Results and limitations of catheter ablation of ventricular tachycardia in non-ischemic cardiomyopathies: endocardial, epicardial and intramural approaches

Authors: Serguladze S.Yu., Pronicheva I.V.

Company: Bakoulev National Medical Research Center for Cardiovascular Surgery, Moscow, 121552, Russian Federation

UDC: 616.124-008.311:615.84
DOI: https://doi.org/10.24022/1810-0694-2021-22-2-139-150

Cite as: Serguladze S.Yu., Pronicheva I.V. Results and limitations of catheter ablation of ventricular tachycardia in non-ischemic cardiomyopathies: endocardial, epicardial and intramural approaches. The Bulletin of Bakoulev Center. Cardiovascular Diseases. 2021; 22 (2): 139–50 (in Russ.). DOI: 10.24022/1810-0694-2021-22-2-139-150

Received / Accepted: 18.03.2021 / 07.04.2021

Keywords: non-ischemic cardiomyopathy ventricular tachycardia electrogram catheter ablation

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Abstract

The ablation of ventricular tachycardia in non-ischemic cardiomyopathy is one of the most challenging procedures in electrophysiology. There are still enormous gaps in our knowledge of the pathophysiology of ventricular tachycardia in non-ischemic cardiomyopathy, and the technology available for ablation of ventricular tachycardia in these patients is far from perfected. The high proportion of epicardial and intramural substrate poses problems for access, which likely accounts for the observed higher rates of arrhythmia recurrence following ablation. In addition, fundamental differences in scar localization, extent, and transmurality which results in variable electrophysiologic properties and less apparent ablation targets, compared to ischaemic cardiomyopathy. Recent evidence has highlighted the better delineation of a diseased myocardium through the incorporation of 3D mapping systems, which can facilitate the identification of critical arrhythmogenic substrates. New technologies and techniques available for ablation of ventricular tachycardia have expanded significantly in recent years, and as a result, the success rates of non-ischemic substrate ablation, given the characteristics of its distribution, also improved. In this review, we address the pathophysiology underlying ventricular tachycardia in non-ischemic cardiomyopathy and its inherent problems associated with electroanatomical characterization of the substrate and subsequent catheter ablation, including the use of new ancillary techniques that are gaining popularity.

References

Charron P., Arad M., Arbustini E., Basso C., Bilinska Z., Elliott P. et al. European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Genetic counselling and testing in cardiomyopathies: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur. Heart J. 2010; 31 (22): 2715–26. DOI: 10.1093/eurheartj/ehq271
Kadish A., Dyer A., Daubert J.P., Quigg R., Estes N.A., Anderson K.P. et al. Defibrillators in Non-Ischemic Cardiomyopathy Treatment Evaluation (DEFINITE) Investigators. Prophylactic defibrillator implantation in patients with nonischemic dilated cardiomyopathy. N. Engl. J. Med. 2004; 350 (21): 2151–8. DOI: 10.1056/NEJMoa033088
Bricen~o D.F., Gupta T., Romero J., Kolte D., Khera S., Villablanca P.A. et al. Catheter ablation of ventricular tachycardia in nonischemic cardiomyopathy: A propensity score-matched analysis of in-hospital outcomes in the United States. J. Cardiovasc. Electrophysiol. 2018; 29 (5): 771–9. DOI: 10.1111/jce.13452
Sacher F., Tedrow U.B., Field M.E., Raymond J.M., Koplan B.A., Epstein L.M., Stevenson W.G. Ventricular tachycardia ablation: evolution of patients and procedures over 8 years. Circ. Arrhythm. Electrophysiol. 2008; 1 (3): 153–61. DOI: 10.1161/CIRCEP.108.76947
Dinov B., Fiedler L., Schönbauer R., Bollmann A., Rolf S., Piorkowski C. et al. Outcomes in catheter ablation of ventricular tachycardia in dilated nonischemic cardiomyopathy compared with ischemic cardiomyopathy: results from the Prospective Heart Centre of Leipzig VT (HELP-VT) Study. Circulation. 2014; 129 (7): 728–36. DOI: 10.1161/CIRCULATIONAHA.113.003063
König S., Ueberham L., Müller-Röthing R., Wiedemann M., Ulbrich M., Sause A. et al. Catheter ablation of ventricular arrhythmias and in-hospital mortality: insights from the german-wide helios hospital network of 5052 cases. Europace. 2020; 22 (1): 100–8. DOI: 10.1093/europace/euz260
Hsia H.H., Xiong N. Mapping and ablation of ventricular arrhythmias in cardiomyopathies. Card. Electrophysiol. Clin. 2019; 11 (4): 635–55. DOI: 10.1016/j.ccep.2019.08.005
Dello Russo A., Casella M., Pieroni M., Pelargonio G., Bartoletti S., Santangeli P. et al. Drug-refractory ventricular tachycardias after myocarditis: endocardial and epicardial radiofrequency catheter ablation. Circ. Arrhythm. Electrophysiol. 2012; 5 (3): 492–8. DOI: 10.1161/CIRCEP.111.965012
Bockeria L.A., Bazaev V.A., Filatov A.G., Kovalev A.S. Case of successful mapping of epicardial surface of the basal part of the left ventricle during ventricular tachyarrhythmia radiofrequency ablation. Annals of Arrhythmology. 2012; 9 (3): 56–60 (in Russ.).
Callans D.J., Ren J.F., Michele J., Marchlinski F.E., Dillon S.M. Electroanatomic left ventricular mapping in the porcine model of healed anterior myocardial infarction. Correlation with intracardiac echocardiography and pathological analysis. Circulation. 1999; 100 (16): 1744–50. DOI: 10.1161/01.cir.100.16.1744
Dickfeld T., Tian J., Ahmad G., Jimenez A., Turgeman A., Kuk R. et al. MRI-guided ventricular tachycardia ablation: integration of late gadolinium-enhanced 3D scar in patients with implantable cardioverterdefibrillators. Circ. Arrhythm. Electrophysiol. 2011; 4 (2): 172–84. DOI: 10.1161/CIRCEP.110.958744
Piers S.R., Tao Q., van Huls van Taxis C.F, Schalij M.J., van der Geest R.J., Zeppenfeld K. Contrast-enhanced MRI-derived scar patterns and associated ventricular tachycardias in nonischemic cardiomyopathy: implications for the ablation strategy. Circ. Arrhythm. Electrophysiol. 2013; 6 (5): 875–83. DOI: 10.1161/CIRCEP.113.000537
Chung F.P., Lin C.Y., Lin Y.J., Chang S.L., Lo L.W., Hu Y.F. et al. Ventricular arrhythmias in nonischemic cardiomyopathy. J. Arrhythm. 2018; 34 (4): 336–46. DOI: 10.1002/joa3.12028
Piers S.R., van Huls van Taxis C.F., Tao Q., van der Geest R.J., Askar S.F., Siebelink H.M. et al. Epicardial substrate mapping for ventricular tachycardia ablation in patients with non-ischaemic cardiomyopathy: a new algorithm to differentiate between scar and viable myocardium developed by simultaneous integration of computed tomography and contrast-enhanced magnetic resonance imaging. Eur. Heart J. 2013; 34 (8): 586–96. DOI: 10.1093/eurheartj/ehs382
Glashan C.A., Androulakis A.F.A., Tao Q., Glashan R.N., Wisse L.J., Ebert M. et al. Whole human heart histology to validate electroanatomical voltage mapping in patients with non-ischaemic cardiomyopathy and ventricular tachycardia. Eur. Heart J. 2018; 39 (31): 2867–75. DOI: 10.1093/eurheartj/ehy168
Nakahara S., Tung R., Ramirez R.J., Michowitz Y., Vaseghi M., Buch E. et al. Characterization of the arrhythmogenic substrate in ischemic and nonischemic cardiomyopathy implications for catheter ablation of hemodynamically unstable ventricular tachycardia. J. Am. Coll. Cardiol. 2010; 55 (21): 2355–65. DOI: 10.1016/j.jacc.2010.01.041
Soejima K., Stevenson W.G., Sapp J.L., Selwyn A.P., Couper G., Epstein L.M. Endocardial and epicardial radiofrequency ablation of ventricular tachycardia associated with dilated cardiomyopathy: the importance of low-voltage scars. J. Am. Coll. Cardiol. 2004; 43 (10): 1834–42. DOI: 10.1016/j.jacc.2004.01.029
Kumar S., Baldinger S.H., Gandjbakhch E., Maury P., Sellal J.M., Androulakis A.F. et al. Long-term arrhythmic and nonarrhythmic outcomes of lamin A/C mutation carriers. J. Am. Coll. Cardiol. 2016; 68 (21): 2299–307. DOI: 10.1016/j.jacc.2016.08.058
Dinov B., Arya A., Schratter A., Schirripa V., Fiedler L., Sommer P. et al. Catheter ablation of ventricular tachycardia and mortality in patients with nonischemic dilated cardiomyopathy: can noninducibility after ablation be a predictor for reduced mortality? Circ. Arrhythm. Electrophysiol. 2015; 8 (3): 598–605. DOI: 10.1161/CIRCEP.114.002295
Oloriz T., Silberbauer J., Maccabelli G., Mizuno H., Baratto F., Kirubakaran S. et al. Catheter ablation of ventricular arrhythmia in nonischemic cardiomyopathy: anteroseptal versus inferolateral scar sub-types. Circ. Arrhythm. Electrophysiol. 2014; 7 (3): 414–23. DOI: 10.1161/CIRCEP.114.001568
Hsia H.H., Callans D.J., Marchlinski F.E.. Characterization of endocardial electrophysiological substrate in patients with nonischemic cardiomyopathy and monomorphic ventricular tachycardia. Circulation. 2003; 108 (6): 704–10. DOI: 10.1161/01.CIR.0000083725.72693.EA
Haqqani H.M., Tschabrunn C.M., Tzou W.S., Dixit S., Cooper J.M., Riley M.P. et al. Isolated septal substrate for ventricular tachycardia in nonischemic dilated cardiomyopathy: incidence, characterization, and implications. Heart Rhythm. 2011; 8 (8): 1169–76. DOI: 10.1016/j.hrthm.2011.03.008
Betensky B.P., Kapa S., Desjardins B., Garcia F.C., Callans D.J., Dixit S. et al. Characterization of transseptal activation during septal pacing: criteria for identification of intramural ventricular tachycardia substrate in nonischemic cardiomyopathy. Circ. Arrhythm. Electrophysiol. 2013; 6 (6): 1123–30. DOI: 10.1161/CIRCEP.113.000682
Kumar S., Barbhaiya C., Nagashima K., Choi E.K., Epstein L.M., John R.M. et al. Ventricular tachycardia in cardiac sarcoidosis: characterization of ventricular substrate and outcomes of catheter ablation. Circ. Arrhythm. Electrophysiol. 2015; 8 (1): 87–93. DOI: 10.1161/CIRCEP.114.002145
Naruse Y., Sekiguchi Y., Nogami A., Okada H., Yamauchi Y., Machino T. et al. Systematic treatment approach to ventricular tachycardia in cardiac sarcoidosis. Circ. Arrhythm. Electrophysiol. 2014; 7 (3): 407–13. DOI: 10.1161/CIRCEP.113.000734
Marchlinski F.E., Zado E., Dixit S., Gerstenfeld E., Callans D.J., Hsia H. et al. Electroanatomic substrate and outcome of catheter ablative therapy for ventricular tachycardia in setting of right ventricular cardiomyopathy. Circulation. 2004; 110 (16): 2293–8. DOI: 10.1161/01.CIR.0000145154.02436.90
Berte B., Sacher F., Cochet H., Mahida S., Yamashita S., Lim H. et al. Postmyocarditis ventricular tachycardia in patients with epicardial-only scar: a specific entity requiring a specific approach. J. Cardiovasc. Electrophysiol. 2015; 26 (1): 42–50. DOI: 10.1111/jce.12555
Maccabelli G., Tsiachris D., Silberbauer J., Esposito A., Bisceglia C., Baratto F. et al. Imaging and epicardial substrate ablation of ventricular tachycardia in patients late after myocarditis. Europace. 2014; 16 (9): 1363–72. DOI: 10.1093/europace/euu017
Sepehrkhouy S., Gho J.M.I.H., van Es R., Harakalova M., de Jonge N., Dooijes D. et al. Distinct fibrosis pattern in desmosomal and phospholamban mutation carriers in hereditary cardiomyopathies. Heart Rhythm. 2017; 14 (7): 1024–32. DOI: 10.1016/j.hrthm. 2017.03.034
Dukkipati S.R., d’Avila A., Soejima K., Bala R., Inada K., Singh S. et al. Long-term outcomes of combined epicardial and endocardial ablation of monomorphic ventricular tachycardia related to hypertrophic cardiomyopathy. Circ. Arrhythm. Electrophysiol. 2011; 4 (2): 185–94. DOI: 10.1161/CIRCEP.110.957290
Kumar S., Romero J., Mehta N.K., Fujii A., Kapur S., Baldinger S.H. et al. Long-term outcomes after catheter ablation of ventricular tachycardia in patients with and without structural heart disease. Heart Rhythm. 2016; 13 (10): 1957–63. DOI: 10.1016/j.hrthm. 2016.07.001
Piers S.R., Leong D.P., van Huls van Taxis C.F., Tayyebi M., Trines S.A., Pijnappels D.A. et al. Outcome of ventricular tachycardia ablation in patients with nonischemic cardiomyopathy: the impact of noninducibility. Circ. Arrhythm. Electrophysiol. 2013; 6 (3): 513–21. DOI: 10.1161/CIRCEP.113.000089
Muser D. Santangeli P., Castro S.A., Pathak R.K., Liang J.J., Hayashi T. et al. Long-term outcome after catheter ablation of ventricular tachycardia in patients with nonischemic dilated cardiomyopathy. Circ. Arrhythm. Electrophysiol. 2016; 9 (10): e004328. DOI: 10.1161/CIRCEP.116.004328
Romero J., Di Biase L., Diaz J.C., Quispe R., Du X., Briceno D. et al. Early versus late referral for catheter ablation of ventricular tachycardia in patients with structural heart disease: a systematic review and meta-analysis of clinical outcomes. JACC Clin. Electrophysiol. 2018; 4 (3): 374–82. DOI: 10.1016/j.jacep.2017.12.008
Romero J., Cerrud-Rodriguez R.C., Di Biase L., Diaz J.C., Alviz I., Grupposo V. et al. Combined endocardial-epicardial versus endocardial catheter ablation alone for ventricular tachycardia in structural heart disease: a systematic review and meta-analysis. JACC Clin. Electrophysiol. 2019; 5 (1): 13–24. DOI: 10.1016/j.jacep.2018.08.010
Vaseghi M., Hu T.Y., Tung R., Vergara P., Frankel D.S., Di Biase L. et al. Outcomes of catheter ablation of ventricular tachycardia based on etiology in nonischemic heart disease: an international ventricular tachycardia ablation center collaborative study. JACC Clin. Electrophysiol. 2018; 4 (9): 1141–50. DOI: 10.1016/j.jacep. 2018.05.00
Kumar S., Tedrow U.B., Stevenson W.G. Adjunctive interventional techniques when percutaneous catheter ablation for drug refractory ventricular arrhythmias fail: a contemporary review. Circ. Arrhythm. Electrophysiol. 2017; 10 (2): e003676. DOI: 10.1161/CIRCEP.116.003676
Nagashima K., Watanabe I., Okumura Y., Ohkubo K., Kofune M., Ohya T. et al. Lesion formation by ventricular septal ablation with irrigated electrodes: comparison of bipolar and sequential unipolar ablation. Circ. J. 2011; 75 (3): 565–70. DOI: 10.1253/circj.cj-10-0870
Sivagangabalan G., Barry M.A., Huang K., Lu J., Pouliopoulos J., Thomas S.P. et al. Bipolar ablation of the interventricular septum is more efficient at creating a transmural line than sequential unipolar ablation. Pacing Clin. Electrophysiol. 2010; 33 (1): 16–26. DOI: 10.1111/j.1540-8159.2009.02602.x
Koruth J.S., Dukkipati S., Miller M.A., Neuzil P., d’Avila A., Reddy V.Y. Bipolar irrigated radiofrequency ablation: a therapeutic option for refractory intramural atrial and ventricular tachycardia circuits. Heart Rhythm. 2012; 9 (12): 1932–41. DOI: 10.1016/j.hrthm. 2012.08.001
Yamada T., Maddox W.R., McElderry H.T., Doppalapudi H., Plumb V.J., Kay G.N. Radiofrequency catheter ablation of idiopathic ventricular arrhythmias originating from intramural foci in the left ventricular outflow tract: efficacy of sequential versus simultaneous unipolar catheter ablation. Circ. Arrhythm. Electrophysiol. 2015; 8 (2): 344–52. DOI: 10.1161/CIRCEP.114.002259150
Nguyen D.T., Gerstenfeld E.P., Tzou W.S., Jurgens P.T., Zheng L., Schuller J. et al. Radiofrequency ablation using an open irrigated electrode cooled with half-normal saline. JACC Clin. Electrophysiol. 2017; 3 (10): 1103–10. DOI: 10.1016/j.jacep.2017.03.006
Nguyen D.T., Tzou W.S., Sandhu A., Gianni C., Anter E., Tung R. et al. Prospective multicenter experience with cooled radiofrequency ablation using high impedance irrigant to target deep myocardial substrate refractory to standard ablation. JACC Clin. Electrophysiol. 2018; 4 (9): 1176–85. DOI: 10.1016/j.jacep.2018.06.021
AbdelWahab A., Stevenson W., Thompson K., Parkash R., Gray C., Gardner M. et al. Intramural ventricular recording and pacing in patients with refractory ventricular tachycardia: initial findings and feasibility with a retractable needle catheter. Circ. Arrhythm. Electrophysiol. 2015; 8 (5): 1181–8. DOI: 10.1161/CIRCEP.115.002940
Di Biase L., Santangeli P., Burkhardt D.J., Bai R., Mohanty P., Carbucicchio C. et al. Endo-epicardial homogenization of the scar versus limited substrate ablation for the treatment of electrical storms in patients with ischemic cardiomyopathy. J. Am. Coll. Cardiol. 2012; 60 (2): 132–41. DOI: 10.1016/j.jacc.2012.03.044
Gökogˇlan Y., Mohanty S., Gianni C., Santangeli P., Trivedi C., Günes M.F. et al. Scar homogenization versus limited-substrate ablation in patients with nonischemic cardiomyopathy and ventricular tachycardia. J. Am. Coll. Cardiol. 2016; 68 (18): 1990–8. DOI: 10.1016/j.jacc.2016.08.033
Sosa E., Scanavacca M., d’Avila A., Pilleggi F. A new technique to perform epicardial mapping in the electrophysiology laboratory. J. Cardiovasc. Electrophysiol. 1996; 7 (6): 531–6. DOI: 10.1111/j.1540-8167.1996.tb00559.x 48. Kumar S., Bazaz R., Barbhaiya C.R., Enriquez A.D., Helmbold A.F., Chinitz J.S. et al. "Needle-in-needle" epicardial access: Preliminary observations with a modified technique for facilitating epicardial interventional procedures. Heart Rhythm. 2015; 12 (7): 1691–7. DOI: 10.1016/j.hrthm.2015.03.045
Gunda S., Reddy M., Pillarisetti J., Atoui M., Badhwar N., Swarup V. et al. Differences in complication rates between large bore needle and a long micropuncture needle during epicardial access: time to change clinical practice? Circ. Arrhythm. Electrophysiol. 2015; 8 (4): 890–5. DOI: 10.1161/CIRCEP.115.002921
Romero J., Shivkumar K., Di Biase L., Avendano R., Anderson R.D., Natale A. et al. Mastering the art of epicardial access in cardiac electrophysiology. Heart Rhythm. 2019; 16 (11): 1738–49. DOI: 10.1016/j.hrthm.2019.04.038
Desjardins B., Morady F., Bogun F. Effect of epicardial fat on electroanatomical mapping and epicardial catheter ablation. J. Am. Coll. Cardiol. 2010; 56 (16): 1320–7. DOI: 10.1016/j.jacc.2010.04.054
Sacher F., Roberts-Thomson K., Maury P., Tedrow U., Nault I., Steven D. et al. Epicardial ventricular tachycardia ablation a multicenter safety study. J. Am. Coll. Cardiol. 2010; 55 (21): 2366–72. DOI: 10.1016/j.jacc. 2009.10.084 53. Sánchez-Quintana D., Ho S.Y., Climent V., Murillo M., Cabrera J.A. Anatomic evaluation of the left phrenic nerve relevant to epicardial and endocardial catheter ablation: implications for phrenic nerve injury. Heart Rhythm. 2009; 6 (6): 764–8. DOI: 10.1016/j.hrthm.2009.02.029
Okubo K., Trevisi N., Foppoli L., Bisceglia C., Baratto F., Gigli L. et al. Phrenic nerve limitation during epicardial catheter ablation of ventricular tachycardia. JACC Clin. Electrophysiol. 2019; 5 (1): 81–90. DOI: 10.1016/j.jacep.2018.08.011
D’Avila A., Neuzil P., Thiagalingam A., Gutierrez P., Aleong R., Ruskin J.N. et al. Experimental efficacy of pericardial instillation of anti-inflammatory agents during percutaneous epicardial catheter ablation to prevent postprocedure pericarditis. J. Cardiovasc. Electrophysiol. 2007; 18 (11): 1178–83. DOI: 10.1111/j.1540-8167.2007.00945.x

About the authors

Sergey Yu. Serguladze, Dr. Med. Sc., Professor, Head of Department, Cardiac Surgeon, ORCID
Irina V. Pronicheva, Cand. Med. Sc., Senior Researcher, Cardiologist, ORCID

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Chief Editor

Elena Z. Golukhova, MD, PhD, DSc, Professor, Academician of Russian Academy of Sciences, Director of Bakoulev National Medical Research Center for Cardiovascular Surgery

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