Publications by authors named "Jackson Liang"

184 Publications

Coronary Arterial Vasospasm: A Rare Complication of Vein of Marshall Ethanol Infusion for Atrial Fibrillation.

JACC Case Rep 2020 Sep 15;2(11):1766-1770. Epub 2020 Sep 15.

Arrhythmia Advanced Therapy Center, AOI Universal Hospital, Kanagawa, Japan.

A 75-year-old man was admitted for repeat ablation of atrial fibrillation. At 30 min after infusion of 3.5 ml of ethanol into the vein of Marshall, inferior ST-segment elevation with coronary arterial vasospasm was observed. This is the first report of coronary vasospasm after chemical ablation of the vein of Marshall. ().
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jaccas.2020.06.046DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8312119PMC
September 2020

Substrate Characterization and Outcomes of Ventricular Tachycardia Ablation in Titin Cardiomyopathy: A Multicenter Study.

Circ Arrhythm Electrophysiol 2021 Jul 28. Epub 2021 Jul 28.

Section of Cardiac Electrophysiology, Hospital of the University of Pennsylvania, Philadelphia, PA.

- Truncating variants of the titin gene (TTNtv) are a leading cause of dilated cardiomyopathy (DCM) and have been associated with an increased risk of ventricular arrhythmias. This study evaluated the substrate distribution and the acute and long-term outcomes of patients with TTN-related cardiomyopathy undergoing ventricular tachycardia (VT) ablation. - This multicenter registry included 15 patients with DCM (age 59±11 years, 93% male, ejection fraction 30±12%) and genotypically confirmed TTNtvs who underwent VT ablation between July 2014 and July 2020. - All patients presented with sustained monomorphic VT, including electrical storm in 4 of them. A median of 2 VTs per patient were induced during the procedure (cycle-length 318±68 ms) and the predominant morphologies were left bundle branch block with inferior axis (39%) and right bundle branch block with inferior axis (29%). A complete map of the left ventricle (LV) was created in 12 patients and showed voltage abnormalities mainly at the periaortic (92%) and basal septal region (58%). A preprocedural cardiac magnetic resonance imaging was available in 13 patients and in 11 there was evidence of LV delayed gadolinium enhancement, with predominantly midmyocardial distribution. Sequential ablation from both sides of the septum was required in 47% of patients to target septal intramural substrate and epicardial ablation was performed in 20%. At the end of the procedure, the clinical VT was noninducible in all patients, while in 3 cases a non-clinical VT was still inducible. After a follow-up of 26.5±23.0 months, 53% of patients experienced VT recurrence, 20% received transplant or mechanical circulatory support and 7% died. - The arrhythmogenic substrate in TTN-related cardiomyopathy involves the basal septal and perivalvular regions. Long-term outcomes of catheter ablation are modest, with high recurrence rate, likely related to an intramural location of VT circuits.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCEP.121.010006DOI Listing
July 2021

Pacemaker malfunction? What is the mechanism?

J Electrocardiol 2021 Jul 16;68:34-36. Epub 2021 Jul 16.

Section of Electrophysiology, University of Michigan, MI, USA.

Pacing artifacts on ECG are commonly encountered in clinical practice. We present a case of an external interference from a chronic retained abdominal generator leading to an ECG manifestation of atria lead malfunction. Careful attention to history and physical examination can identify sources of external pacemaker artifact.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jelectrocard.2021.07.002DOI Listing
July 2021

Diagnosis, significance, and management of ventricular thrombi in patients referred for VT ablation.

J Cardiovasc Electrophysiol 2021 Jul 16. Epub 2021 Jul 16.

Division of Cardiovascular Medicine and Radiology, University of Michigan, Ann Arbor, Michigan, USA.

Introduction: In patients with structural heart disease presenting with ventricular tachycardia (VT), detection of ventricular thrombi and subsequent management can be challenging. This study aimed to assess the value of multimodality imaging with cardiac magnetic resonance imaging (CMR), contrast-enhanced transthoracic echocardiography (TTE), and computed tomography (CT) for thrombus detection as well as a management algorithm geared towards anticoagulation and deferred ablation for patients referred for VT ablation.

Methods And Results: A total of 154 consecutive patients referred for VT ablation underwent preprocedural multimodality imaging with CMR, CT, and TTE. In 9 patients (6%) a new ventricular thrombus was detected and anticoagulation was initiated. Thrombi were detected by CMR in nine patients, by CT in seven patients, and by TTE in two patients. Five patients eventually underwent endocardial VT ablation procedures 6.0 ± 2.0 months after initiation of anticoagulation with one patient also requiring an epicardial approach. Two patients died while on anticoagulation, unrelated to ventricular arrhythmia. Four of five patients were rendered non-inducible and no testing was performed in 1/5 patients. Areas containing left ventricular thrombi were non-excitable with pacing. Six of thirty-two inducible VTs were mapped in close vicinity of ventricular thrombi. No clinical embolic events occurred during the ablation procedures.

Conclusions: Ventricular thrombus was detected in 6% of consecutive patients with structural heart disease undergoing VT ablation. CMR was the most sensitive modality, while contrast-enhanced TTE failed to detect the majority of thrombi. Anticoagulation followed by ablation can be safely and successfully performed in patients with ventricular thrombi.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jce.15177DOI Listing
July 2021

Cardiac Magnetic Resonance Imaging and Ventricular Tachycardias Involving the Sinuses of Valsalva in Patients With Nonischemic Cardiomyopathy.

JACC Clin Electrophysiol 2021 Jun 22. Epub 2021 Jun 22.

Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA. Electronic address:

Objectives: The goal of this study was to investigate the relationship between cardiac scar on late gadolinium enhancement cardiac resonance imaging (LGE-CMR) and the presence of ventricular tachycardia (VT) ablation target sites within the sinuses of Valsalva (SV).

Background: Patients with idiopathic dilated cardiomyopathy (IDCM) often have scarring involving the basal myocardium, including the SV, allowing targeting of VTs from within the SV.

Methods: Forty-three consecutive patients with IDCM underwent a VT ablation procedure with pre-procedure LGE-CMR. Retrospectively, scar characteristics were compared between patients with and without VT target sites in the SV. The ratio between SV-related scarring and the total cardiac scarring was defined as the SV scar index: SV-related scarring/total cardiac scarring.

Results: VT target sites were identified in the SV in 22 (51%) of 43 patients. LGE-CMR identified peri-aortic scarring involving the SV in 34 patients (79%). Scarring extended to the septum in 26 patients, involved the lateral basal wall in 4, and both areas in 13 patients. Scar volume within the SV was larger in patients with SV-VT targets (1.7 ± 0.9 cm vs. 0.7 ± 0.6 cm; p < 0.0001) compared with other patients. A cutoff scar volume identifying SV-VT targets was 1.23 cm in the short-axis view (area under the curve 0.82; sensitivity 0.64; specificity 0.91). The SV scar index was significantly greater in patients who had SV-VT target sites (0.33 ± 0.2 vs. 0.09 ± 0.09; p < 0.0001).

Conclusions: Patients with IDCM undergoing ablation of VT often have peri-aortic scarring visualized on LGE-CMR. Both the presence and the extent of scarring adjacent to the aortic annulus are associated with the presence of VT target sites within the SV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2021.03.017DOI Listing
June 2021

Coronary Venous Mapping and Catheter Ablation for Ventricular Arrhythmias.

Methodist Debakey Cardiovasc J 2021 Apr 25;17(1):13-18. Epub 2021 Mar 25.

University of Michigan, Ann Arbor, Michigan.

Catheter ablation is an effective treatment method for ventricular arrhythmias (VAs). These arrhythmias can often be mapped and targeted with ablation from the left and right ventricular endocardium. However, in some situations the VA site of origin or substrate may be intramural or epicardial in nature. In these cases, the coronary venous system (CVS) provides an effective vantage point for mapping and ablation. This review highlights situations in which CVS mapping may be helpful and discusses techniques for CVS mapping and ablation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.14797/HUZR1007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8158455PMC
April 2021

Double ProGlide preclose technique for vascular access closure after leadless pacemaker implantation.

J Interv Card Electrophysiol 2021 May 24. Epub 2021 May 24.

Division of Cardiovascular Medicine, Cardiac Arrhythmia Service, University of Michigan, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA.

Purpose: The use of vascular closure devices in patients receiving the Micra leadless pacemaker may shorten time to ambulation, facilitate same-day discharge, and reduce risk of venous thrombosis associated with manual hemostasis. We sought evaluate the feasibility of double Perclose ProGlide (Abbott, CA) preclosure for access site hemostasis after leadless pacemaker implant.

Methods: Patients with leadless pacemaker implant and double preclosure for access hemostasis from 2020 to 2021 were reviewed for complications requiring increase of flat time or transfusion, incidence of venous thromboembolism, and hemoglobin decrement. Two ProGlide devices were deployed with a double preclose technique after ultrasound guided wire access. Patients were instructed to lay flat for 2-4 h and were allowed to ambulate after.

Results: A total of 36 patients (age 74.5 ± 15.1 years, BMI 27.9 ± 9.0 kg/m, 30% female gender) were included with 6 having prior venous thromboembolism, 21 with AF, and 15 with chronic kidney disease. Anticoagulation was continued in 14 (8 direct oral anticoagulants, 2 warfarin, 4 intravenous heparin) and interrupted in 5. In one patient, minor rebleeding prompted 10 min of manual pressure and extension of flat time by 2 h. No patients had other complications, prolongation of flat time, transfusion, delayed re-initiation of anticoagulation, or venous thromboembolism within 30 days.

Conclusions: The double preclose technique is a safe and feasible method of achieving access site hemostasis and facilitates early ambulation after leadless pacemaker implantation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10840-021-01009-8DOI Listing
May 2021

Gross Anatomic and Histologic Tissue Evaluation After Steam Pop During Radiofrequency Ablation of Ventricular Tachycardia.

JACC Clin Electrophysiol 2021 04;7(4):561-562

Cardiology Division, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2021.01.004DOI Listing
April 2021

Comparative Efficacy of Dofetilide Versus Amiodarone in Patients With Atrial Fibrillation.

JACC Clin Electrophysiol 2021 05 31;7(5):642-648. Epub 2021 Mar 31.

Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA. Electronic address:

Objectives: The study's goal was to compare the efficacy and safety of dofetilide (DOF) versus amiodarone (AMIO) in patients with atrial fibrillation (AF).

Background: Comparative efficacy of DOF versus AMIO in patients with AF has not been well established. In addition, proarrhythmia has been a concern with DOF therapy.

Methods: Rhythm control was attempted by using DOF in 657 consecutive patients (mean age 72 ± 9 years; 35% women) with AF (n = 528) or atrial flutter and AF (n = 129) between January 2014 and December 2018.

Results: DOF was successfully initiated in 573 (87%) of 657 patients, including 510 (89%) with persistent AF and 63 (11%) with paroxysmal AF. During a mean follow-up of 19 ± 7 months, sinus rhythm was maintained in 361 (63%) of the 573 DOF-treated patients. At 12 months, patients on DOF had a similar likelihood of experiencing recurrent atrial arrhythmias compared with the 2,476 consecutive patients treated with AMIO for rhythm control during the study period (37% vs. 39%; p = 0.56). The efficacy of DOF and AMIO was also similar in specific subgroups of patients, including patients >75 years of age, with a low left ventricular ejection fraction, obesity, renal insufficiency, and prior catheter ablation for AF. Among patients with atypical atrial flutter, likelihood of recurrent atrial flutter was similar between the DOF (43 of 108 [40%]) and AMIO (211 of 555 [38%]; p = 0.69) groups.

Conclusions: When properly initiated and monitored, DOF has efficacy comparable to that of amiodarone for rhythm control in patients with AF.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2020.11.027DOI Listing
May 2021

Periprocedural Acute Kidney Injury in Patients With Structural Heart Disease Undergoing Catheter Ablation of VT.

JACC Clin Electrophysiol 2021 02 28;7(2):174-186. Epub 2020 Oct 28.

Electrophysiology Section, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. Electronic address:

Objectives: This study sought to examine the impact of periprocedural acute kidney injury (AKI) in scar-related ventricular tachycardia (VT) patients undergoing radiofrequency catheter ablation (RFCA) on short- and long-term outcomes.

Background: The clinical significance of periprocedural AKI in patients with scar-related VT undergoing RFCA has not been previously investigated.

Methods: This study included 317 consecutive patients with scar-related VT undergoing RFCA (age: 64 ± 13 years, mean left ventricular ejection fraction: 33 ± 13%, 55% ischemic cardiomyopathy). Periprocedural AKI was defined as an absolute increase in creatinine of ≥0.3 mg/dl over 48 h or an increase of >1.5× the baseline values within 1 week post-procedure.

Results: Periprocedural AKI occurred in 31 patients (10%). Independent predictors of AKI included chronic kidney disease (odds ratio [OR]: 3.43; 95% confidence interval [CI]: 1.48 to 7.96; p = 0.004), atrial fibrillation (OR: 2.42; 95% CI: 1.01 to 5.78; p = 0.047), and peri-procedural acute hemodynamic decompensation (OR: 3.98; 95% CI: 1.17 to 13.52; p = 0.003). After a median follow-up of 39 months (interquartile range: 6 to 65 months), 95 patients (30%) died. Periprocedural AKI was associated with increased risk of early mortality (within 30 days; hazard ratio [HR]: 9.91; 95% CI: 2.87 to 34.22; p < 0.001) and late mortality (within 1 year) (HR: 4.57; 95% CI: 2.08 to 10.05; p < 0.001). After multivariable adjustment, AKI remained independently associated with increased risk of early and late mortality (HR: 4.49; 95% CI: 1.1 to 18.36; p = 0.04, and HR: 3.28; 95% CI: 1.43 to 7.49; p = 0.005, respectively).

Conclusions: Periprocedural AKI occurs in 10% of patients undergoing RFCA of scar-related VT and is strongly associated with increased risk of early and late post-procedural mortality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2020.08.018DOI Listing
February 2021

Effect of metformin on outcomes of catheter ablation for atrial fibrillation.

J Cardiovasc Electrophysiol 2021 May 2;32(5):1232-1239. Epub 2021 Mar 2.

Cardiac Arrhythmia Service, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA.

Background: Diabetes mellitus (DM) is a risk factor for atrial fibrillation (AF). The effect of antidiabetic medications on AF or the outcomes of catheter ablation (CA) has not been well described. We sought to determine whether metformin treatment is associated with a lower risk of atrial arrhythmias after CA in patients with DM and AF.

Methods And Results: A first CA was performed in 271 consecutive patients with DM and AF (age: 65 ± 9 years, women: 34%; and paroxysmal AF: 51%). At a median of 13 months after CA (interquartile range: 6-30), 100/182 patients (55%) treated with metformin remained in sinus rhythm without antiarrhythmic drug therapy, compared with 36/89 patients (40%) not receiving metformin (p = .03). There was a significant association between metformin therapy and freedom from recurrent atrial arrhythmias after CA in multivariable Cox hazards models (hazard ratio [HR]: 0.66; ±95% confidence interval [CI]: 0.44-0.98; p = .04) that adjusted for age, sex, body mass index, AF type (paroxysmal vs. nonparoxysmal), antiarrhythmic medication, obstructive sleep apnea, chronic kidney disease, coronary artery disease, left ventricular ejection fraction, and left atrial diameter. A Cox model that also incorporated other antidiabetic agents and fasting blood glucose demonstrated a similar reduction in the risk of recurrent atrial arrhythmias with metformin treatment (HR: 0.63; ±95% CI: 0.42-0.96; p = .03).

Conclusions: In patients with DM, treatment with metformin appears to be independently associated with a significant reduction in the risk of recurrent atrial arrhythmias after CA for AF. Whether this effect is due to glycemic control or pleiotropic effects on electroanatomical mechanisms of AF remains to be determined.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jce.14954DOI Listing
May 2021

Stroke, Timing of Atrial Fibrillation Diagnosis, and Risk of Death.

Neurology 2021 03 3;96(12):e1655-e1662. Epub 2021 Feb 3.

From the Division of Cardiovascular Medicine, Department of Medicine (A.B., Y.B., M.C.H., J.A., D.J.C., N.C., S.D., A.E.E., D.S.F., F.C.G., R.K., J.J.L., D.L., S.N., M.P.R., P.S., R.D.S., G.E.S., F.M., R.D.), and Department of Neurology (S.R.M., S.E.K.), Perelman School of Medicine at the University of Pennsylvania School of Medicine, Philadelphia; Department of Biostatistics (R.K.), University of Washington, Seattle; and Division of Cardiology (P.J.P.), St. Vincent Medical Group, Indianapolis, IN.

Objective: To evaluate the prognosis of patients with ischemic stroke according to the timing of an atrial fibrillation (AF) diagnosis, we created an inception cohort of incident stroke events and compared the risk of death between patients with stroke with (1) sinus rhythm, (2) known AF (KAF), and (3) AF diagnosed after stroke (AFDAS).

Methods: We used the Penn AF Free study to create an inception cohort of patients with incident stroke. Mortality events were identified after linkage with the National Death Index through June 30, 2017. We also evaluated initiation of anticoagulants and antiplatelets across the study duration. Cox proportional hazards models evaluated associations between stroke subtypes and death.

Results: We identified 1,489 individuals who developed an incident ischemic stroke event: 985 did not develop AF at any point during the study period, 215 had KAF before stroke, 160 had AF detected ≤6 months after stroke, and 129 had AF detected >6 months after stroke. After a median follow-up of 4.9 years (interquartile range 1.9-6.8), 686 deaths occurred. The annualized mortality rate was 8.8% in the stroke, no AF group; 12.2% in the KAF group; 15.8% in the AFDAS ≤6 months group; and 12.7% in the AFDAS >6 months group. Patients in the AFDAS ≤6 months group had the highest independent risk of all-cause mortality even after multivariable adjustment for demographics, clinical risk factors, and the use of antithrombotic therapies (hazard ratio 1.62 [1.22-2.14]). Compared to the stroke, no AF group, those with KAF had a higher mortality risk that was rendered nonsignificant after adjustment.

Conclusions: The AFDAS group had the highest risk of death, which was not explained by comorbidities or use of antithrombotic therapies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1212/WNL.0000000000011633DOI Listing
March 2021

The value of cardiac magnetic resonance imaging and programmed ventricular stimulation in patients with ventricular noncompaction and ventricular arrhythmias.

J Cardiovasc Electrophysiol 2021 Mar 23;32(3):745-754. Epub 2021 Jan 23.

Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA.

Introduction: Left ventricular noncompaction (LVNC) is associated with ventricular arrhythmias (VA) including premature ventricular complexes, and ventricular tachycardia (VT). The value of imaging with delayed enhancement cardiac magnetic resonance (DE-CMR) and programmed ventricular stimulation (PVS) for risk stratification in patients with VA and LVNC is unknown. The purpose of this study was to determine whether DE-CMR and PVS are beneficial for risk stratification and whether CMR helps to identify VA target sites.

Methods And Results: Consecutive patients with LVNC undergoing ablation for VAs were included, all patients had preprocedure DE-CMR. A total of 23 patients (7 women, 46 ± 14 years, ejection fraction 35 ± 14) were included and followed for 2.9 ± 2.2 years. DE-CMR scar was present in 12/23 patients (52%). PVS was performed in 20/23 patients, 8/10 patients (80%) with scar were inducible for VT compared to 0/10 (0%) patients without scar (p < .001). VA target sites in patients with scarring were located adjacent to areas of scarring in all but 1 patient and ablation was successful in 15/23 patients (65%). Patients with scar had worse survival free of VT than those without scar (log rank p = .01) and patients with inducible VT had worse survival free of VT than those who were noninducible (log rank p < .001).

Conclusions: The presence of CMR defined scar in patients with LVNC was associated with inducible VT and worse outcomes. Inducibility for VT was associated with VT recurrence. Furthermore, CMR is beneficial in localizing the arrhythmogenic substrate in LVNC and therefore can aid in procedural planning.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jce.14884DOI Listing
March 2021

Prognostic Value of Nonischemic Ringlike Left Ventricular Scar in Patients With Apparently Idiopathic Nonsustained Ventricular Arrhythmias.

Circulation 2021 Apr 6;143(14):1359-1373. Epub 2021 Jan 6.

Cardiac Electrophysiology, Cardiovascular Division (D.M., S.A.C., I.L., A.E., J.J.L., S.D., R.D., F.C.G., D.J.C., D.S.F., F.E.M., P.S.), Hospital of the University of Pennsylvania, Philadelphia.

Background: Left ventricular (LV) scar on late gadolinium enhancement (LGE) cardiac magnetic resonance has been correlated with life-threatening arrhythmic events in patients with apparently idiopathic ventricular arrhythmias (VAs). We investigated the prognostic significance of a specific LV-LGE phenotype characterized by a ringlike pattern of fibrosis.

Methods: A total of 686 patients with apparently idiopathic nonsustained VA underwent contrast-enhanced cardiac magnetic resonance. A ringlike pattern of LV scar was defined as LV subepicardial/midmyocardial LGE involving at least 3 contiguous segments in the same short-axis slice. The end point of the study was time to the composite outcome of all-cause death, resuscitated cardiac arrest because of ventricular fibrillation or hemodynamically unstable ventricular tachycardia and appropriate implantable cardioverter defibrillator therapy.

Results: A total of 28 patients (4%) had a ringlike pattern of scar (group A), 78 (11%) had a non-ringlike pattern (group B), and 580 (85%) had normal cardiac magnetic resonance with no LGE (group C). Group A patients were younger compared with groups B and C (median age, 40 vs 52 vs 45 years; <0.01), more frequently men (96% vs 82% vs 55%; <0.01), with a higher prevalence of family history of sudden cardiac death or cardiomyopathy (39% vs 14% vs 6%; <0.01) and more frequent history of unexplained syncope (18% vs 9% vs 3%; <0.01). All patients in group A showed VA with a right bundle-branch block morphology versus 69% in group B and 21% in group C (<0.01). Multifocal VAs were observed in 46% of group A patients compared with 26% of group B and 4% of group C (<0.01). After a median follow-up of 61 months (range, 34-84 months), the composite outcome occurred in 14 patients (50.0%) in group A versus 15 (19.0%) in group B and 2 (0.3%) in group C (<0.01). After multivariable adjustment, the presence of LGE with ringlike pattern remained independently associated with increased risk of the composite end point (hazard ratio, 68.98 [95% CI, 14.67-324.39], <0.01).

Conclusions: In patients with apparently idiopathic nonsustained VA, nonischemic LV scar with a ringlike pattern is associated with malignant arrhythmic events.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCULATIONAHA.120.047640DOI Listing
April 2021

Impact of Intramural Scar on Mapping and Ablation of Premature Ventricular Complexes.

JACC Clin Electrophysiol 2021 Jun 24;7(6):733-741. Epub 2020 Dec 24.

Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA. Electronic address:

Objectives: This study sought to determine intramural scar characteristics associated with successful premature ventricular complex (PVC) ablations.

Background: Ablating ventricular arrhythmias (VAs) originating from intramural scarring can be challenging. Imaging of intramural scar location may help to determine whether the scar is within reach of the ablation catheter.

Methods: Mapping and ablation of premature ventricular complexes (PVCs) was performed in a consecutive series of patients with intramural scarring and frequent PVCs. Data from delayed enhanced cardiac magnetic resonance were assessed and the proximity of the endocardium containing the breakout site to the intramural scar was correlated with outcomes.

Results: Fifty-six patients were included, and intramural VAs were successfully targeted in 42 patients (75%) and ablation failed in 14 patients (25%). Scarring was more superficial to the endocardium in patients with successful ablations compared with patients with failed procedures (0.35 mm [interquartile range (IQR): 0.22 to 1.20 mm] vs. 2.45 mm [IQR: 1.60 to 3.13 mm]; p < 0.001). In 18 (32%) patients, ablation at the breakout site resulted in a significant change of the PVC-QRS morphology that could successfully be ablated in 9 of 12 patients from another anatomical aspect of the wall harboring the intramural scar. The scar was larger in size (1.79 cm [IQR: 1.25 to 2.85 cm] vs. 1.00 cm [IQR: 0.59 to 1.68 cm]; p < 0.005) compared with patients who did not have a change in the PVC-QRS morphology with ablation.

Conclusions: VAs in patients with intramural scaring can be successfully ablated especially if the intramural scar is within close proximity to the anatomic area containing the breakout site. Changes in the QRS-PVC morphology often precede successful ablation at another breakout site and indicate larger intramural scars.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2020.11.004DOI Listing
June 2021

Strategies for Catheter Ablation of Left Ventricular Papillary Muscle Arrhythmias: An Institutional Experience.

JACC Clin Electrophysiol 2020 10 16;6(11):1381-1392. Epub 2020 Sep 16.

Electrophysiology Section, Cardiology Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA. Electronic address:

Objectives: This study sought to address whether technological innovations such as contact force sensing (CFS) can improve acute and long-term ablation outcomes of left ventricular papillary muscle (LV PAP) ventricular arrhythmias (VAs).

Background: Catheter ablation of LV PAP VAs has been less efficacious than another focal VAs. It remains unclear whether technological innovations such as CFS can improve acute and long-term ablation outcomes of LV PAP VA.

Methods: From January 2015 to December 2019, a total of 137 patients underwent LV PAP VA ablation. VA site of origin (SOO) was identified using activation and pace-mapping guided by intracardiac echocardiography. Radiofrequency energy (20 to 50 W for 60 to 90 s) was delivered by irrigated catheter with or without CFS. We defined acute success as complete suppression of targeted VA ≥30 min post ablation and clinical success as ≥80% VA burden reduction at outpatient follow-up.

Results: VA manifested as premature ventricular complexes in 98 (71%), nonsustained ventricular tachycardia in 18 (13%), sustained ventricular tachycardia in 12 (9%) and premature ventricular complexes induced ventricular fibrillation in 9 (7%). VA SOO was anterolateral PAP in 51 (37%), posteromedial PAP in 73 (53%), and both PAPs in 13 (10%). VAs were targeted using CFS in 97 (71%) and non-CFS in 40 (29%). After a single procedure, acute success was achieved in 130 (95%) and clinical success was achieved in 112 (82%); neither was impacted by VA SOO and/or CFS. Complications occurred in 5 patients (3.6%).

Conclusion: Independent of CFS technology, intracardiac echocardiography-guided catheter ablation is highly efficacious and may be considered as first-line therapy in the management of LV PAP VA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2020.06.026DOI Listing
October 2020

Mapping and Ablation of Intramural Ventricular Arrhythmias: A Stepwise Approach Focused on the Site of Origin.

JACC Clin Electrophysiol 2020 10 12;6(11):1339-1348. Epub 2020 Aug 12.

Division of Cardiovascular Medicine and Radiology, University of Michigan, Ann Arbor, Michigan, USA. Electronic address:

Objectives: This study sought to establish a mapping and ablation strategy to target intramural ventricular arrhythmias (VAs) by identifying the precise arrhythmia site of origin (SOO).

Background: Radiofrequency ablation of intramural VAs is challenging because the arrhythmia origin is difficult to localize.

Methods: In 83 consecutive patients with intramural VAs, a stepwise mapping approach was performed: ablation targeted directly the SOO when possible followed by the closest adjacent anatomical structure when necessary. If the SOO could not be identified, the earliest endocardial breakout sites were ablated. Safety and procedural outcomes between patients in whom the SOO could and could not be identified were compared.

Results: The SOO was identified in 19 of 83 (23%) patients, and radiofrequency ablation was effective in eliminating VAs in all 19 (100%) patients by ablation at the SOO alone (n = 3), at the SOO and an anatomically adjacent area (n = 7), or at an anatomically adjacent area alone (n = 9). Breakout site mapping and ablation in the remaining 64 patients in whom the SOO was not identified was effective in 43 of 64 patients, which was significantly less than in patients in whom the SOO was identified (67% vs. 100%; p < 0.05).

Conclusions: Identification of the SOO was associated with a successful ablation procedure by either targeting the SOO directly or targeting an adjacent anatomical structure. Ablation at the breakout sites of intramural VAs has a lower efficacy than when the SOO can be directly targeted.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2020.05.021DOI Listing
October 2020

Late Multimodality Imaging After Steam Pops During Radiofrequency Catheter Ablation for Ventricular Arrhythmias.

JACC Clin Electrophysiol 2020 10;6(10):1332-1334

Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2020.05.038DOI Listing
October 2020

Association of septal late gadolinium enhancement on cardiac magnetic resonance with ventricular tachycardia ablation targets in nonischemic cardiomyopathy.

J Cardiovasc Electrophysiol 2020 12 27;31(12):3262-3276. Epub 2020 Oct 27.

Department of Medicine, Cardiovascular Division, Cardiology and Electrophysiology Section, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Background: Ablation of septal substrate-associated ventricular tachycardia (VT) in patients with nonischemic cardiomyopathy (NICM) is challenging. We sought to standardize the characterization of septal substrates on late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) and to examine the association of that substrate with VT exit and isthmus sites on invasive mapping.

Methods: LGE-CMR was performed before electroanatomic mapping and ablation for VT in 20 NICM patients. LGE extent and distribution were quantified using myocardial signal-intensity Z scores (SI-Z). The SI-Z thresholds correlating to previously validated voltage thresholds, for abnormal tissue and dense scar were defined.

Results: Bipolar and unipolar (electrogram) voltage amplitude measurements from the LV and RV were negatively associated with SI-Z from LGE-CMR imaging (p < .05). SI-Z thresholds for appropriate CMR identification of septal substrates were determined to be greater than -.15 for border zone and greater than .03 for a dense scar. Among all patients, 34 critical VT sites were identified with SI-Z distribution in the range of -.97 to .06. Thirty (88.2%) critical sites were located in the dense LGE, 1 (2.9%) in the border zone, and 3 (8.9%) in healthy tissue but within 7 mm of LGE. Of note, critical VT sites were all located at the basal septum close to valves (distance to aortic valve: 17.5 ± 31.2 mm, mitral valve: 21.2 ± 8.7 mm) in nonsarcoidosis cases.

Conclusions: Critical sites of septal VT in NICM patients are predominantly in the CMR defined dense scar when using standardized signal-intensity thresholds.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jce.14777DOI Listing
December 2020

Clinical significance of myocardial scar in patients with frequent premature ventricular complexes undergoing catheter ablation.

Heart Rhythm 2021 01 25;18(1):20-26. Epub 2020 Jul 25.

Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan. Electronic address:

Background: Frequent premature ventricular complexes (PVCs) can result in PVC-induced cardiomyopathy (PICM). Scarring has been described in patients with frequent PVCs in the absence of apparent heart disease and in patients with known cardiomyopathy.

Objective: The purpose of this study was to determine the impact of focal myocardial scarring as detected by cardiac magnetic resonance imaging (CMR) on PICM, procedural outcomes, and recovery of left ventricular function in patients with frequent PVCs.

Methods: A total of 351 consecutive patients (181 men; age 53 ± 15 years; ejection fraction [EF] 51% ± 12%) with frequent PVCs referred for ablation were included. CMR was performed in all patients before the ablation procedure. A ≥10% increase in EF or normalization of a previously abnormal EF was defined as evidence of PICM.

Results: Myocardial scarring was present in 134 of 351 patients (38%); 66 of 134 patients (49%) with scarring and 54 of 217 patients (25%) without scarring had improvement or normalization of EF after ablation. The presence of myocardial scarring, PVC burden >22%, male sex, asymptomatic status, and PVC QRS width >150 ms were associated with PICM by univariate analysis (P <.01 for all). The presence of scar was independently associated with PICM (odds ratio 2.2; 95% confidence interval 1.3-3.7; P <.005). The success rate of PVC ablation was lower in patients with scarring than in patients without focal scarring (mean 70% vs 82%; P <.01).

Conclusion: Focal scar defined by CMR is independently associated with PICM. Although ablation outcomes are worse in the presence of scarring, EF recovery can occur in most of these patients after ablation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hrthm.2020.07.030DOI Listing
January 2021

Multimodality Imaging to Guide Ventricular Tachycardia Ablation in Patients with Non-ischaemic Cardiomyopathy.

Arrhythm Electrophysiol Rev 2020 Feb;8(4):255-264

Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US.

Catheter ablation is an effective treatment option for ventricular tachycardia (VT) in patients with non-ischaemic cardiomyopathy (NICM). The heterogeneous nature of NICM aetiologies and VT substrate in patients with NICM play a role in long-term ablation outcomes in this population. Over the past decades, more precise identification of NICM aetiologies and better characterisation of various substrates have been made. Application of multimodal imaging has greatly contributed to the accurate diagnosis of NICM subtypes and improved VT ablation strategies. This article summarises the current knowledge of multimodal imaging used in the characterisation of non-ischaemic NICM substrates, procedural planning and image integration for the optimisation of VT ablation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.15420/aer.2019.37.3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7358957PMC
February 2020

Can Anticoagulation Be Stopped After Ablation of Atrial Fibrillation?

Curr Cardiol Rep 2020 06 19;22(8):58. Epub 2020 Jun 19.

Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, 9 Founders Pavilion, 3400 Spruce Street, Philadelphia, PA, 19104, USA.

Purpose Of Review: This review discusses the pros and cons of discontinuing oral anticoagulation therapy (OAT) after catheter ablation of atrial fibrillation (AF), and data from relevant studies, and summarizes the most recent Expert Consensus recommendations on the topic.

Recent Findings: Patients with AF are at risk of cerebrovascular embolic events (CVEs) including stroke and transient ischemic attacks. OAT can be effective in preventing CVEs, while catheter ablation is an effective treatment to eliminate AF. Whether OAT can be safely discontinued after successful AF ablation remains a controversial topic. Retrospective studies have suggested that successful AF ablation may mitigate the risk of CVE such that OAT may be discontinued in select patients after AF ablation. In certain patients with AF who undergo successful AF ablation, OAT might be able to be safely discontinued with continued long-term rhythm monitoring.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11886-020-01313-1DOI Listing
June 2020

Risk Stratification of Patients With Apparently Idiopathic Premature Ventricular Contractions: A Multicenter International CMR Registry.

JACC Clin Electrophysiol 2020 06 18;6(6):722-735. Epub 2019 Dec 18.

Department of Cardiovascular Medicine, Flinders Medical Centre, Bedford Park, Adelaide, Australia; Cardiac Imaging Unit, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, United Kingdom. Electronic address:

Objectives: This study investigated the prevalence and prognostic significance of concealed myocardial abnormalities identified by cardiac magnetic resonance (CMR) imaging in patients with apparently idiopathic premature ventricular contractions (PVCs).

Background: The role of CMR imaging in patients with frequent PVCs and otherwise negative diagnostic workup is uncertain.

Methods: This was a multicenter, international study that included 518 patients (age 44 ± 15 years; 57% men) with frequent (>1,000/24 h) PVCs and negative routine diagnostic workup. Patients underwent a comprehensive CMR protocol including late gadolinium enhancement imaging for detection of necrosis and/or fibrosis. The study endpoint was a composite of sudden cardiac death, resuscitated cardiac arrest, and nonfatal episodes of ventricular fibrillation or sustained ventricular tachycardia that required appropriate implantable cardioverter-defibrillator therapy.

Results: Myocardial abnormalities were found in 85 (16%) patients. Male gender (odds ratio [OR]: 4.28; 95% confidence interval [CI]: 2.06 to 8.93; p = 0.01), family history of sudden cardiac death and/or cardiomyopathy (OR: 3.61; 95% CI: 1.33 to 9.82; p = 0.01), multifocal PVCs (OR: 11.12; 95% CI: 4.35 to 28.46; p < 0.01), and non-left bundle branch block inferior axis morphology (OR: 14.11; 95% CI: 7.35 to 27.07; p < 0.01) were all significantly related to the presence of myocardial abnormalities. After a median follow-up of 67 months, the composite endpoint occurred in 26 (5%) patients. Subjects with myocardial abnormalities on CMR had a higher incidence of the composite outcome (n = 25; 29%) compared with those without abnormalities (n = 1; 0.2%; p < 0.01).

Conclusions: CMR can identify concealed myocardial abnormalities in 16% of patients with apparently idiopathic frequent PVCs. Presence of myocardial abnormalities on CMR predict worse clinical outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacep.2019.10.015DOI Listing
June 2020

Association of scar distribution with epicardial electrograms and surface ventricular tachycardia QRS duration in nonischemic cardiomyopathy.

J Cardiovasc Electrophysiol 2020 08 24;31(8):2032-2040. Epub 2020 Jun 24.

Section of Cardiac Electrophysiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Introduction: The association of late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) with epicardial and surface ventricular tachycardia (VT) electrogram features, in nonischemic cardiomyopathy (NICM), is unknown. We sought to define the association of LGE and viable wall thickness with epicardial electrogram features and exit site paced QRS duration in patients with NICM.

Methods: A total of 19 patients (age 53.5 ± 11.5 years) with NICM (ejection fraction 40.2 ± 13.2%) underwent CMR before VT ablation. LGE transmurality was quantified on CMR and coregistered with 2294 endocardial and 2724 epicardial map points.

Results: Both bipolar and unipolar voltage were associated with transmural signal intensity on CMR. Longer electrogram duration and fractionated potentials were associated with increased LGE transmurality, but late potentials or local abnormal ventricular activity were more prevalent in nontransmural versus transmural LGE regions (p < .05). Of all critical VT sites, 19% were located adjacent to regions with LGE but normal bipolar and unipolar voltage. Exit site QRS duration was affected by LGE transmurality and intramural scar location, but not by wall thickness, at the impulse origin.

Conclusions: In patients with NICM and VT, LGE is associated with epicardial electrogram features and may predict critical VT sites. Additionally, exit site QRS duration is affected by LGE transmurality and intramural location at the impulse origin or exit.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jce.14618DOI Listing
August 2020

QRS morphology in lead V for the rapid localization of idiopathic ventricular arrhythmias originating from the left ventricular papillary muscles: A novel electrocardiographic criterion.

Heart Rhythm 2020 10 23;17(10):1711-1718. Epub 2020 May 23.

Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. Electronic address:

Background: Twelve-lead electrocardiogram (ECG) criteria have been developed to identify idiopathic ventricular arrhythmias (VAs) from the left ventricular (LV) papillary muscles (PAPs), but accurate localization remains a challenge.

Objective: The purpose of this study was to develop ECG criteria for accurate localization of LV PAP VAs using lead V exclusively.

Methods: Consecutive patients undergoing mapping and ablation of VAs from the LV PAPs guided by intracardiac echocardiography from 2007 to 2018 were reviewed (study group). The QRS morphology in lead V was compared to patients with VAs with a "right bundle branch block" morphology from other LV locations (reference group). Patients with structural heart disease were excluded.

Results: One hundred eleven patients with LV PAP VAs (mean age 54 ± 16 years; 65% men) were identified, including 64 (55%) from the posteromedial PAP and 47 (42%) from the anterolateral PAP. The reference group included patients with VAs from the following LV locations: fascicles (n = 21), outflow tract (n = 36), ostium (n = 37), inferobasal segment (n = 12), and apex (5). PAP VAs showed 3 distinct QRS morphologies in lead V 93% of the time: Rr (53%), R with a slurred downslope (29%), and RR (11%). Sensitivity, specificity, positive predictive value, and negative predictive value for the 3 morphologies combined are 93%, 98%, 98%, and 93%, respectively. The intrinsicoid deflection of PAP VAs in lead V was shorter than that of the reference group (63 ± 13 ms vs 79 ± 24 ms; P < .001). An intrinsicoid deflection time of <74 ms best differentiated the 2 groups (sensitivity 79%; specificity 87%).

Conclusion: VAs originating from the LV PAPs manifest unique QRS morphologies in lead V, which can aid in rapid and accurate localization.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hrthm.2020.05.021DOI Listing
October 2020

Radiofrequency ablation in dense ventricular scar-Longer continuous lesions may be beneficial.

J Cardiovasc Electrophysiol 2020 07 15;31(7):1891. Epub 2020 May 15.

Electrophysiology Section, Division of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jce.14535DOI Listing
July 2020

Bipolar ablation for intramural ventricular tachycardia substrate: Ready for prime time?

Heart Rhythm 2020 09 1;17(9):1508-1509. Epub 2020 May 1.

Electrophysiology Section, Cardiology Division, Department of Medicine, University of Michigan, Ann Arbor, Michigan. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.hrthm.2020.04.034DOI Listing
September 2020

Collateral injury of the conduction system during catheter ablation of septal substrate in nonischemic cardiomyopathy.

J Cardiovasc Electrophysiol 2020 07 5;31(7):1726-1739. Epub 2020 May 5.

Department of Medicine, Cardiac Electrophysiology, Cardiovascular Medicine Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

Introduction: In patients with nonischemic cardiomyopathy (NICM) little is known about the clinical impact of catheter ablation (CA) of septal ventricular tachycardia (VT) resulting in the collateral injury of the conduction system (CICS).

Methods And Results: Ninety-five consecutive patients with NICM underwent CA of septal VT. Outcomes in patients with no baseline conduction abnormalities who developed CICS (group 1, n = 28 [29%]) were compared to patients with no CICS (group 2, n = 17 [18%]) and to patients with preexisting conduction abnormalities or biventricular pacing (group 3, n = 50 [53%]). Group-1 patients were younger, had a higher left ventricular ejection fraction and a lower prevalence of New York Heart Association III/IV class compared to group 3 while no significant differences were observed with group 2. After a median follow-up of 15 months, VT recurred in 14% of patients in group 1, 12% in group 2 (P = .94) and 32% in group 3 (P = .08) while death/transplant occurred in 14% of patients in group 1, 18% in group 2 (P = .69) and 28% in group 3 (P = .15). A worsening of left ventricular ejection fraction (LVEF) (median LVEF variation, -5%) was observed in group 1 compared to group 2 (median LVEF variation, 0%; P < .01) but not group-3 patients (median LVEF variation, -4%; P = .08) with a consequent higher need for new biventricular pacing in group 1 (43%) compared to group 2 (12%; P = .03) and group 3 (16%; P < .01).

Conclusions: In patients with NICM and septal substrate, sparing the abnormal substrate harboring the conduction system provides acceptable VT control while preventing a worsening of the systolic function.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jce.14498DOI Listing
July 2020

Disruption of EGF Feedback by Intestinal Tumors and Neighboring Cells in Drosophila.

Curr Biol 2020 04 2;30(8):1537-1546.e3. Epub 2020 Apr 2.

Department of Molecular and Cellular Physiology, Stanford University School of Medicine, Stanford, CA 94305, USA. Electronic address:

In healthy adult organs, robust feedback mechanisms control cell turnover to enforce homeostatic equilibrium between cell division and death [1, 2]. Nascent tumors must subvert these mechanisms to achieve cancerous overgrowth [3-7]. Elucidating the nature of this subversion can reveal how cancers become established and may suggest strategies to prevent tumor progression. In adult Drosophila intestine, a well-studied model of homeostatic cell turnover, the linchpin of cell equilibrium is feedback control of the epidermal growth factor (EGF) protease Rhomboid (Rho). Expression of Rho in apoptotic cells enables them to secrete EGFs, which stimulate nearby stem cells to undergo replacement divisions [8]. As in mammals, loss of adenomatous polyposis coli (APC) causes Drosophila intestinal stem cells to form adenomas [9]. Here, we demonstrate that Drosophila APC tumors trigger widespread Rho expression in non-apoptotic cells, resulting in chronic EGF signaling. Initially, nascent APC tumors induce rho in neighboring wild-type cells via acute, non-autonomous activation of Jun N-terminal kinase (JNK). During later growth and multilayering, APC tumors induce rho in tumor cells by autonomous downregulation of E-cadherin (E-cad) and consequent activity of p120-catenin. This sequential dysregulation of tumor non-autonomous and -autonomous EGF signaling converts tissue-level feedback into feed-forward activation that drives cancerous overgrowth. Because Rho, EGF receptor (EGFR), and E-cad are associated with colorectal cancer in humans [10-17], our findings may shed light on how human colorectal tumors progress.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.cub.2020.01.082DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7409949PMC
April 2020
-->