Epicardial substrate ablation for Brugada syndrome

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Epicardial substrate ablation for Brugada syndrome Koonlawee Nademanee, MD, FHRS, Meleze Hocini, MD, Michel Haïssaguerre, MD Heart Rhythm Volume 14, Issue 3, Pages 457-461 (March 2017) DOI: 10.1016/j.hrthm.2016.12.001 Copyright © 2016 The Authors Terms and Conditions

Figure 1 The CARTO-Merge map shows a left anterior oblique view of the cardiac computed tomography scan that is merged with the electroanatomic maps of the right ventricular outflow tract epicardium of a patient with Brugada syndrome with frequent implantable cardioverter-defibrillator discharges. The arrow shows abnormal prolonged low-voltage fractionated electrograms recorded from that site of the right ventricular outflow tract epicardium. Abl-d = bipolar ablation distal; Abl-p = bipolar ablation proximal; Abl-d-Uni = unipolar ablation distal. Heart Rhythm 2017 14, 457-461DOI: (10.1016/j.hrthm.2016.12.001) Copyright © 2016 The Authors Terms and Conditions

Figure 2 Example of the large Brugada syndrome substrate areas of a patient with multiple implantable cardioverter-defibrillator shocks due to recurrent ventricular fibrillation. A: Anterior view of the electroanatomic map of the RV epicardium combined with the RV angiographic image using CartoUnivu software, displaying a large area of the right ventricular outflow tract and RV proper with abnormal fractionated late potentials. Abnormal electrograms are shown in the right panel (pink dots). B: Lateral view of the RV epicardial map highlighting abnormal substrate areas involved at the inferior wall RV epicardium where fractionated late potentials are also recorded after ajmaline infusion, as shown in the left panel. Abl-d = bipolar ablation distal; Abl-p = bipolar ablation proximal; Abl-d-Uni = unipolar ablation distal; RV = right ventricular; V1 ICS3 = lead V1 at the third intercostal space; V2 ICS3 = lead V2 at the third intercostal space. Heart Rhythm 2017 14, 457-461DOI: (10.1016/j.hrthm.2016.12.001) Copyright © 2016 The Authors Terms and Conditions

Figure 3 Effect of ajmaline on the epicardial substrate of a patient with Brugada syndrome with multiple implantable cardioverter-defibrillator discharges. A composite of the electroanatomic maps of the right ventricular epicardium, integrated with a fluoroscopic image of the heart using CartoUnivu software, displays and compares the substrate area at baseline and after ajmaline administration. A: Baseline abnormal substrate areas were tagged along the boundary with pink dots. B: Substrate areas were expanded after ajmaline administration (50 mg). Blue dots were used to tag the boundary of the abnormal areas that harbor fractionated late potentials after ajmaline administration. Heart Rhythm 2017 14, 457-461DOI: (10.1016/j.hrthm.2016.12.001) Copyright © 2016 The Authors Terms and Conditions

Figure 4 Example of a desirable acute ablation effect on the electrogram. The left panel shows a fractionated electrogram recorded from the distal pair of the ablation catheter. After ablation for 20 seconds at 40 W, the electrogram continuously recorded from the distal pair of the ablation catheter recorded from the same site is now drastically reduced in amplitude, with disappearance of the mid and late components of the fractionated signals recorded before ablation, suggesting that radiofrequency energy eliminated the intramyocardial substrate site below the epicardial surface. Abbreviations as in Figure 2. Heart Rhythm 2017 14, 457-461DOI: (10.1016/j.hrthm.2016.12.001) Copyright © 2016 The Authors Terms and Conditions