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Ablation of Intramural Ventricular Arrhythmias
Quick Takes
- Radiofrequency ablation targeting the premature ventricular complex site of origin (SOO) directly or through a SOO-guided approach resulted in a high acute and long-term success rate.
- Patients in whom the SOO could not be identified and in whom ablation targeted early breakout sites had only modest acute and long-term outcomes.
- A SOO-guided ablation approach is recommended over targeting early sites of activation whenever feasible.
Study Questions:
What is the optimal mapping and ablation strategy to target intramural ventricular arrhythmias (VAs) by identifying the precise arrhythmia site of origin (SOO)?
Methods:
The investigators performed a stepwise mapping approach in 83 consecutive patients with intramural VAs; 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. A receiver-operating characteristic curve was created using local electrogram-QRS activation times to distinguish between the SOO versus early breakout sites; the area under the curve was calculated, and a cutoff value was determined using the Youden index.
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:
The authors concluded that identification of the SOO was associated with a successful ablation procedure by either targeting the SOO directly or targeting an adjacent anatomical structure.
Perspective:
This study reports that radiofrequency ablation targeting the premature ventricular complex SOO directly or through a SOO-guided approach resulted in a high acute and long-term success rate. Of note, patients in whom the SOO could not be identified and in whom ablation targeted early breakout sites had only modest acute and long-term outcomes. These data suggest that whenever feasible, a SOO-guided ablation approach is recommended over targeting early sites of activation.
Clinical Topics: Arrhythmias and Clinical EP, Noninvasive Imaging, Prevention, Implantable Devices, EP Basic Science, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias
Keywords: Arrhythmias, Cardiac, Catheter Ablation, Diagnostic Imaging, Endocardium, Outcome Assessment, Health Care, Primary Prevention, ROC Curve, Ventricular Premature Complexes
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