Epicardial Approach to Mapping and Ablation of VT: Clinical and ECG Predictors of Epicardial Location

Transcription

1 Epicardial Approach to Mapping and Ablation of VT: Clinical and ECG Predictors of Epicardial Location Mathew D. Hutchinson, MD, FACC, FHRS Perelman School of Medicine University of Pennsylvania

2 Presenter Disclosure Information Within the past 12 months, the presenter has had a financial interest / arrangement* with the organizations listed below: Company Name: Medtronic St. Jude Medical Medicomp Biosense Webster Sorin Group Relationship: Advisory Panel, Lecture Honoraria Lecture Honoraria Consultant Sponsored Research, Lecture Honoraria Advisory Panel *All support modest

3 Outline Epicardial substate in specific disease states Preoperative MR and ECG clues Intraoperative mapping and imaging clues

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5 Endo PM Epi Infarct Location Subendocardial Circuit Subepicardial Circuit RF Lesion Anterior (N=14) 100% 14% Healthy Inferior (N=14) 71% 36% Non-ablated Substrate Josephson et al. Circulation 1982; 66: Kaltenbrunner et al. Circulation 1991; 84: Epi

6 13% total 68% 48% 6% total 39% also required endo RF Sarkozy et al. Circ Arrhyth Electrophysiol 2013; 6: Tung et al. Heart Rhythm 2013; 10: 490-8

7 22 suspected Epi (20 prior endo RF) Epi vs. Endo scar 82% vs. 54% 55.3± 33.5 cm2 vs. 22.9± 32.4 cm 2 Wide, split or late pots - 50% Soejima et al. J Am Coll Cardiol 2004; 10: Cano et al. J Am Coll Cardiol 2009; 54:

8 >1.5 mv >1.0 mv <0.5 mv <0.5 mv 38 ± 32 cm 2 95 ± 47 cm 2 13 pts: Mean 2.2 prior endo procedures Epi RF adjacent to normal or ineffective endo regions in 76% Long term VT freedom 77-91% Epi-endo vs. endo (Bai): 85 vs. 52% at 3 yrs Garcia et al. Circulation 2009; 120: Thiene et al. Cardiovasc Pathol 2001; 10: Berruezo et al. Circ Arrhythm Electrophysiol 2012; 5: Bai et al. Circ Arrhythm Electrophysiol 2011; 4:

9 >1.5 mv >5.5 mv >1.0 mv <0.5 mv <0.8 mv <0.5 mv 23 Pts Task Force Criteria ARVC 91% EAM vs. 39% CMR scars present Marra et al. Circ Arrythm Electrophysiol 2012; 5: Sensitivity Specificity PPV NPV Accuracy EA Scar RV DGE LV DGE

10 HCM LV 10 patients: all men, 57±9 yo, EF 57±13% Phenotype: 5 ASH, 5 mid cavity (3 apical aneurysm) Bipolar scar Endo/Epi 5, Epi 3, Endo 1 Apex 7/9, Lat 3/9, Ant-Lat 3/9, Inf 1/9 Dukkipati et al. Circ Arrhythm Electrophysiol 2011; 4:

11 DGE CMR in Nonischemic CM 29 consecutive pts 19 VT pts, all with DGE 42% 14/29 with DGE (3 sarcoid) 7/14 endo 2/14 epi 47% 5/14 intramural Bogun et al. J Am Coll Cardiol 2009; 53: Piers et al. Circ Arrhythm Electrophysiol 2013; 6:

12 Isolated Septal Substrate Relatively uncommon (11.3%) 9/30 normal bipolar, all with unipolar low voltage 80 ± 36 cm 2 LV 72 ± 51 cm 2 RV Epi approach limited utility Patchy, smaller area of scar Often adjacent to coronary vasculature Haqqani et al. Heart Rhythm : I II III avr avl avf V1 V2 V3 V4 V5 V6

13 Epi Endo Epicardial ECG Criteria- Ischemic CM 90% ischemic 0% ischemic; 67% NICM Sensitivity Specificity Pseudo Delta Pseudodelta wave 34ms 83% 95% 74 ±32 ms vs. 50±23 ms 96% 29% Intrinsicoid deflection time 87% 90% 85ms (V2) 72±46 ms vs. 63±36 ms 39% 24% Shortest RS complex 121ms 76% 85% 127 ±37 ms vs. 98 ±32 ms 53% 29% Intrinsicoid Deflection Time Berruezo et al. Circulation 2004; 109: Bazan et al. Heart Rhythm 2007; 4: Martinek et al. J Cardiovasc Electrophysiol 2012; 23: Shortest RS Complex

14 Epicardial ECG Criteria- LV EPI ENDO EPI ENDO I II III avr avl avf Anterior LV I I II III avr avl avf V1 V2 V3 V4 V5 Inferior LV V1 V2 V3 V4 V5 V6 III avf II V6 Bazan et al. Heart Rhythm 2007; 4:

15 Epicardial ECG Criteria- RV RV Inferior Wall RV Free Wall II V2 LV V6 III EPI ENDO RV V4 V5 avf V3 V1 V2 EPI ENDO Bazan et al. Heart Rhythm 2006; 3:

16 >1.5 mv LV <0.5 mv Pericardium LV Bala et al. Circ Arrhythmia Electrophysiol :667-73

17 ENDO BIP >1.5 mv ENDO UNI >8.3 mv EPI BIP >1.0 mv <0.5 mv <0.5 mv <0.5 mv ENDO UNI EPI BIP DGE MR Unipolar Nonoverlap Unipolar- Bipolar Overlap M-M DE Normal ENDO Hutchinson et al. Circ Arrythm Electrophysiol 2011; 4:49-55 Normal EPI

18 Adjusting Unipolar Threshold 8.3 mv 9.4 mv 10.5 mv

19 VT1 VT2 Endo PM Endo LAT Bipolar Unipolar

20 34 ms >1.0 mv -139 ms <0.5 mv Base RAO Apex >1.5 mv <0.5 mv

21 Transmural Circuits in LVCM EPI ENDO Epicardial Isthmus Site Endocardial Exit Site

22 82 yo M with ICM, EF 20% IMI 1989, CABG 2010 Failed 2 previous endocardial ablations Recurrent slow VT, shocks Termination >60sec PM Pap

23 PLV GCV LV LV PLV PM

24 Summary CMP phenotype predicts EPI substate: ARVC/D >LVCM (inf/lat scar) > ICM Failure of endo ablation remains best predictor of need for epi procedure ECG predictors for epi VT origin are disease-specific CMR, voltage mapping, and ICE provide clues to the presence of epicardial scar

25 Thank You!

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