title: Percutaneous epicardial ablation of ventricular arrhythmias arising from the left ventricular summit: outcomes and electrocardiogram correlates of success.
abstract: BACKGROUND
  Percutaneous epicardial ablation of ventricular arrhythmias arising from the left ventricular summit is limited by the presence of major coronary vessels and epicardial fat. We report the outcomes of percutaneous epicardial mapping and ablation of ventricular arrhythmias arising from the left ventricular summit and the ECG features associated with successful ablation.
  
  
  RESULTS
  Between January 2003 and December 2012, a total of 23 consecutive patients (49 ± 14 years; 39% men) with ventricular arrhythmias arising from the left ventricular summit underwent percutaneous epicardial instrumentation for mapping and ablation because of unsuccessful ablation from the coronary venous system and multiple endocardial LV/right ventricular sites. Successful epicardial ablation was achieved in 5 (22%) patients. In the remaining 18 (78%) cases, ablation was aborted for either close proximity to major coronary arteries or poor energy delivery over epicardial fat. The Q-wave amplitude ratio in aVL/aVR was higher in the successful group, with a ratio of > 1.85 present in 4 (80%) patients in the successful group versus 2 (11%) in the unsuccessful group (P = 0.008). The ratio of R/S wave in V1 was greater in the successful group, with 4 (80%) patients in the successful group having a R/S ratio of > 2 in V1 versus 5 (28%) in the unsuccessful group (P = 0.056). None of the patients in the successful group had an initial q wave in lead V1, as opposed to 6 (33%) in the unsuccessful group. The presence of at least 2 of the 3 ECG criteria above predicted successful ablation with 100% sensitivity and 72% specificity.
  
  
  CONCLUSIONS
  Epicardial instrumentation for mapping and ablation of ventricular arrhythmias arising from the left ventricular summit is successful only in a minority of patients because of close proximity to major coronary arteries and epicardial fat. A Q-wave ratio of > 1.85 in aVL/aVR, a R/S ratio of > 2 in V1, and absence of q waves in lead V1 help identify appropriate candidates for epicardial ablation.
authors: From the Department of Medicine, Electrophysiology Section, Cardiovascular Division (P.S., F.E.M., E.S.Z., D.B., M.D.H., D.L., D.S.F., M.P.R., G.E.S., F.C.G., R.B., D.J.C., S.D.) and Department of Radiology (B.D.), Hospital of the University of Pennsylvania, Philadelphia.
authors: Pasquale
authors: P
authors: Santangeli
authors: From the Department of Medicine, Electrophysiology Section, Cardiovascular Division (P.S., F.E.M., E.S.Z., D.B., M.D.H., D.L., D.S.F., M.P.R., G.E.S., F.C.G., R.B., D.J.C., S.D.) and Department of Radiology (B.D.), Hospital of the University of Pennsylvania, Philadelphia.
authors: Francis E
authors: FE
authors: Marchlinski
authors: From the Department of Medicine, Electrophysiology Section, Cardiovascular Division (P.S., F.E.M., E.S.Z., D.B., M.D.H., D.L., D.S.F., M.P.R., G.E.S., F.C.G., R.B., D.J.C., S.D.) and Department of Radiology (B.D.), Hospital of the University of Pennsylvania, Philadelphia.
authors: Erica S
authors: ES
authors: Zado
authors: From the Department of Medicine, Electrophysiology Section, Cardiovascular Division (P.S., F.E.M., E.S.Z., D.B., M.D.H., D.L., D.S.F., M.P.R., G.E.S., F.C.G., R.B., D.J.C., S.D.) and Department of Radiology (B.D.), Hospital of the University of Pennsylvania, Philadelphia.
authors: Daniel
authors: D
authors: Benhayon
authors: From the Department of Medicine, Electrophysiology Section, Cardiovascular Division (P.S., F.E.M., E.S.Z., D.B., M.D.H., D.L., D.S.F., M.P.R., G.E.S., F.C.G., R.B., D.J.C., S.D.) and Department of Radiology (B.D.), Hospital of the University of Pennsylvania, Philadelphia.
authors: Mathew D
authors: MD
authors: Hutchinson
authors: From the Department of Medicine, Electrophysiology Section, Cardiovascular Division (P.S., F.E.M., E.S.Z., D.B., M.D.H., D.L., D.S.F., M.P.R., G.E.S., F.C.G., R.B., D.J.C., S.D.) and Department of Radiology (B.D.), Hospital of the University of Pennsylvania, Philadelphia.
authors: David
authors: D
authors: Lin
authors: From the Department of Medicine, Electrophysiology Section, Cardiovascular Division (P.S., F.E.M., E.S.Z., D.B., M.D.H., D.L., D.S.F., M.P.R., G.E.S., F.C.G., R.B., D.J.C., S.D.) and Department of Radiology (B.D.), Hospital of the University of Pennsylvania, Philadelphia.
authors: David S
authors: DS
authors: Frankel
authors: From the Department of Medicine, Electrophysiology Section, Cardiovascular Division (P.S., F.E.M., E.S.Z., D.B., M.D.H., D.L., D.S.F., M.P.R., G.E.S., F.C.G., R.B., D.J.C., S.D.) and Department of Radiology (B.D.), Hospital of the University of Pennsylvania, Philadelphia.
authors: Michael P
authors: MP
authors: Riley
authors: From the Department of Medicine, Electrophysiology Section, Cardiovascular Division (P.S., F.E.M., E.S.Z., D.B., M.D.H., D.L., D.S.F., M.P.R., G.E.S., F.C.G., R.B., D.J.C., S.D.) and Department of Radiology (B.D.), Hospital of the University of Pennsylvania, Philadelphia.
authors: Gregory E
authors: GE
authors: Supple
authors: From the Department of Medicine, Electrophysiology Section, Cardiovascular Division (P.S., F.E.M., E.S.Z., D.B., M.D.H., D.L., D.S.F., M.P.R., G.E.S., F.C.G., R.B., D.J.C., S.D.) and Department of Radiology (B.D.), Hospital of the University of Pennsylvania, Philadelphia.
authors: Fermin C
authors: FC
authors: Garcia
authors: From the Department of Medicine, Electrophysiology Section, Cardiovascular Division (P.S., F.E.M., E.S.Z., D.B., M.D.H., D.L., D.S.F., M.P.R., G.E.S., F.C.G., R.B., D.J.C., S.D.) and Department of Radiology (B.D.), Hospital of the University of Pennsylvania, Philadelphia.
authors: Rupa
authors: R
authors: Bala
authors: From the Department of Medicine, Electrophysiology Section, Cardiovascular Division (P.S., F.E.M., E.S.Z., D.B., M.D.H., D.L., D.S.F., M.P.R., G.E.S., F.C.G., R.B., D.J.C., S.D.) and Department of Radiology (B.D.), Hospital of the University of Pennsylvania, Philadelphia.
authors: Benoit
authors: B
authors: Desjardins
authors: From the Department of Medicine, Electrophysiology Section, Cardiovascular Division (P.S., F.E.M., E.S.Z., D.B., M.D.H., D.L., D.S.F., M.P.R., G.E.S., F.C.G., R.B., D.J.C., S.D.) and Department of Radiology (B.D.), Hospital of the University of Pennsylvania, Philadelphia.
authors: David J
authors: DJ
authors: Callans
authors: From the Department of Medicine, Electrophysiology Section, Cardiovascular Division (P.S., F.E.M., E.S.Z., D.B., M.D.H., D.L., D.S.F., M.P.R., G.E.S., F.C.G., R.B., D.J.C., S.D.) and Department of Radiology (B.D.), Hospital of the University of Pennsylvania, Philadelphia. sanjay.dixit@uphs.upenn.edu.
authors: Sanjay
authors: S
authors: Dixit
mesh_terms: D000200:Action Potentials; D000328:Adult; D000368:Aged; D017115:Catheter Ablation / Q000009:adverse effects / Q000379:methods*; D004562:Electrocardiography; D056149:Epicardial Mapping; D005260:Female; D006339:Heart Rate; D006352:Heart Ventricles / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010496:Pericardium / Q000503:physiopathology / Q000601:surgery*; D015143:Philadelphia; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012307:Risk Factors; D017180:Tachycardia, Ventricular / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D016277:Ventricular Function, Left; D016278:Ventricular Function, Right
keywords: catheter ablation; epicardial mapping; tachycardia, ventricular