is frequently limited by close proximity to coronary arteries
and epicardial adipose tissue. Alternative strategies and technologies are needed
to address these substrate locations.
•
Prolonged high-power ablation from the endocardium may create a deeper lesion to target
remote locations across the myocardial wall, and early termination should not be expected
during radiofrequency delivery in such cases. Optimal biophysical parameters require
further clarification to maintain safety.
Introduction
Epicardial mapping and ablation have emerged in the last decade as a strategy to increase
the success rate for the eradication of arrhythmogenic circuits in complex scar substrates.
It has been established that epicardial mapping and ablation are generally required
for some arrhythmic substrates such as in arrhythmogenic right ventricular dysplasia,
Brugada syndrome, Chagas cardiomyopathy, nonischemic cardiomyopathy (NICM), and to
a lesser extent in ischemic cardiomyopathy (ICM). Ablation in patients with NICM has
been shown to be inferior to that in patients with ICM, as scar patterns are more
variable with epicardial and intramural locations. In addition, the arrhythmic mechanism
of ventricular tachycardia (VT) in patients with NICM is not always macroreentrant,
as focal and automatic sites of origin have been reported in up to 20% of patients.
Furthermore, delivering radiofrequency (RF) lesions in the epicardial space might
be limited because of significant epicardial fat as well as close proximity to phrenic
nerves and coronary vasculature.
In this report, we present a case of a patient with NICM and VT, in whom (1) a microreentrant
mechanism was demonstrated by activation and entrainment mapping and (2) successful
elimination of an epicardial circuit was achieved with ablation through normal endocardial
tissue because of proximity of the epicardial site of origin to a coronary artery.
Case report
This is the case report of a 63-year-old man with NICM diagnosed 8 years before admission,
presumed to be secondary to viral myocarditis. The patient had a left ventricular
ejection fraction (LVEF) of 20%, had New York Heart Association class III symptoms,
and had received a cardiac resynchronization therapy-defibrillator for the primary
prevention of sudden cardiac death. The patient was brought to the emergency department
after collapsing at home, with bystander cardiopulmonary resuscitation initiated.
He was found to be in slow VT at 134 beats/min (cycle length 447 ms), which was below
the detection zone for his implantable cardioverter-defibrillator, and received therapy
using an automated external defibrillator. In the emergency department, he had several
similar episodes, resulting in hypotension and loss of consciousness. He required
cardiopulmonary resuscitation and automated external defibrillator shocks on 2 more
occasions. VT recurred despite intravenous amiodarone and lidocaine.
A 12-lead electrocardiogram revealed VT with a right bundle branch block morphology,
positive concordance, and right inferior axis. A transthoracic echocardiogram showed
dilated left ventricular (LV) left ventricular internal dimension, diastole (LVIDd
(2D) 7.12 cm) with normal wall thickness (interventricular septum, diastole IVSd (2D)
0.89 cm; left ventricular posterior wall, diastole LVPWd (2D) 1.01 cm), severe LV
diastolic dysfunction (grade III, restrictive physiology), as well as severe LV systolic
dysfunction (LVEF 23%). Subsequently, the patient underwent emergent coronary angiography,
which showed normal coronary arteries. Positron emission tomography with 18F-fluorodeoxyglucose
was negative for cardiac sarcoidosis.
A semi-emergent invasive electrophysiology study for ablation was performed. Clinical
VT was induced with triple extrastimuli (500/320/350) using noninvasive programmed
stimulation at the beginning of the procedure (tachycardia cycle length 470–500 ms,
right inferior axis, and right bundle branch block pattern with R waves across the
precordium). The QRS width during VT was 290 ms, with a pseudo-delta wave of 105 ms,
an intrinsicoid deflection time of 174 ms, and a maximum deflection index of 60%—all
suggestive of an epicardial site of origin. The coronary sinus could not be cannulated
past the LV pacing lead because of narrow and tortuous anatomy. A 2-mm spacing decapolar
catheter (CARTO 3, Biosense Webster Inc, Diamond Bar, CA) was used to map the endocardium
and epicardium. Subxiphoid epicardial access was obtained using a Tuohy epidural needle.
After epicardial access, an LV and right ventricular (RV) epicardial voltage map (539
points) was obtained, which showed a small area of scar in the LV basal anterolateral
wall (Figure 1). Intravenous heparin was administered for a retrograde aortic approach;
a high-density endocardial LV electroanatomic map (282 points) was created, which
revealed no endocardial scar (Figure 1). A small perivalvular scar was seen on the
basal anterolateral region of the epicardium with split and fractionated electrograms.
Activation mapping revealed the earliest site of activation in the basal anterior
epicardial LV wall (−50 ms) (Figure 1). The best pace maps of clinical VT were noted
in close proximity to the basal anterolateral LV scar. Concealed entrainment was also
observed in this area (Figure 1).
In order to assess the mechanism of tachycardia, entrainment mapping was performed
from the RV apex. There was evidence of progressive fusion from the endocardial RV
apex with pacing at different rates (Figure 2). The QRS width was narrower with lower
limb lead amplitudes during overdrive pacing at 430 ms compared to 390 ms. This is
highly suggestive of the presence of both constant and progressive fusion. The earliest
site was mapped to the epicardium with a focal propagation (Online Supplemental Video
1). It was felt that the mechanism of arrhythmia was microreentrant, and therefore,
unmapped sites with mid-diastolic activation were unlikely to be found. Left coronary
angiography revealed that this site was close to the second diagonal artery (Figure
1). The ablation catheter (4-mm ThermoCool DF) was positioned endocardially directly
opposite to the earliest epicardial activation site, where activation was seen just
after the QRS onset (Figure 1). Of note, entrainment mapping from the endocardium
revealed overt fusion. Ablation was performed in the power mode setting at 50 W (temperature
<42°C). Termination was noted at 24 seconds during the first lesion (90 seconds),
but VT was reinducible and a second application (90 seconds) was delivered where termination
was observed again at 26 seconds (Figure 3). Another consolidation RF lesion was delivered
with a total RF time of 4 minutes. Biophysical changes with significant impedance
drops (>30 Ω) were observed during ablation 1 and 2. No steam pops were observed.
VT was no longer inducible with triple extrastimuli in the RV and epicardial/endocardial
LV at different sites. Antiarrhythmic agents were discontinued, and the patient has
remained free from VT recurrence at 10 months of follow-up.
Discussion
We present this case report to highlight the following:
1.
Arrhythmias in scar-related cardiomyopathy should not be assumed to be macroreentrant.
2.
Coronary arteries remain a significant anatomical limitation in patients with NICM
and arrhythmias arising from the LV summit.
3.
Prolonged endocardial high-power RF applications can be an effective therapeutic alternative
for eliminating remote sites of origin.
Overall, it is estimated that VT ablation requires epicardial ablation in 13% of patients
with a risk of 5% and 2% of acute and delayed major complications related to epicardial
access, respectively.
1
RF ablation in the epicardial space for basal anterolateral substrates is frequently
limited by a variety of factors including thick epicardial fat, close proximity to
the phrenic nerve, and coronary vasculature as well as inability to deliver high power
because of poor cooling.
Studies recommend avoidance of RF ablation within 5 mm of coronary arteries, as injury
has been reported in animal models and human cases.
2
As in the case presented in this report, our target was in the vicinity of a medium
caliber diagonal artery. The options for RF ablation at this point were limited, since
the coronary sinus could not be cannulated distally (LV lead and narrow lumen). Options
included a hybrid procedure using a limited lateral thoracotomy with direct visualization,
3
sacrificing the artery in a patient with already severely impaired LVEF, or implementing
more aggressive measures such as bilateral cervicothoracic sympathectomy (ie, resection
of the lower half of the stellate ganglion and the first 4 thoracic ganglia via thoracoscopy)
and renal artery sympathetic denervation.4, 5 Cryotherapy might be useful for epicardial
VT ablation to decrease the risk of coronary artery injury and, in theory, to improve
lesion depth.
6
The coronary venous system through the distal great cardiac vein and the anterior
interventricular vein course in the basal part of the epicardial surface of the LV
has been shown to be a successful ablation site in patients with premature ventricular
contractions and VT. It is tempting to hypothesize that some epicardial VTs may arise
close to the coronary venous system, which may therefore be a suitable site to map
and ablate these arrhythmias. Application of RF energy within the coronary venous
system raises concern for thermal injury to the vein itself or to the neighboring
coronary arteries, and isolated reports have documented the risk of venous stenosis,
vein rupture, thrombosis, and even acute coronary occlusion.
7
Similarly, the left phrenic nerve may be vulnerable when ablating in the vicinity
of the obtuse marginal vein or the great cardiac vein.
8
Irrigated catheters have been demonstrated to allow more power to be delivered before
temperatures reach a point in which thrombus/clots are formed. This report describes
the feasibility of transmural ablation from the endocardium for epicardial circuits
with longer RF applications at higher power (Online Supplemental Video 2). Yokokawa
et al
9
have described ablation of epicardial VT from nonepicardial sites, where 3 patients
were described to have success with endocardial ablation alone. Komatsu et al
10
recently evaluated the feasibility and safety of epicardial substrate elimination
by delivering endocardial RF energy in patients with scar-related VT, where endocardial
ablation could abolish all epicardial local abnormal ventricular activity (LAVA) in
4 patients with ICM and 2 patients with arrhythmogenic right ventricular cardiomyopathy
(ARVC) whereas all patients with NICM required epicardial ablation. Endocardial ablation
was able to eliminate epicardial LAVA at least partially in 15 patients with ICM (83%),
11 with arrhythmogenic right ventricular cardiomyopathy (ARVC) (73%), and 2 with NICM
(13%), contributing to a significant reduction in epicardial RF applications. ADDIN
EN.CITE ADDIN EN.CITE.DATA 10 Prolonged endocardial ablation with an impact on epicardial
substrate may be one reason that the need for epicardial ablation is currently underestimated.
Although standard RF applications have been shown to reach a maximum lesion size between
20 and 60 seconds, irrigated ablation has the potential to create deeper lesions with
longer duration applications. Nakagawa et al
11
demonstrated a continuing steep rise in tissue temperature at 7-mm depth at 60 seconds
in a canine thigh muscle preparation. Furthermore, extending the duration of RF delivery
may overcome intermittent tissue contact, as Olson et al
12
demonstrated comparable lesion size between constant contact at 60 seconds and intermittent
contact lesions at 90 seconds. Additional studies are required to understand the maximum
effective duration of irrigated ablation.
The theoretical advantage of prolonged high-power ablation must be weighed against
the potential risks of char or thrombus formation and steam pops. In a retrospective
analysis of RF applications, Seiler et al
13
demonstrated that 80% of steam pops were associated with an impedance drop of >18
Ω. However, there was significant overlap between those with and without steam pops
(22 ± 7 Ω vs 18 ± 8 Ω) and 31% of the lesions that did not result in steam pops had
an impedance of >18 Ω. Although tissue temperature is not always correlated with the
catheter-tissue interface temperature via irrigated technology, it is our institutional
practice to set a maximum catheter temperature to 45°C and carefully observe for sudden
increases and decreases in impedance. In this particular case, we did not observe
a specific impedance drop cutoff, as this was a “bailout” option and this strategy
should be reserved for cases that fail traditional approaches. Further studies to
characterize and guide long-duration, high-powered lesions in animal models may be
helpful to optimize safety and efficacy of this strategy.