Septal Coronary Venous Mapping to Guide Substrate Characterization and Ablation of Intramural Septal Ventricular
David F Briceño1, Andres Enriquez2, Jackson J Liang1
1Electrophysiology Section, Cardiovascular Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
Insights
Septal coronary venous mapping aids in characterizing and ablating intramural septal ventricular arrhythmias (VA). This technique helps identify targets, leading to reduced arrhythmia burden and improved patient outcomes.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- Intramural septal ventricular arrhythmias (VA) pose significant challenges for accurate substrate definition and effective catheter ablation.
- Current mapping techniques may not fully delineate the arrhythmogenic substrate in the septum.
Purpose of the Study:
- To evaluate the utility of septal coronary venous mapping for characterizing the substrate of intramural septal VA.
- To assess the effectiveness of this approach in guiding catheter ablation for these challenging arrhythmias.
Main Methods:
- A septal coronary venous mapping procedure was performed in 12 patients with structural heart disease and recurrent VA, involving wire advancement into septal perforator branches.
- Five patients with idiopathic VA served as controls for comparison of substrate characteristics.
- Ablation strategies targeted early activation, pace map match, and entrainment sites identified from intraseptal recordings.
Main Results:
- Patients with intramural septal VA exhibited larger septal unipolar voltage abnormalities compared to bipolar abnormalities (p=0.01).
- Septal coronary venous mapping revealed low-voltage, fractionated electrograms in patients with VA substrate versus controls (p=0.007 and p=0.03).
- Following ablation, there was a significant reduction in premature ventricular contraction (PVC) burden (22% to 4%, p=0.005) and implantable cardioverter-defibrillator therapies (5 to 1, p=0.001).
Conclusions:
- Septal coronary venous mapping is a valuable tool for characterizing the arrhythmia substrate in patients with suspected intramural septal VA.
- This mapping technique can help identify optimal ablation targets, thereby guiding successful endocardial ablation.
- The findings suggest improved clinical outcomes with reduced arrhythmia burden after ablation guided by this method.
Objectives:
This study describes the use of septal coronary venous mapping to facilitate substrate characterization and ablation of intramural septal ventricular arrhythmia (VA).
Background:
Intramural septal VA represents a challenge for substrate definition and catheter ablation.
Methods:
Between 2015 and 2018, 12 patients with structural heart disease, recurrent VA, and suspected intramural septal substrate underwent a septal coronary venous procedure in which mapping was performed by advancement of a wire into the septal perforator branches of the anterior interventricular vein. A total of 5 patients with idiopathic VA were also included as control subjects to compare substrate characteristics.
Results:
Patients were 63 ± 14 years of age, and 11 (92%) were men. Most patients with structural heart disease had nonischemic cardiomyopathy (83%). Six patients underwent ablation for premature ventricular contractions (PVC) and 6 for ventricular tachycardia. All patients had larger septal unipolar voltage abnormalities than bipolar voltage abnormalities (mean area 35.3 ± 16.8 cm2 vs. 10.7 ± 8.4 cm2, respectively; p = 0.01), Patients with idiopathic VA had normal voltage. Septal coronary venous mapping revealed low-voltage, fractionated, and multicomponent electrograms in sinus rhythm in all patients with substrate compared to that in patients with idiopathic VA (amplitude 0.9 ± 0.9 mV vs. 4.4 ± 3.7 mV, respectively; p = 0.007; and duration 147 ± 48 ms vs. 92 ± 10 ms, respectively; p = 0.03). Ablation targeted early activation, pace map match, and/or good entrainment sites from intraseptal recording. Over a mean follow-up of 339 ± 240 days, the PVC and insertable cardioverter-defibrillator therapies burden were significantly reduced (from a mean of 22 ± 11% to 4 ± 8%; p = 0.005; and a mean 5 ± 2 to 1 ± 1; p = 0.001, respectively). Most patients (80%) with idiopathic VA remained arrhythmia free.
Conclusions:
In patients with suspected intramural septal VA, mapping of the septal coronary veins may be helpful to characterize the arrhythmia substrate, identify ablation targets, and guide endocardial ablation.
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