EHRA EUROPACE How to perform epicardial ventricular tachycardia mapping and ablation
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1 EHRA EUROPACE 2011 How to perform epicardial ventricular tachycardia mapping and ablation Jacob Atié Director Arrhythmias Department Federal University of Rio de janeiro
2 Presenter Disclosure Information None Jacob Atié Director Arrhythmias Department Federal University of Rio de Janeiro
3 Epicardial Mapping / Ablation Why Epicardial Ablation? How to predict? How to perform? In Whom? When?
4 HCMP Epicardial VT SCAR RF Normal Tissue d Avila,Sosa, Scanavacca. Heart Rhythm 09/2006. Vol 3;9:
5 ARVC/ Dysplasia Cruz F, Atie J, Am J Pathology 1990:3,
6 DCMP - MRI Most pt have an ICD Delayed Enhacement
7 Epicardial Tachycardia How to predict epicardial tachycardia? ECG
8 ECG Recognition of Epicardial VT Endo Epi A B ID=126 ms ID=179 ms Intrinsic deflection = 27 ms = 72 ms RS= 165 ms RS= 213 ms STIM REG TAT Berruezo. Circulation 2004; 109:
9 ECG Criteria to Identify Epicardial VT Algorhythm 14 pt with NICMP 102 epi 67 endo pacemap Vallès, Marchlinski. Circ Arrhythm Electrophysiol. 2010;3:63-71.
10 Epicardial Mapping / Ablation HOW to PERFORM?
11 Epicardial techniques in the EP Lab Sosa et al. JCE 1996
12
13 Tuohy needle Larrey s space André D Avila frame
14 Subxyphoid pericardial space acces Avoid perfuration of the left liver lobus, stomach and colon Courtesy M. Scanavacca
15 RV CS Tuohy needle Xyphoid contrast needle Guide wire Epicardial catheter Epicardial catheter Sosa. JCE- 1996;7: 531 Sosa. JACC- 2000;35: 1442
16 Courtesy Dr Sosa
17
18 Pericardial Access Sacher et al. JACC 2010;55;
19 Needle, Sheeths and Catheters Needle tuohy Sheeths normal steerable Catheters irrigated open or closed Two punctures Sheeth bigger catheter Take out the catheter from time to time
20 Mapping and Ablation VT Chagas Disease Endocardial mapping Epicardial mapping scar scar
21 Correlation Endo e Epi
22 Relationship of fat thickness with low-voltage area Low voltage 6 mm (> 4mm) 3 mm Tung. Epicardial Fat and Scar in Porcine Infarct Model. Heart Rhythm 2010;7:
23 Electroanatomic map and gross pathologic correlation Tung.. Heart Rhythm 2010;7:
24 Coronary anatomy RV LV
25 Acute and Chronic Effects of Epicardial RF Delivered on Epicardial Coronary Arteries In Porcine Media thickness 0.25 mm 0.28 mm Acute chronic Results: 1. no infarction 2. no vascular thrombosis 3. intimal thickening 4. long-term significance? Intimal tickening 0.13 mm x 0.18 mm Acute chronic 20 days 70 days Ville, Sosa, Circ Arrhythm Electrophysiol Jun
26 HRS/EHRA VT Ablation Consensus Document Deliver RF in epicardial ablation at least 5 mm distance from coronary artery Clinical situation will determine where to go
27 In whom do we need to perform epicardial mapping
28 ARVC-VT: Endocardial Ablation WHY? Progressive and difuse disease? Epicardial substrate? Survival Free of Ventricular Tachycardia Recurrence Dalal. J. Am. Coll. Cardiol. 2007;50;
29 ARV Dysplasia / C RV and LV Cruz F, Atie J, Am J Pathology 1990:3,
30 13 pt VT ablation Endocardial No success Endocardial x Epicardial ARVD Garcia, Marchlinski. Circulation 2009; 120:
31 Identification of Slow Conduction on Epi VT PACE Garcia, Marchlinski. Circulation 2009; 120:
32 Outcome with Epicardial Ablation 13 pt FUP: 18, months VT target : endo 4 pt : 9 VT epi 13 pt: 27 VT Inducible after ablation : 2 pt Recurrence VT : 2 +1 pt Garcia, Marchlinski. Circulation 2009; 120:
33 Epicardial and Endocardial Mapping of HCM-related VT Multicentric (4) - 11 pt EP Study SCAR MMVT: 7 Epi: 3 PVT: 1 Epi + Endo: 5 MMVT is uncommon Non inducible: 3 Endo only: 1 and scar related No scar: 2 EPI and ENDO map Should be considered Apex involvement: 7 Dukkipati, Reddy, Soejima,,Bala,,Marchlinski, Inada, Stevenson, Heart Rhythm 2010
34 Chagas VT Ablation with regular 4mm catheter -Recurrence- Scanavacca-Sosa-. Pacing Clin Electrophisiology 2002;25(3):368-71
35 Endocardial and Epicardial Radiofrequency Ablation of Ventricular Tachycardia Associated With Dilated Cardiomyopathy Soejima et al. JACC 2004;43:
36 After Inferior MI more epicardial circuits Tedrow, Stevenson. JCE 2009;20(6):710-3
37 Male 52 years ; Post MI VT Multiple shocks (ICD) Endocardial ablation 2x (1 year); epicardial 2x (6 months) 410ms
38 Epicardial ablation Sub-xyphoid window
39 Male 52 years ; Post MI VT Multiple shocks Endocardial ablation 2x (1 year); epicardial 2x (6 months)
40 Recurrence events Combined Endocardial and Epicardial RF Ablation of VTs N = 376 pts 3-year recurrence 1-year recurrence 1,8,6,4,2 0 Chagas VT Post MI-VT IDCM P = epicardial VTs Other VTs Chagas Post-MI (IDCM) Provided by Sosa in 2008
41 Epicardial Ventricular Tachycardia Ablation Multicenter Study 156/913 (17%) Safety and midterm complications months 45 Acute complications:5% 40 Pericardial effusion 8 Coronary 35stenosis 1 % Freedon from VT 71% Chronic complications:2% Late tamponade 1 Coronary occlusion 1 Inflamatory pericardium 1 Ischemic Idiop CMP ARVD No CMP other CMP 5 0 Ischemic Idiop CMP ARVD No CMP other CMP All Adapted from Sacher et al. JACC 2010;55;
42 Epicardial Mapping A First Line Approach? Protetic Ao and Mitral valve Trombus in the left ventricle Failed endocardial ablation Wire in the epicardial space + Heparine + Endo map Chagas Disease ARVC, DCM + epicardial ECG (MRI) Ischemic Inferior MI + epicardial ECG (MRI) HCM + epicardial ECG?? (MRI)
43 Thank you
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