J.M. Evans, John Silberbauer, B. Glover, A. Kontogeorgis, A.J.A. McLellan, S. Panikker, B.J. Sieniewicz, C.A. Martin, M.R. Burg, R. Providencia, J.M. Behar, M.C. Burke (+118 others)
2016 Europace  
Cardiac arrhythmias are thought to affect over 2 million people per annum in the UK. Symptoms include palpitations, fatigue and breathlessness in addition to anxiety/worry. These symptoms can have a negative impact on a patient's quality of life. Treatment for cardiac arrhythmias includes ablation of cardiac tissue in an effort to reduce or abolish these symptoms. The importance of the patient's perspective is becoming increasingly recognised. Patient Reported Outcome Measures (PROMs) tools are
more » ... beginning to be used more widely in order to capture the patient's perspective on the success or lack of success of a given procedure. We collected data from people who underwent cardiac ablation for arrhythmia at 3 centres using PROMs tools comprising EQ-5D-5L, with visual analogue scores (VAS),and the Cardiff Cardiac Ablation PROM (C-CAP) which includes symptom severity scores and impact on life scores. Valid questionnaires were completed pre-ablation, post-ablation and at 1 year follow-up. Questionnaire responses at each of the three time-points were compared. In addition outcomes were analysed for different arrhythmia substrates, including: AF, AVNRT, accessory pathways, atrial flutters, ectopic beats and ventricular tachycardia. Data were not normally distributed and thus analysed using the non-parametric Friedman test. Results were visualised through the use of boxplots. A total of 370 patients completed and returned questionnaires for pre-ablation, post-ablation and at 1 year follow-up and so were included for analysis. EQ-5D-5L indices at post-ablation and at 1 year follow-up were significantly higher ( p , 0.001, n ¼ 370) than pre-ablation. VAS scores were also significantly higher ( p , 0.001, n ¼ 363) at post-ablation and 1 year follow-up than pre-ablation. Symptom severity scores were significantly lower ( p , 0.001, n ¼ 275) at postablation and 1 year follow-up than pre-ablation. Impact on life scores were significantly lower ( p , 0.001, n ¼ 319) at post-ablation and 1 year follow-up than pre-ablation. In addition, impact on life scores were significantly lower (p , 0.001) at 1 year follow-up than post-ablation. Results were analysed at substrate level where significant increases in EQ-5D-5L and VAS scores were observed following ablation in addition to significant reductions in impact on life scores and symptom severity. Studies often report the results of successful cardiac ablation without considering or presenting the patient's perspective on the procedure. Conditions suffered by a patient can have a negative impact on their quality of life. PROMs tools help to capture the patient's perspective and allow the success of a procedure to be measured within the context of an individual. Cardiac ablation has been shown to positively impact on a patient's symptoms and their quality of life. Furthermore, cardiac ablation was shown to positively impact on symptoms suffered by patients with different types of arrhythmias. Introduction: Widespread adoption of first-line endo-epicardial ventricular tachycardia ablation has not been taken up due to the risk of lacerating coronary vessels and puncturing the right ventricle with direct subxiphoid puncture. This study assessed the feasibility of intentional coronary venous perforation and exit with subsequent pericardial CO2 insufflation as a novel method for assisting subxiphoid pericardial puncture in the setting of epicardial mapping and ablation for ventricular tachycardia. The technique required that coronary venous perforation would not lead to significant bleeding, even in the presence of heparinisation. Methods: A lateral branch of the coronary sinus was subselected using a diagnostic JR4 coronary catheter inside a steerable sheath, via femoral access, and a distal branch then perforated intentionally using a high tip load 0.014" angioplasty wire. Either a micro-catheter or over the wire balloon was then passed over this into the pericardial space allowing up to 150 ml of pericardial CO2 insufflation which allowed direct visualisation of subxiphoid anterior pericardial access using a 22 G micro-needle technique. Results: Intentional coronary vein exit was achieved in all 12 patients. In one, this confirmed widespread pericardial adhesions and therefore only endocardial ablation was undertaken. The other patients underwent successful pericardial CO 2 insufflation and subxiphoid access allowing epicardial ventricular mapping and ablation. The mean volume of CO 2 insufflated was 143.3 + 16.1 ml. The immediate pericardial aspirate was dry or contained serous fluid in all but one patient. In no patient (8 patients) did this prevent transseptal access and subsequent heparinisation to a target ACT of 350 s. No re-bleeding was seen after heparinisation. Seven patients had left ventricular coronary venous leads and there were no displacements. In one patient, no suitable lateral or anterolateral branches were seen on coronary sinus venography and coronary venous exit was therefore undertaken alongside the left ventricular lead, which was used as a 'road map' to guide coronary vein exit. Conclusions: We report the first human trans-coronary vein exit procedure. Coronary vein exit and subsequent percutaneous subxiphoid anterior access using a micro-needle puncture after CO2 pericardial insufflation can be achieved reliably and safely. The use of this novel technique to safely access the pericardial space safely has the potential to expand the indications for firstline epicardial access for ventricular tachycardia ablation affording a more comprehensive mapping and ablation procedure. Background: Catheter ablation therapy has become a key intervention in treatment of recurrent Ventricular Tachycardias (VT). Current techniques focus on isolating and ablating potential isthmus or channel within lowvoltage regions (scar). However success is limited, with 50% recurrence rate within 2 years. We test the efficacy of an automated fractionation detection method based on prior published techniques that may potentially increase the accuracy and success rate of ablation therapy by more accurately identifying arrhythmogenic regions. Methods: A train of pacing with three different timings, close to ventricular effective refractory period (VERP), was introduced from the apex of the Right Ventricle (RV); wherein every subsequent extrastimuli was 50 milliseconds faster (starting at VERP þ 150). Surface and intracardiac activations were recorded from different sites of the left ventricle (LV) in 10 patients using a commercial electroanatomic mapping system. Recorded signals were processed with Teager-Kasers Energy Operator (TKEO) for peak detection. Fractionation features were extracted, which were categorized into latency, electrogram (EGM) duration, and deflections. Latency is the normalized delay between pace and start of activation, EGM duration is the duration of the activation and deflections are the number of peaks in activation. Surface EGM was used for reference. Performance was evaluated by comparing data obtained from test and control cohorts. Results: Patient cohort consisted of 5 tests (age 56.6 + 6 years, 80% male) and 5 controls (age 53.2 + 3.3 years, 60% male), with and without VT respectively. 1350 segments of a duration of approximately 30 second were obtained, with an average of 131 + 71 segments per patient. Test patients showed a significantly larger mean and standard deviation for all three pace timings, and for all features (p , 0.05). All patients showed a significant increase in latency as pacing approached VERP (p , 0.05). Highly fractionated regions and potential ablation sites were obtained by filtering test data, with 'normal' values obtained from control patients. Normal values are defined as any value which fell under mean þ2*standard deviation in the control dataset. Conclusion: This study demonstrates that fractionation, as defined by latency, EGM duration and deflections, is correlative with arrhythmia, and that this data might be useful in isolating arrhythmogenic tissue for better targeted ablation. Furthermore, we showed that this process may be automated using an automated fractionation detection method and can be readily deployed in contemporary mapping systems. Introduction: Contact force sensing (CF) catheters have improved acute outcomes and medium-term recurrence rates following AF ablation, however data supporting the use of CF in ventricular tachycardia (VT) ablation is limited. Objective: To evaluate outcome following VT ablation with and without CF at a large tertiary referral hospital in London, UK. Methods: Retrospective review of all VT ablations performed between 1/1/2010 and 31/12/2014.Data collection included: demographics, VT etiology and presentation, procedural complications, follow-up. Failure of VT ablation was adjudicated based on VT recurrence,re-do VT ablation and appropriate ICD therapies. (A priori, all congenital VT was excluded as most were performed using remote magnetic navigation at our institution.) Results: 220 consecutive cases were identified (median age 65yrs, range 15-90; 76% male),classified as ischemic in 122 (55.5%), cardiomyopathy in 86 (39%) and occurring in structurally normal hearts in 12 (5.5%). Presentation was VT storm in 54 (23%). There were 15 (6.8%) procedural complications. There was no significant difference in any of these variables between CF and non-CF groups. Follow up data was available in 173 (78%) (mean duration 1.3 yrs, range 0.2-5 yrs). There were 79 events. Kaplan-Meier curves (Figure 1 ) were statistically identical between CF and non-CF groups (log-rank p ¼ 0.91). Conclusions: There was no improvement in VT ablation outcomes using CF catheters compared to non-CF catheter in a large, single centre study. Prospective studies to evaluate further are needed.
doi:10.1093/europace/euw271 fatcat:sk4sozfl35gijca4xnmenmmiqi