1 2 3 4 5 6 7 8 9 10 11Q1 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Q4 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54
Safety of radiofrequency catheter ablation without coronary angiography in aortic cusp ventricular arrhythmias Kurt S. Hoffmayer, PharmD, MD,* Thomas A. Dewland, MD,† Henry H. Hsia, MD,† Nitish Badhwar, MBBS,† Jonathan C. Hsu, MD, MAS,† Zian H. Tseng, MD, MAS,† Gregory M. Marcus, MD, MAS,† Melvin M. Scheinman, MD,† Edward P. Gerstenfeld, MD† From the *Division of Cardiology, Section of Electrophysiology, University of Wisconsin, Madison, Wisconsin, and †Division of Cardiology, Section of Electrophysiology, University of California, San Francisco, California. BACKGROUND Ventricular arrhythmias (VAs) originating from the aortic root are common. Coronary angiography is typically recommended before catheter ablation to document proximity of the ablation catheter to the coronary ostia. OBJECTIVE To investigate how often catheter ablation in the aortic root could be guided by phased-array intracardiac echocardiography (ICE) and electroanatomic mapping without requiring aortography or coronary angiography. METHODS We reviewed consecutive patients referred for aortic root VAs to operators experienced in the use of ICE at a single center. An ICE catheter and a 3.5-mm irrigated ablation catheter were used in all cases, and the need for angiography before ablation was documented. Acute success and acute and 30-day complications were noted. RESULTS Thirty-five patients (age 58 ⫾ 13 years; 74% men) were referred for the ablation of VAs; 32 of 35 (91%) underwent ablation using ICE and 3-dimensional mapping without the need for coronary angiography. Successful acute ablation was achieved in
Introduction Radiofrequency catheter ablation is a safe and reliable technique for treating patients with ventricular arrhythmias (VAs) originating from the outflow tract.1 Approximately 10%–15% of idiopathic ventricular tachycardia (VT) originates from the left ventricular outflow tract and can be mapped and ablated from within the aortic root.2–9 VA origin
Dr Scheinman has received speaker’s fees from St Jude Medical, Boston Scientific, Medtronic, Biosense, and Biotronik; he has also received consultant fees from Jansen. Dr Gerstenfeld has received honoraria from Biosense Webster. Address reprint requests and correspondence: Dr Edward P. Gerstenfeld, Division of Cardiology, Section of Electrophysiology, University of California, San Francisco, 500 Parnassus Avenue, MUE-434, Box 1354, San Francisco, CA 94143. E-mail address: egerstenfeld @medicine.ucsf.edu.
1547-5271/$-see front matter B 2014 Heart Rhythm Society. All rights reserved.
29 of 35 (83%) patients. In all cases, the catheter tip was directly visualized with ICE 41 cm from the coronary ostia. The site of origin of the earliest VA was the left cusp (17 of 35 [49%]), right cusp (9 of 35 [26%]), right-left cusp junction (8 of 35 [23%]), or right-noncoronary cusp junction (1 of 35 [3%]). There were no cases of coronary injury, embolic stroke, aortic root perforation, worsening of aortic regurgitation, or death acutely or at 30 days. CONCLUSION Radiofrequency ablation of VAs originating from the aortic root may be safely performed using ICE and electroanatomic mapping in the majority of cases without the need for coronary angiography. KEYWORDS Catheter ablation; Ventricular tachycardia; Premature ventricular contractions; Aortic cusp ABBREVIATIONS ICE ¼ intracardiac echocardiography; VA ¼ ventricular arrhythmias; VT ¼ ventricular tachycardia (Heart Rhythm 2014;0:0–5) rights reserved.
I
2014 Heart Rhythm Society. All
from the left cusp is most common, followed by the right cusp, and then the left-right cusp junction.6,7 Catheter ablation in the aortic cusps can be challenging owing to the complex anatomic relationships of the aortic valve, coronary arteries, and veins.1,10 The use of intracardiac echocardiography (ICE) allows real-time visualization of the aortic cusp anatomy, coronary ostia, and catheter tip. Threedimensional electroanatomic mapping allows the reconstruction of the aortic root anatomy and precise tracking of catheter location during mapping and ablation lesions. Together, these modalities can help improve procedural outcome and reduce the need for fluoroscopy, aortography, and coronary angiography.1 We sought to investigate how often catheter ablation in the aortic root could be guided by phased-array ICE and electroanatomic mapping without needing aortography or coronary angiography. http://dx.doi.org/10.1016/j.hrthm.2014.04.019
55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72
2 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129
Methods We retrospectively reviewed consecutive patients referred to operators experienced in the use of ICE at a single center for electrophysiology study and ablation of left ventricular out flow tract arrhythmias with ablation lesions delivered in the aortic cusps from January 2011 to February 2014. Procedural parameters, baseline characteristics, and medical history were reviewed.
Electrophysiology study Informed consent was obtained from all patients. Catheter selection and mapping strategy were dependent on the operators. Electroanatomic mapping (Carto, Biosense Webster, Diamond Bar, CA, or NavX, St Jude Medical, St Paul, MN) and phased-array ICE (AcuNav, Siemens Medical Solutions USA, Inc, Malvern, PA) were used to guide aortic cusp ablation in all cases; in some cases, 3-dimensional ICE reconstruction was used (CartoSound, Biosense Webster). A retrograde aortic approach to map and ablate in the aortic cusps was used. Coronary angiography was performed at the discretion of the attending electrophysiologist if it was felt that ICE views were not adequate to ensure safe distance of the ablation catheter tip from the coronary ostia. Heparin was given to all patients after accessing the femoral artery and titrated to maintain an activated clotting time of 4250 seconds. A 3.5-mm open-irrigated catheter (ThermoCool or ThermoCool SF, Biosense Webster) was used in all cases for mapping and ablation. Radiofrequency energy was delivered in the “power-controlled” mode. Acute success and acute and 30-day complications were recorded in a prospective
Heart Rhythm, Vol 0, No 0, Month 2014 database. Successful ablation was defined as the complete elimination of the VT/premature ventricular contraction focus at the end of a 30-minute waiting period.
ICE views For catheter ablation in the aortic cusps, the ICE catheter was positioned in the right ventricular inflow region, just past the tricuspid valve. Doppler color flow was used to determine the degree of aortic regurgitation before and after ablation. Before ablation, care was taken to localize the tip of the catheter. This often required advancing or withdrawal of the ICE catheter to the correct plane and rotation to allow visualization of the catheter tip accompanied by echogenic shadowing. If the catheter tip location was not verified, the catheter was flushed at 60 mL/min, allowing visualization of bubbles emanating from the tip of the catheter (Figures 1 and 2). For ablation performed in the left cusp or at the left-right cusp junction, the left main coronary ostium is easily visualized at approximately 6 o’clock of the cross-sectional view of the aortic root. Once the left main ostium was visualized, the catheter was rotated or advanced to locate the catheter tip to determine the distance from the coronary ostium. If the catheter tip was seen in the same plane as the coronary ostia, or the catheter tip could not be clearly visualized, coronary angiography was performed. When mapping localized the VA to the right aortic cusp, a longaxis view of the aortic root was obtained (Figure 3). If the catheter tip was located at the level of the aortic cusp leaflets, a safe distance from the right coronary ostium was assumed. If the catheter tip was at a level higher than the aortic sinus of
P R I N T & W E B 4 C / F Figure 1 Left panel: 12-lead electrocardiogram of the premature ventricular contraction originating from the left-right aortic cusp junction. Right panel: P Intracardiac echocardiography (ICE) imaging showing the location of the right (R), left (L), and noncoronary (NC) cusps. The ICE catheter was positioned in the O right ventricular inflow region, just past the tricuspid valve. The left main (LM; arrow) coronary ostium is easily visualized at 6 o’clock on the cross-sectional view of the aortic root. The ablation catheter tip (Abl) is located at the left-right cusp junction at a safe distance from the LM ostium. Bubbles are visualized after flushing the catheter for confirmation of tip location. Full movie is available online.
130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 F1 146 F2 147 148 149 Q5 150 151 152 153 154 155 156 F3 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186
Hoffmayer et al 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243
Safety of Cusp VT Ablation Without Angiography
3
P R I N T & W E B 4 C / F Figure 2 Left panel: 12-lead electrocardiogram of a premature ventricular contraction originating from the left cusp, along with bipolar ablation/mapping P electrograms 1,2 and 3,4. CartoSound map (A) and right (B) cross-sectional view of the aortic valve as seen with phased-array intracardiac echocardiography O (ICE) in patient 34. The locations of the right (R), left (L), and noncoronary (NC) cusps are visualized. The use of 3-dimensional ICE allows direct measurement of the distance of the left main (LM, orange tag) ostium to the successful ablation site (red tag), which is only 12.4 mm away. The blue tags represent sites of 12/ 12 lead pace-map matches.
P R I N T & W E B 4 C / F Figure 3 A longitudinal view of the left ventricular outflow tract as seen with phased-array intracardiac echocardiography (ICE) (A) and CartoSound images P (B: right lateral view and C: right anterior oblique) during a right cusp premature ventricular contraction ablation in patient 35. A: ICE demonstrating a O longitudinal view of the left ventricular outflow tract obtained from the right atrium at the level of the fossa ovalis. The catheter tip (arrow) is visualized at the level of the aortic cusps (sinuses of Valsalva) below the level of the right coronary artery ostium. B and C: CartoSound images showing the location of the right (R), left (L), and noncoronary (NC) cusps. The left main (LM) ostium is labeled with a purple dot. Ablation lesions are labeled within the right cusp in red, with the location of 12/12 matching pace maps in blue. RV ¼ right ventricle.
244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300
4 301 302 303 304 305 306 307 308 309 310 311 T1 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 Q6 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357
Valsalva, above the sinotubular junction, the aortic or coronary angiography was performed. When ICE was coupled with electroanatomic mapping (CartoSound), each aortic cusp leaflet and the left main coronary ostium, as it entered the aortic root, was tagged on the map. This allowed clear visualization of the distance between the catheter tip and the coronary ostium (Figures 2 and 3).
Results A total of 35 cases were identified from January 2011 to February 2014 (Table 1) where electroanatomic mapping and phased-array ICE were used. The majority of patients presented with premature ventricular contractions (28 of 35 [80%]), with the remaining 7 of 35 (20%) presenting with sustained VT. The mean age was 58 ⫾ 13 years, with the majority being men (26 of 35 [74%]). The majority of patients had idiopathic VT (29 of 35 [83%]), while 5 (14%) patients had a history of nonischemic cardiomyopathy and 1 (3%) had hypertrophic cardiomyopathy. The local electrogram onset occurred 33.1 ⫾ 11.8 ms before QRS onset. Successful ablation was achieved in 29 of 35 (83%) patients, with the remaining having transient suppression with resumption of VAs (5 of 35 [14%]) or complete failure of suppression (1 of 35 [3%]). The left cusp was the site of VA origin in the majority of patients (17 of 35 [49%]), followed by the right cusp (9 of 35 [26%]), left-right cusp junction (8 of 35 [23%]) and then right-noncoronary cusp junction (1 of 35 [3%]). There was no significant relationship between the success rate of ablation and the location of VA origin. The left main coronary ostium could be visualized with ICE in 100% of the cases. Coronary angiography was performed in 3 of 35 (9%) patients because of the proximity of the ablation catheter and radiofrequency lesion delivery to the coronary ostia. This includes ablation in the left cusp in 2 patients, right-left cusp junction in 0 patients, and right cusp in 1 patient. In all 3 cases, coronary angiography documented a distance of 45 mm from the coronary ostia and ablation was performed. There was a statistical trend to perform coronary angiography if the origin was the right cusp (2 of 9 [22%] vs 1 of 26 [4%]; P ¼ .09), where ICE imaging of the coronary ostium is more challenging. Angiography was never needed when ablation was performed at the right-left cusp junction, which was clearly distinct from the coronary ostia. There were no cases of coronary artery injury, embolic stroke, aortic root perforation, worsening of aortic regurgitation, or death acutely. There were no additional complications noted at 30-day follow-up after the procedure.
Discussion Traditionally, coronary angiography has been recommended before catheter ablation in the aortic root to ensure a safe distance from the coronary ostia.4,7,11 However, coronary angiography has risk, including allergic reaction or renal injury from contrast use, vascular injury from a second arterial access, additional radiation exposure, and rarely air
Heart Rhythm, Vol 0, No 0, Month 2014 Table 1
Patient characteristics
Age Case (y) Sex 1
57
2 3
44 76
4 5 6 7 8 9 10 11 12
69 67 49 48 63 30 49 71 49
13 14 15 16
64 62 59 23
17 18
85 66
19 20
62 61
21 22
61 55
23 24 25 26 27 28 29 30 31
52 64 59 72 47 72 51 63 66
32
55
33 34 35
50 33 68
Cusp ablation VA location
Female PVC Right-left junction Female VT Left Female PVC Right-left junction Male PVC Left Male PVC Left* Male PVC Left Male PVC Left Male PVC Right Female VT Left Female PVC Right Male PVC Left Male VT Rightnoncoronary junction Male VT Right Male PVC Left Male PVC Left Female PVC Right-left junction Male PVC Left Female PVC Right-left junction Male PVC Right Male PVC Right-left junction Male PVC Left* Male VT Right-left junction Female PVC Right Male VT Left Male PVC Left Male PVC Left Male PVC Left Male PVC Right Male PVC Right Male PVC Right Male PVC Left-right junction Male PVC Left-right junction Male VT Left Female PVC Left Male PVC Right
Angiography Success No
Yes
No No
No Yes
No No No Yes No No Yes No No
Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes No No No
Yes Yes Yes No
No No
No No
No No
Yes Yes
No No
No Yes
No No No No No No No No No
Yes Yes Yes Yes Yes Yes Yes Yes Yes
No
Yes
No No No
No Yes Yes
Successful ablation was defined as a complete elimination of the VT/PVC focus at the end of a 30-minute waiting period. PVC ¼ premature ventricular contraction; VT ¼ ventricular tachycardia. * Ablation lesions placed in the left cusp after previous ablation in aortomitral continuity was unsuccessful.
embolus or coronary dissection. ICE allows direct visualization of the ablation catheter tip, aortic cusps, left main coronary ostium, and surrounding anatomy. This eliminates the need for angiography in the majority of patients undergoing ablation of VAs from the aortic root. We find that with careful use of ICE and electroanatomic mapping, coronary angiography can be avoided and ablation in the aortic root can be safely performed in the majority (91%) of the patients. Three patients in our study did require coronary angiography because of the proximity of the ablation catheter to the
358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414
Hoffmayer et al 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451
Safety of Cusp VT Ablation Without Angiography
coronary ostia. Two of 3 patients had VAs originating from the right cusp, which revealed a statistical trend to perform coronary angiography. This is likely explained from the more challenging imaging of the right coronary ostium vs the left coronary ostium. However, given the location of the right coronary ostium above the aortic valve, when the catheter tip is located at the cusp level, within the sinus of Valsalva on the long-axis view, angiography can often be avoided. VAs originating from the left-right cusp junction were always a safe distance from the coronary ostia. Therefore, coronary angiography can uniformly be avoided when the catheter tip is identified at this region (23% of the cases).
Study limitations This study was performed in an electrophysiology laboratory in which the operators have significant experience in the use of phased-array ICE and who took great care confirming catheter tip location. If operators are uncertain of the proper views or if ablation catheter tip location cannot be confirmed, then coronary angiography or aortography is always the safest option. Anomalous insertion of the left main coronary artery can rarely occur; if the left main ostium is not visualized, then coronary angiography should be performed. There is a small risk of damaging the right coronary artery if the origin of the ostium is low. However, this is a rare anomaly and is identified in only 0.10% of all coronary anomalies.12 In our series, all successful ablation lesions were 410 mm away from the coronary artery ostium as visualized by ICE and electroanatomic mapping. If the mapping catheter is visualized within 10 mm of the coronary artery ostium, then coronary angiography should be performed before ablation.
Conclusion Our series suggests that radiofrequency ablation of VAs originating from the aortic root may be safely performed
5
using phased-array ICE in the majority of cases without the need for coronary angiography.
References 1. Hoffmayer KS, Gerstenfeld EP. Diagnosis and management of idiopathic ventricular tachycardia. Curr Prob Cardiol 2013;38:131–158. 2. Badhwar N, Scheinman MM. Idiopathic ventricular tachycardia: diagnosis and management. Curr Prob Cardiol 2007;32:7–43. 3. Bala R, Garcia FC, Hutchinson MD, et al. Electrocardiographic and electrophysiologic features of ventricular arrhythmias originating from the right/left coronary cusp commissure. Heart Rhythm 2010;7:312–322. 4. Hachiya H, Aonuma K, Yamauchi Y, Igawa M, Nogami A, Iesaka Y. How to diagnose, locate, and ablate coronary cusp ventricular tachycardia. J Cardiovasc Electrophysiol 2002;13:551–556. 5. Callans DJ, Menz V, Schwartzman D, Gottlieb CD, Marchlinski FE. Repetitive monomorphic tachycardia from the left ventricular outflow tract: electrocardiographic patterns consistent with a left ventricular site of origin. J Am Coll Cardiol 1997;29:1023–1027. 6. Yamada T, Yoshida N, Murakami Y, et al. Electrocardiographic characteristics of ventricular arrhythmias originating from the junction of the left and right coronary sinuses of Valsalva in the aorta: the activation pattern as a rationale for the electrocardiographic characteristics. Heart Rhythm 2008;5: 184–192. 7. Yamada T, McElderry HT, Doppalapudi H, et al. Idiopathic ventricular arrhythmias originating from the aortic root prevalence, electrocardiographic and electrophysiologic characteristics, and results of radiofrequency catheter ablation. J Am Coll Cardiol 2008;52:139–147. 8. Yamada T, McElderry HT, Okada T, Murakami Y, Doppalapudi H, Yoshida N, Alfred JD, Murohara T, Kay GN. Idiopathic focal ventricular arrhythmias originating from the anterior papillary muscle in the left ventricle. J Cardiovasc Electrophysiol 2009;20:866–872. 9. Kanagaratnam L, Tomassoni G, Schweikert R, Pavia S, Bash D, Beheiry S, Neibauer M, Saliba W, Chung M, Tchou P, Natale A. Ventricular tachycardias arising from the aortic sinus of valsalva: an under-recognized variant of left outflow tract ventricular tachycardia. J Am Coll Cardiol 2001;37: 1408–1414. 10. Callans DJ. Catheter ablation of idiopathic ventricular tachycardia arising from the aortic root. JCardiovasc Electrophysiol 2009;20:969–972. 11. Ouyang F, Fotuhi P, Ho SY, Hebe J, Volkmer M, Goya M, Burns M, Antz M, Ernst S, Cappato R, Kuck KH. Repetitive monomorphic ventricular tachycardia originating from the aortic sinus cusp: electrocardiographic characterization for guiding catheter ablation. J Am Coll Cardiol 2002;39:500–508. 12. Angelini P, Velasco JA, Flamm S. Coronary anomalies: incidence, pathophysiology, and clinical relevance. Circulation 2002;105:2449–2454.
452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487
Safety of radiofrequency catheter ablation without coronary angiography in aortic cusp ventricular arrhythmias Kurt S. Hoffmayer, PharmD, MD,* Thomas A. Dewland, MD,† Henry H. Hsia, MD,† Nitish Badhwar, MBBS,† Jonathan C. Hsu, MD, MAS,† Zian H. Tseng, MD, MAS,† Gregory M. Marcus, MD, MAS,† Melvin M. Scheinman, MD,† Edward P. Gerstenfeld, MD† From the *Division of Cardiology, Section of Electrophysiology, University of Wisconsin, Madison, Wisconsin, and †Division of Cardiology, Section of Electrophysiology, University of California, San Francisco, California. BACKGROUND Ventricular arrhythmias (VAs) originating from the aortic root are common. Coronary angiography is typically recommended before catheter ablation to document proximity of the ablation catheter to the coronary ostia. OBJECTIVE To investigate how often catheter ablation in the aortic root could be guided by phased-array intracardiac echocardiography (ICE) and electroanatomic mapping without requiring aortography or coronary angiography. METHODS We reviewed consecutive patients referred for aortic root VAs to operators experienced in the use of ICE at a single center. An ICE catheter and a 3.5-mm irrigated ablation catheter were used in all cases, and the need for angiography before ablation was documented. Acute success and acute and 30-day complications were noted. RESULTS Thirty-five patients (age 58 ⫾ 13 years; 74% men) were referred for the ablation of VAs; 32 of 35 (91%) underwent ablation using ICE and 3-dimensional mapping without the need for coronary angiography. Successful acute ablation was achieved in
Introduction Radiofrequency catheter ablation is a safe and reliable technique for treating patients with ventricular arrhythmias (VAs) originating from the outflow tract.1 Approximately 10%–15% of idiopathic ventricular tachycardia (VT) originates from the left ventricular outflow tract and can be mapped and ablated from within the aortic root.2–9 VA origin
Dr Scheinman has received speaker’s fees from St Jude Medical, Boston Scientific, Medtronic, Biosense, and Biotronik; he has also received consultant fees from Jansen. Dr Gerstenfeld has received honoraria from Biosense Webster. Address reprint requests and correspondence: Dr Edward P. Gerstenfeld, Division of Cardiology, Section of Electrophysiology, University of California, San Francisco, 500 Parnassus Avenue, MUE-434, Box 1354, San Francisco, CA 94143. E-mail address: egerstenfeld @medicine.ucsf.edu.
1547-5271/$-see front matter B 2014 Heart Rhythm Society. All rights reserved.
29 of 35 (83%) patients. In all cases, the catheter tip was directly visualized with ICE 41 cm from the coronary ostia. The site of origin of the earliest VA was the left cusp (17 of 35 [49%]), right cusp (9 of 35 [26%]), right-left cusp junction (8 of 35 [23%]), or right-noncoronary cusp junction (1 of 35 [3%]). There were no cases of coronary injury, embolic stroke, aortic root perforation, worsening of aortic regurgitation, or death acutely or at 30 days. CONCLUSION Radiofrequency ablation of VAs originating from the aortic root may be safely performed using ICE and electroanatomic mapping in the majority of cases without the need for coronary angiography. KEYWORDS Catheter ablation; Ventricular tachycardia; Premature ventricular contractions; Aortic cusp ABBREVIATIONS ICE ¼ intracardiac echocardiography; VA ¼ ventricular arrhythmias; VT ¼ ventricular tachycardia (Heart Rhythm 2014;0:0–5) rights reserved.
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2014 Heart Rhythm Society. All
from the left cusp is most common, followed by the right cusp, and then the left-right cusp junction.6,7 Catheter ablation in the aortic cusps can be challenging owing to the complex anatomic relationships of the aortic valve, coronary arteries, and veins.1,10 The use of intracardiac echocardiography (ICE) allows real-time visualization of the aortic cusp anatomy, coronary ostia, and catheter tip. Threedimensional electroanatomic mapping allows the reconstruction of the aortic root anatomy and precise tracking of catheter location during mapping and ablation lesions. Together, these modalities can help improve procedural outcome and reduce the need for fluoroscopy, aortography, and coronary angiography.1 We sought to investigate how often catheter ablation in the aortic root could be guided by phased-array ICE and electroanatomic mapping without needing aortography or coronary angiography. http://dx.doi.org/10.1016/j.hrthm.2014.04.019
55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72
2 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129
Methods We retrospectively reviewed consecutive patients referred to operators experienced in the use of ICE at a single center for electrophysiology study and ablation of left ventricular out flow tract arrhythmias with ablation lesions delivered in the aortic cusps from January 2011 to February 2014. Procedural parameters, baseline characteristics, and medical history were reviewed.
Electrophysiology study Informed consent was obtained from all patients. Catheter selection and mapping strategy were dependent on the operators. Electroanatomic mapping (Carto, Biosense Webster, Diamond Bar, CA, or NavX, St Jude Medical, St Paul, MN) and phased-array ICE (AcuNav, Siemens Medical Solutions USA, Inc, Malvern, PA) were used to guide aortic cusp ablation in all cases; in some cases, 3-dimensional ICE reconstruction was used (CartoSound, Biosense Webster). A retrograde aortic approach to map and ablate in the aortic cusps was used. Coronary angiography was performed at the discretion of the attending electrophysiologist if it was felt that ICE views were not adequate to ensure safe distance of the ablation catheter tip from the coronary ostia. Heparin was given to all patients after accessing the femoral artery and titrated to maintain an activated clotting time of 4250 seconds. A 3.5-mm open-irrigated catheter (ThermoCool or ThermoCool SF, Biosense Webster) was used in all cases for mapping and ablation. Radiofrequency energy was delivered in the “power-controlled” mode. Acute success and acute and 30-day complications were recorded in a prospective
Heart Rhythm, Vol 0, No 0, Month 2014 database. Successful ablation was defined as the complete elimination of the VT/premature ventricular contraction focus at the end of a 30-minute waiting period.
ICE views For catheter ablation in the aortic cusps, the ICE catheter was positioned in the right ventricular inflow region, just past the tricuspid valve. Doppler color flow was used to determine the degree of aortic regurgitation before and after ablation. Before ablation, care was taken to localize the tip of the catheter. This often required advancing or withdrawal of the ICE catheter to the correct plane and rotation to allow visualization of the catheter tip accompanied by echogenic shadowing. If the catheter tip location was not verified, the catheter was flushed at 60 mL/min, allowing visualization of bubbles emanating from the tip of the catheter (Figures 1 and 2). For ablation performed in the left cusp or at the left-right cusp junction, the left main coronary ostium is easily visualized at approximately 6 o’clock of the cross-sectional view of the aortic root. Once the left main ostium was visualized, the catheter was rotated or advanced to locate the catheter tip to determine the distance from the coronary ostium. If the catheter tip was seen in the same plane as the coronary ostia, or the catheter tip could not be clearly visualized, coronary angiography was performed. When mapping localized the VA to the right aortic cusp, a longaxis view of the aortic root was obtained (Figure 3). If the catheter tip was located at the level of the aortic cusp leaflets, a safe distance from the right coronary ostium was assumed. If the catheter tip was at a level higher than the aortic sinus of
P R I N T & W E B 4 C / F Figure 1 Left panel: 12-lead electrocardiogram of the premature ventricular contraction originating from the left-right aortic cusp junction. Right panel: P Intracardiac echocardiography (ICE) imaging showing the location of the right (R), left (L), and noncoronary (NC) cusps. The ICE catheter was positioned in the O right ventricular inflow region, just past the tricuspid valve. The left main (LM; arrow) coronary ostium is easily visualized at 6 o’clock on the cross-sectional view of the aortic root. The ablation catheter tip (Abl) is located at the left-right cusp junction at a safe distance from the LM ostium. Bubbles are visualized after flushing the catheter for confirmation of tip location. Full movie is available online.
130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 F1 146 F2 147 148 149 Q5 150 151 152 153 154 155 156 F3 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186
Hoffmayer et al 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243
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P R I N T & W E B 4 C / F Figure 2 Left panel: 12-lead electrocardiogram of a premature ventricular contraction originating from the left cusp, along with bipolar ablation/mapping P electrograms 1,2 and 3,4. CartoSound map (A) and right (B) cross-sectional view of the aortic valve as seen with phased-array intracardiac echocardiography O (ICE) in patient 34. The locations of the right (R), left (L), and noncoronary (NC) cusps are visualized. The use of 3-dimensional ICE allows direct measurement of the distance of the left main (LM, orange tag) ostium to the successful ablation site (red tag), which is only 12.4 mm away. The blue tags represent sites of 12/ 12 lead pace-map matches.
P R I N T & W E B 4 C / F Figure 3 A longitudinal view of the left ventricular outflow tract as seen with phased-array intracardiac echocardiography (ICE) (A) and CartoSound images P (B: right lateral view and C: right anterior oblique) during a right cusp premature ventricular contraction ablation in patient 35. A: ICE demonstrating a O longitudinal view of the left ventricular outflow tract obtained from the right atrium at the level of the fossa ovalis. The catheter tip (arrow) is visualized at the level of the aortic cusps (sinuses of Valsalva) below the level of the right coronary artery ostium. B and C: CartoSound images showing the location of the right (R), left (L), and noncoronary (NC) cusps. The left main (LM) ostium is labeled with a purple dot. Ablation lesions are labeled within the right cusp in red, with the location of 12/12 matching pace maps in blue. RV ¼ right ventricle.
244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300
4 301 302 303 304 305 306 307 308 309 310 311 T1 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 Q6 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357
Valsalva, above the sinotubular junction, the aortic or coronary angiography was performed. When ICE was coupled with electroanatomic mapping (CartoSound), each aortic cusp leaflet and the left main coronary ostium, as it entered the aortic root, was tagged on the map. This allowed clear visualization of the distance between the catheter tip and the coronary ostium (Figures 2 and 3).
Results A total of 35 cases were identified from January 2011 to February 2014 (Table 1) where electroanatomic mapping and phased-array ICE were used. The majority of patients presented with premature ventricular contractions (28 of 35 [80%]), with the remaining 7 of 35 (20%) presenting with sustained VT. The mean age was 58 ⫾ 13 years, with the majority being men (26 of 35 [74%]). The majority of patients had idiopathic VT (29 of 35 [83%]), while 5 (14%) patients had a history of nonischemic cardiomyopathy and 1 (3%) had hypertrophic cardiomyopathy. The local electrogram onset occurred 33.1 ⫾ 11.8 ms before QRS onset. Successful ablation was achieved in 29 of 35 (83%) patients, with the remaining having transient suppression with resumption of VAs (5 of 35 [14%]) or complete failure of suppression (1 of 35 [3%]). The left cusp was the site of VA origin in the majority of patients (17 of 35 [49%]), followed by the right cusp (9 of 35 [26%]), left-right cusp junction (8 of 35 [23%]) and then right-noncoronary cusp junction (1 of 35 [3%]). There was no significant relationship between the success rate of ablation and the location of VA origin. The left main coronary ostium could be visualized with ICE in 100% of the cases. Coronary angiography was performed in 3 of 35 (9%) patients because of the proximity of the ablation catheter and radiofrequency lesion delivery to the coronary ostia. This includes ablation in the left cusp in 2 patients, right-left cusp junction in 0 patients, and right cusp in 1 patient. In all 3 cases, coronary angiography documented a distance of 45 mm from the coronary ostia and ablation was performed. There was a statistical trend to perform coronary angiography if the origin was the right cusp (2 of 9 [22%] vs 1 of 26 [4%]; P ¼ .09), where ICE imaging of the coronary ostium is more challenging. Angiography was never needed when ablation was performed at the right-left cusp junction, which was clearly distinct from the coronary ostia. There were no cases of coronary artery injury, embolic stroke, aortic root perforation, worsening of aortic regurgitation, or death acutely. There were no additional complications noted at 30-day follow-up after the procedure.
Discussion Traditionally, coronary angiography has been recommended before catheter ablation in the aortic root to ensure a safe distance from the coronary ostia.4,7,11 However, coronary angiography has risk, including allergic reaction or renal injury from contrast use, vascular injury from a second arterial access, additional radiation exposure, and rarely air
Heart Rhythm, Vol 0, No 0, Month 2014 Table 1
Patient characteristics
Age Case (y) Sex 1
57
2 3
44 76
4 5 6 7 8 9 10 11 12
69 67 49 48 63 30 49 71 49
13 14 15 16
64 62 59 23
17 18
85 66
19 20
62 61
21 22
61 55
23 24 25 26 27 28 29 30 31
52 64 59 72 47 72 51 63 66
32
55
33 34 35
50 33 68
Cusp ablation VA location
Female PVC Right-left junction Female VT Left Female PVC Right-left junction Male PVC Left Male PVC Left* Male PVC Left Male PVC Left Male PVC Right Female VT Left Female PVC Right Male PVC Left Male VT Rightnoncoronary junction Male VT Right Male PVC Left Male PVC Left Female PVC Right-left junction Male PVC Left Female PVC Right-left junction Male PVC Right Male PVC Right-left junction Male PVC Left* Male VT Right-left junction Female PVC Right Male VT Left Male PVC Left Male PVC Left Male PVC Left Male PVC Right Male PVC Right Male PVC Right Male PVC Left-right junction Male PVC Left-right junction Male VT Left Female PVC Left Male PVC Right
Angiography Success No
Yes
No No
No Yes
No No No Yes No No Yes No No
Yes Yes Yes Yes Yes Yes Yes Yes Yes
Yes No No No
Yes Yes Yes No
No No
No No
No No
Yes Yes
No No
No Yes
No No No No No No No No No
Yes Yes Yes Yes Yes Yes Yes Yes Yes
No
Yes
No No No
No Yes Yes
Successful ablation was defined as a complete elimination of the VT/PVC focus at the end of a 30-minute waiting period. PVC ¼ premature ventricular contraction; VT ¼ ventricular tachycardia. * Ablation lesions placed in the left cusp after previous ablation in aortomitral continuity was unsuccessful.
embolus or coronary dissection. ICE allows direct visualization of the ablation catheter tip, aortic cusps, left main coronary ostium, and surrounding anatomy. This eliminates the need for angiography in the majority of patients undergoing ablation of VAs from the aortic root. We find that with careful use of ICE and electroanatomic mapping, coronary angiography can be avoided and ablation in the aortic root can be safely performed in the majority (91%) of the patients. Three patients in our study did require coronary angiography because of the proximity of the ablation catheter to the
358 359 360 361 362 363 364 365 366 367 368 369 370 371 372 373 374 375 376 377 378 379 380 381 382 383 384 385 386 387 388 389 390 391 392 393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 410 411 412 413 414
Hoffmayer et al 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451
Safety of Cusp VT Ablation Without Angiography
coronary ostia. Two of 3 patients had VAs originating from the right cusp, which revealed a statistical trend to perform coronary angiography. This is likely explained from the more challenging imaging of the right coronary ostium vs the left coronary ostium. However, given the location of the right coronary ostium above the aortic valve, when the catheter tip is located at the cusp level, within the sinus of Valsalva on the long-axis view, angiography can often be avoided. VAs originating from the left-right cusp junction were always a safe distance from the coronary ostia. Therefore, coronary angiography can uniformly be avoided when the catheter tip is identified at this region (23% of the cases).
Study limitations This study was performed in an electrophysiology laboratory in which the operators have significant experience in the use of phased-array ICE and who took great care confirming catheter tip location. If operators are uncertain of the proper views or if ablation catheter tip location cannot be confirmed, then coronary angiography or aortography is always the safest option. Anomalous insertion of the left main coronary artery can rarely occur; if the left main ostium is not visualized, then coronary angiography should be performed. There is a small risk of damaging the right coronary artery if the origin of the ostium is low. However, this is a rare anomaly and is identified in only 0.10% of all coronary anomalies.12 In our series, all successful ablation lesions were 410 mm away from the coronary artery ostium as visualized by ICE and electroanatomic mapping. If the mapping catheter is visualized within 10 mm of the coronary artery ostium, then coronary angiography should be performed before ablation.
Conclusion Our series suggests that radiofrequency ablation of VAs originating from the aortic root may be safely performed
5
using phased-array ICE in the majority of cases without the need for coronary angiography.
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