A novel simplified approach to radiofrequency catheter ablation of idiopathic ventricular outflow tract premature ventricular contractions (Record no. 15958)

Metadata
000 -Etiqueta do registo
campo de controlo de comprimento fixo nam a22 4500
001 - Identificador do registo
Campo de controlo 15958
100 ## - Dados Gerais de Proc.
Dados gerais de processamento 20230313d2023 k||y0pory50 ba
101 ## - Língua da publicação
Língua do texto, banda sonora, etc. Inglês
102 ## - País de Publicação
País de publicação Portugal
200 ## - Título
Título próprio A novel simplified approach to radiofrequency catheter ablation of idiopathic ventricular outflow tract premature ventricular contractions
Informação de outro título from substrate analysis to results
Primeira menção de responsabilidade Leonor Parreira
Outras menções de responsabilidade orien. Pedro Reis Adragão, Roberto Palma Reis
210 ## - Publicação, Distribuição
Lugar da edição, distribuição, etc. Lisboa
Nome do editor, distribuidor, etc. NOVA Medical School, Universidade NOVA de Lisboa
Data da publicação, distribuição, etc. 2023
215 ## - Descrição física
Descrição física 344 p.
328 ## - Nota de dissertação ou tese
Instituição que confere o grau académico Faculdade de Ciências Médicas, Universidade NOVA de Lisboa
Especificações da dissertação ou tese e tipo de grau académico Tese de Doutoramento
Área cientifica do grau académico Medicina
Ano do grau académico 2023
330 ## - Sumário ou Resumo
Texto da nota Summary: Premature ventricular contractions (PVCs) are a common finding in the general population. The most common site of PVCs, in patients without structural heart disease, is the right ventricular outflow tract (RVOT) and the left ventricular outflow tract (LVOT). The prognosis associated with frequent PVCs depends on the presence of structural heart disease, so that idiopathic PVCs have been considered benign. Recently however, evidence has emerged that a small percentage of those patients may present with polymorphic ventricular tachycardia or ventricular fibrillation or evolve to left ventricular dysfunction. Catheter ablation is indicated for frequent symptomatic PVCs refractory to medical therapy or in case of patient’s preference. Currently, catheter ablation is based on activation mapping, confirmed by pace mapping match of at least 11/12 ECG leads between the paced beat and the PVC morphology. The acute success rate ranges from 78% to 100% according to the series, and to the location of the PVCs. Remote magnetic navigation presents as a good option for PVC ablation offering a high success rate with better safety profile. Intraprocedural low PVC burden occurs in up to 30% to 48% of cases, resulting in either, cancelation of the ablation procedure in up to 11% of patients, or reduction of the success rate from 85% to 56% when ablation is attempted with pace mapping only. Recently non-invasive mapping systems based on the electrocardiogram analysis (ECGI) have been developed. These systems are capable of mapping an arrhythmia with just one beat, instead of the usual point by point acquisition, being especially useful in the case of rare arrhythmias. EGGI also constitutes a valuable noninvasive tool for studying the mechanisms of arrhythmias. With this system we were able to demonstrate the presence of an electrophysiological substrate in the RVOT of patients with PVCs and apparently normal hearts. It has been accepted for many years that in patients with idiopathic PVCs from the outflow tracts, the RVOT displays normal electroanatomical mapping features and electrophysiological properties. However, we have demonstrated that there is a substrate for idiopathic PVCs in the form of low voltage areas (LVAs) that are not detected by usual image methods including cardiac magnetic resonance (CMR). We described for the first time, the association between the presence of ST-segment elevation in V1-V2 at the 2nd intercostal space (ICS) with LVAs across the RVOT and have proposed it as a non-invasive electrocardiographic marker of LVAs. We also identified the presence of abnormal potentials in intracardiac electrograms at the ablation site during diastole, after the T wave of the surface ECG that became presystolic during the PVC and were called diastolic potentials (DPs). In Chapter V we describe in detail the study that validated those findings and evaluated the feasibility and efficacy of a proposed simplified substrate approach, for catheter ablation in patients with low intraprocedural PVC burden, defined as less than 2 PVCs/min in the first 5 minutes of the procedure. It consists of fast mapping of the RVOT in sinus rhythm looking for LVAs and DPs, identifying the area, and finally performing a restricted activation map of the PVCs at that area. Briefly, it was a prospective single-arm clinical trial at two centers and three groups were studied: a) patients with low intraprocedural PVC burden that underwent ablation with the novel simplified approach method (study group); b) patients with low intraprocedural PVC burden that underwent ablation using the standard activation mapping method between 2016 and 2018 (historical group); and c) patients without PVCs, subjected to catheter ablation of supraventricular tachycardias that agreed to have a voltage map of the RVOT in sinus rhythm performed (validation group). The calculated sample size was 38 patients in each group. The exclusion criteria were as follows: known structural heart disease, history of sustained ventricular arrhythmias, inability to perform CMR, previous ablation and standard 12-Lead ECG with evidence of conduction or electrical disease or abnormal QRS morphology were excluded. Patients in the study and validation groups, had an ECG performed at the 2nd ICS and the RVOT mapped in sinus rhythm to assess the presence of ST-segment elevation, and LVAS and DPs, respectively. The results were compared between both groups. The study group and the historical group were compared regarding the efficacy of the new simplified ablation method in terms of abolishment of the PVCs and improvement of procedure speed and success rate. When available, ECGI was performed in the study group to evaluate the accuracy of the method to identify the site of origin of the PVCs. The ECGI was performed with two systems, the Amycard (EP Solutions SA, Switzerland) and the VIVO (Catheter Precision, NJ USA). The prevalence of LVAs and DPs was significantly higher in the study group in comparison with the validation group, respectively, 71% vs 11%, p<0.0001 and 87% vs 8%, p<0.0001. The ST-segment elevation was a good predictor of LVAS with a sensitivity of 87%, specificity of 96%, positive predictor value of 93% and negative predictor value of 91%. The novel simplified approach abolished the PVCs in 90% of the patients as opposed to 47% of patients in the historical group, p<0.0001. Only 74% patients underwent ablation in the historical group versus 100% in the study group. In patients that underwent ablation, the procedure time was significantly lower in the study group when comparing to the historical group, 130 (100-164) vs 183 (160-203) min, p<0.0001 and the success rate was significantly higher, 90% vs 64%, p=0.013. The recurrence rate in patients with a successful ablation after a median follow-up time of 1060 (574-1807) days, was not significantly different between both groups, Log-Rank=0.125 ECGI before ablation was performed in 17 patients in the study group. In 6 patients the ECGI was performed just with the Amycard system, in two just with the VIVO system and in 9 patients both systems were used. We found a good agreement between the ECGI and the invasive mapping, with the predicted site of origin being in the same or contiguous segment of the ablation site in 14/15 patients (93%) with the Amycard system and in 100% of patients with the VIVO system. When both systems were used simultaneously, the agreement between them was 8/9 (90%). So, in conclusion, the proposed approach partially based on substrate mapping including searching for LVAs and DPs, proved to be feasible, faster, and more efficient than the previous approach based exclusively on activation mapping. ST-segment elevation at the 2nd ICS proved to be a good predictor of LVAs. ECGI was a valuable tool to noninvasively predict the site of origin the arrhythmia
606 ## - Nome comum
Koha Internal code 24173
Elemento de entrada Catheter Ablation
606 ## - Nome comum
Koha Internal code 24174
Elemento de entrada Ventricular Premature Complexes
606 ## - Nome comum
Koha Internal code 7375
Elemento de entrada Ventricular Dysfunction
606 ## - Nome comum
Koha Internal code 30
Elemento de entrada Academic Dissertation
700 ## - Responsabilidade principal
Koha Internal Code 24171
Palavra de ordem Parreira
Outra parte do nome Leonor
702 ## - Responsabilidade secundária
Código de função Orientador de tese
Koha Internal Code 9356
Palavra de ordem Adragão
Outra parte do nome Pedro Reis
702 ## - Responsabilidade secundária
Código de função Orientador científico
Koha Internal Code 17491
Palavra de ordem Reis
Outra parte do nome Roberto Palma dos
801 ## - Fonte de origem
País Portugal
Agência NMS
Regras de catalogação RPC
856 ## - Localização e acesso electrónico
URL http://hdl.handle.net/10362/150229
090 ## - Números de controlo do sistema (Koha)
Número biblioitem do Koha (gerado automaticamente) 15958
942 ## - Elementos de entrada adicionados (Koha)
Tipo de item no Koha Documento Eletrónico
Suprimido Disponível no OPAC
Holdings
Removido (estado) Perdido (estado) Data de aquisição Identificador de recurso uniforme Origem do registo (biblioteca) (codificado) Código da organização que empresta ou é detentora (biblioteca) Localização da prateleira Código de barras Cota Tipo de circulação (não pode ser emprestado) Tipo de item e material
Disponível Disponível 2023-03-13 http://hdl.handle.net/10362/150229 Biblioteca NMS|FCM Biblioteca NMS|FCM online 20230048 RUN Normal Documento Eletrónico