Focus on the role of Catheter Ablation: Simple cases Intermediate level Difficult cases (and patients) Impossible (almost )

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1 22nd SHA Scientific Session February 2011, Riyadh, KSA Management of Ventricular Arrhythmias: an Overview Corrado Carbucicchio Ventricular Intensive Care Unit Cardiac Arrhythmias Research Centre Centro Cardiologico Monzino - IRCCS University of Milan Milan, Italy

2 Focus on the role of Catheter Ablation: Simple cases Intermediate level Difficult cases (and patients) Impossible (almost )

3 Simple Cases : - Idiopathic arrhythmias, no structural t Heart Disease

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10 Intermediate level : Arrhythmogenicsubstrate t t in patients t with cardiomyopathy (mainly CAD), tolerated arrhythmias, relatively yp preserved cardiac function

11 CA for VT Almendral J and Josephson M: Circulation 2007; 116:

12 A. S

13 A. S

14 A. S

15 A. S

16 Difficult cases / patients : More complex substrate, t high degree of pleomorphism, advanced cardiomyopathy, non tolerated arrhythmias (typically pts. with an ICD and Electrical Storm or frequent recurrences of VT.) Transcutaneous epicardial mapping

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18 Death from any cause according to RFCA acute result Cardiac Death according to RFCA acute result Class B (RFCA partial success) Class A (RFCA success) Class A (RFCA success) l Ev vent-free Survival Class B (RFCA partial success) Class C (RFCA failure) l Ev vent-free Survival Class C (RFCA failure) Log-Rank test p = Log-Rank test p = Follow up (months) Follow up (months) Electrical Storm recurrence according to RFCA acute result Ventricular Tachycardia recurrence according to RFCA acute result Class A (RFCA success) Log-Rank test p < Class B (RFCA partial success) Event-free e Survival Log-Rank test p < Survival Event-free Class A (RFCA success) Class B (RFCA partial success) Class C (RFCA failure) Class C (RFCA failure) Follow up (months) Follow up (months)

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20 Poole JE et al. NEJM 2008; 359(10):

21 Mapping Strategy High Density electro anatomical mapping Identification of Conduction isthmi (channels channels) and Late / fragmented EGMs Validation by pacemapping or activation mapping during self terminating arrhythmias VT induction (pacing from the best site of mapping) VT mapping and VT termination ti n by RF delivery Lesion reinforcement / strategy of linear ablation Validation! and multisite PVS to test induction

22 G. V CARTO MAP

23 G. V CARTO MAP

24 C. M P A S O Mapping

25 C. M CARTO MAP

26 Almost impossible cases (no conventional approach feasible / effective) : Electrical l Storm + Hemodynamic impairment i / Cardiogenic shock Alternative approaches

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28 Cardiopulmonary Support

29 CPS: How it works

30 CPS activation: mean BP 76 mmhg

31 CA C.A. 72yrs yrs. Systolic disfunction and LV dilatation secondary to valvular heart disease and coronary artery disease Prior infero-apical MI 1991 Mitral and Aortic valve replacement (MSorin 25 A Sorin23) 2004 Upgrade to CRT Sept 2008 recurrent episodes of non tolerated VT Medical Therapy: Mexiletine, Amiodarone, Flecainide id Referred to our Centre because of Electrical storm refractory to any pharmacological treatment (general anaesthesia and respiratory assistance)

32 TRANS-APICAL ENDOCARDIAL APPROACH

33 TRANS-APICAL ENDOCARDIAL APPROACH

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35 CONCLUSIONS A wide spectrum of ventricular arrhythmia is a potential ti target t for Catheter t Ablation Arrhythmia presentation and patient s profile signifcantly yimpact on the role of CA and determine the mapping strategy of choice Catheter Ablation is part of a multidisciplinary approach in patients with severe cardiac disease and unstable hemodynamic conditions

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37 Our Experience at CCM Milano Outcome in patients without ICD ( ) (FU 18 ± 8 mo) 53(/228) pts 8 pts ICD implanted after CA (induction of non-tolerated VTs) 45 pts still without ICD (only tolerated VT induced and ablated) 5 pts (62%) with VT recurrence 7 pts (15%) with VT recurrence 1 Aborted Sudden Death

38 Patients requiring RFCA as a form of primary or secondary treatment for VT ( ) 264 VT pts: ICD at presentation 46/82 pts (56%) with EF >40% 90/101 pts (90%) with EF 30 to 40% 81/81 pts (100%) with EF <30%

39 Long-term outcome after RFCA according to LVEF (FU 21±12 12 months) 264 VT pts undergoing RFCA 82 pts with 101 pts with EF 81 pts with EF >40% 30 to 40% EF <30% 6 pts 11 pts 22 pts (7% recurrence rate) (11% recurrence rate) (27% recurrence rate)

40 Long-term outcome after RFCA according to VT characteristics (FU 21±12 12 months) 264 patients undergoing RFCA 158 pts (60%) 106 pts (40%) with hemodynamically with hemodynamically tolerated VT non-tolerated VT 8% recurrence rate 19% recurrence rate (13 pts) (20 pts)

41 Outcome of patients without ICD 47 RFCA pts 6 pts ICD implanted after RFCA (induction of non-tolerated VTs) 41 pts still without ICD (only tolerated VT induced and ablated) 2 pts (5%) with VT recurrence successfully re-ablated No Sudden Death

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45 Cardiopulmonary Support (Courtesy of Medtronic) Multiple side-holed, arterial al (15F) and venous (17F) cannulas are shown

46 Cardiopulmonary Support (Courtesy of Medtronic) Centrifugal cone-type pump (Bio-Medicus Medtronic; flow rate range: 1-5 l/min)

47 CPS: How it works Ventricular unloading - reduction of left ventricular dimensions and wall stress (minor myocardial oxygen demand) -withdrawal of venous return from the right atrium decreasing pulmonary capillary wedge pressure Increased mean arterial pressure mainly achieved by liquid volume delivery Blood oxygenation

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50 Sinus rhythm Centro Cardiologico Fond. Monzino MI, Italy

51 VT 1 mapping Centro Cardiologico Fond. Monzino MI, Italy

52 VT 2 mapping Centro Cardiologico Fond. Monzino MI, Italy

53 VT 3 mapping Centro Cardiologico Fond. Monzino MI, Italy

54 RF ablation line Centro Cardiologico Fond. Monzino MI, Italy

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57 Carto TV 2010: RESULTS 74 pts. (mean age 60yrs, 28 86) (64 M) (34 CAD, 29 IDCM, 6 ARVD, 4 myocarditis, i 1 neoplasm) + SVT, refractory to AAD; 32 ES; 63 pts. dependent from iv. AAD treatment; 69 ICD In 71 pts. VT induced (1 4 morphologies); in 48/ 71 pts. all VTs terminated by RF 71 pts.: Class A: 56 pts. (79%); Class B: 10 pts. (14%); Class C: 5 pz. (7%) 4 pts. undergoing epicardial mapping; Redo: 5 pts.

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