Management of ventricular tachycardia with structural heart disease

Transcription

1 2017 KSC Rm Art Management of ventricular tachycardia with structural heart disease Jun Kim MD, PhD University of Ulsan College of Medicine Asan Medical Center

2 The Korean Society of Cardiology COI Disclosure Name of First Author:Jun Kim The authors have no financial conflicts of interest to disclose concerning the presentation KSC 2017 The 60 th Annual Scientific Meeting of the Korean Society of Cardiology

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4 Contents Management of ventricular arrhythmias Acute coronary syndrome Early after myocardial infarction(m) stable coronary artery disease after MI with preserved ejection fraction Therapies for patients with or without left ventricular dysfunction Primary prevention of sudden cardiac death Premature ventricular complex with structural heart disease or left ventricular dysfunction Sustained ventricular tachycardia Cardiomyopathy Dilated cardiomyopathy Hypertrophic cardiomyopathy Arrhythmogenic right ventricular dysplasia Restrictive cardiomyopathy

5 Contents Management of ventricular arrhythmias Acute coronary syndrome Early after myocardial infarction(m) stable coronary artery disease after MI with preserved ejection fraction Therapies for patients with or without left ventricular dysfunction Primary prevention of sudden cardiac death Premature ventricular complex with structural heart disease or left ventricular dysfunction Sustained ventricular tachycardia Cardiomyopathy Dilated cardiomyopathy Hypertrophic cardiomyopathy Arrhythmogenic right ventricular dysplasia Restrictive cardiomyopathy

6 Prevention and management of sudden cardiac death associated with acute coronary syndromes: in hospital phase. Indications for revascularization 1. Urgent reperfusion is recommended in patients with STEMI. (I, A) 2. Coronary revascularization is recommended in patients with NSTEMI or unstable angina according to ESC NSTEMI guidelines. (I, C) 3. A coronary angiogram followed, if necessary, by coronary angioplasty within 2 hours of hospital admission is recommended in patients with high-risk NSTEMI, which also includes life-threatening VA. (I, C) 4. Prompt and complete coronary revascularization is recommended to treat myocardial ischemia that may be present in patients with recurrent VT or VF. (I, C) 5. Implantation of an LV assist device or extracorporeal life support should be considered in hemodynamically unstable patients with recurrent VT or VF despite of optimal medical treatment (IIA, B) 6. Cardiac assist support and revascularization in specialized centers may be considered in patients with refractory cardiac arrest ( IIB, C)

7 Prevention and management of sudden cardiac death associated with acute coronary syndromes: in-hospital phase. Defibrillation/cardioversion/drugs/catheter ablation 1. Beta-blockers is recommended for recurrent polymorphic VT. ( I, B) 2. Intravenous amiodarone is recommended for the treatment of polymorphic VT (I, C) 3. Immediate electrical cardioversion or defibrillation is recommended in patients with sustained VT or VF (I, C) 4. Urgent coronary angiography followed, when indicated, by revascularization is recommended in patients with recurrent VT or VF when myocardial ischemia cannot be excluded. (I, C) 5. Correction of electrolyte imbalance is recommended in patients with recurrent VT or VF (I, C)

8 Prevention and management of sudden cardiac death associated with acute coronary syndromes: in-hospital phase. Defibrillation/cardioversion/drugscatheter ablation 6. Oral treatment with beta-blockers should be considered during the hospital stay and continued thereafter in all ACS patients without contraindications. (IIA, B) 7. Radiofrequency catheter ablation at a specialized ablation centers followed by the implantation of an ICD should be considered in patients with recurrent VT/VF or electrical storms despite of complete revascularization and optimal medical treatment (II A, C) 8. Intravenous lidocaine may be considered for the treatment of recurrent sustained VT or VF not responding to beta-blockers or amiodarone or in the presence of contraindication to amiodarone. (II B, C) 9. Prophylactic treatment with anti-arrhythmic drug (other than beta-blockers) is not recommended. (III, B)

9 Prevention and management of sudden cardiac death associated with acute coronary syndromes: in-hospital phase. Pacing/implantable cardioverter defibrillator 1. reprogramming a previously implanted ICD is recommended for patients with recurrent inappropriate ICD therapies. (I, C) 2. Reprogramming a previously implanted ICD should be considered to avoid unnecessary ICD shocks. (IIA, C) 3. ICD implantation or temporary use of WCD may be considered < 40 days after MI in selected patients. (IIB, C) 4. ICD implantation for the primary prevention of SCD is generally not indicated < 40 days after MI. (III, A)

10 17/F Case

11 D0-5 PM

12 D1 D2 D3 D4 D5 D6 D7 D8 D9 D10 D11 D12 D13 D14 WBC Hb PLT ESR 33 CRP CK CK- MB TnI BUN Cr AST ALT TB ALB BNP 2820

13 D0 ECMO

14 Incessant VT

15 D2

16 Brief History 52/M Acute pulmonary edema with tachycardia Risk factors: DM(-), HTN(-), smoking(+) ECG AFL Echo LVEF 32%, LVEDD=55 mm, LVESD=52.6 mm LA 44 mm, MG grade 3, TR Vmax=3.1 m/s CAG 3VD Cardiac MRI; DE in inferior wall, lateral wall

17 CABG + Mitral valve repair MVP with Physio 26mm ring LIMA to LAD (2.0mm) Radial artery to OM 1 (1.5) SVG to PDA (1.5) TTFM Doppler : good flow Intraop TEE -minimal residual MR

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19 Percutaneous coronary intervention (obtuse marginal branch) under IABP

20 Sunday

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22 Before RFCA, times of defibrillation AP view SG catheter single catheter As aortic valve closed during VF, retrograde approach with caution

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24 Contents Management of ventricular arrhythmias Acute coronary syndrome Early after myocardial infarction(mi) stable coronary artery disease after MI with preserved ejection fraction Therapies for patients with or without left ventricular dysfunction Primary prevention of sudden cardiac death Premature ventricular complex with structural heart disease or left ventricular dysfunction Sustained ventricular tachycardia Cardiomyopathy Dilated cardiomyopathy Hypertrophic cardiomyopathy Arrhythmogenic right ventricular dysplasia Restrictive cardiomyopathy

25 Risk stratification for sudden cardiac death early (within 10 days) after myocardial infarction 1. Programmed ventricular stimulation (PVS) after myocardial infarction in patients with reduced LVEF ( 40%) to assess the risk of sudden death. (IIB, B) 2. Non-invasive tests (microvolt T-wave alternans, tests for autonomic dysfunction or SAECG) are not recommended for risk stratification in the early phase after MI. (III, B)

26 Timing of implantable cardioverter defibrillator placement after myocardial infarction. Assessment of left ventricular ejection fraction 1. Early (before discharge) assessment of LVEF is recommended in all patients with AMI. (I, C) 2. Re-evaluation of LVEF 6-12 weeks after MI is recommended to assess the potential need for primary prevention of ICD implantation.(i, C)

27 Contents Management of ventricular arrhythmias Acute coronary syndrome Early after myocardial infarction(m) stable coronary artery disease after MI with preserved ejection fraction Therapies for patients with or without left ventricular dysfunction Primary prevention of sudden cardiac death Premature ventricular complex with structural heart disease or left ventricular dysfunction Sustained ventricular tachycardia Cardiomyopathy Dilated cardiomyopathy Hypertrophic cardiomyopathy Arrhythmogenic right ventricular dysplasia Restrictive cardiomyopathy

28 Risk stratification in patients with stable coronary artery disease after myocardial infarction with preserved ejection fraction 1. Programmed ventricular stimulation should be considered in survivors of a MI with preserved LV function and otherwise unexplained syncope (IIA, C)

29 Revascularization in patients with stable coronary artery disease after myocardial infarction with preserved ejection fraction 1. Coronary revascularization is recommended to reduce the risk of SCD in patients with VF when acute myocardial ischemia precedes the onset of VF (I, B)

30 Use of anti-arrhythmic drugs 1. Amiodarone may be considered for relief of symptoms from VA in survivors of a myocardial infarction but it has no effect on mortality. (IIB, B) 2. Therapy with sodium channel blockers (Class IC) in not recommended to prevent sudden death in patients with CAD or who survived MI. (III, B)

31 Contents Management of ventricular arrhythmias Acute coronary syndrome Early after myocardial infarction(m) stable coronary artery disease after MI with preserved ejection fraction Therapies for patients with or without left ventricular dysfunction Primary prevention of sudden cardiac death Premature ventricular complex with structural heart disease or left ventricular dysfunction Sustained ventricular tachycardia Cardiomyopathy Dilated cardiomyopathy Hypertrophic cardiomyopathy Arrhythmogenic right ventricular dysplasia Restrictive cardiomyopathy

32 Case 72/M 20 yrs ago, MI at SNUH 2002, normal coronaries at UUH 2003, heart transplant was recommended for HF DC cardioversion of sustained VT LVEF 29%, LV apical aneurysm. Normal coronary arteries non-viable myocardium in LAD territory.

33 VT

34 SR

35 Which is appropriate treatment for 1. single-chamber ICD this patient? 2. Cardiac resynchronization therapy with defibrillator (CRT-D) 3. Catheter ablation 4. Amiodarone 5. Sotalol

36 single chamber ICD No VT under control of cordarone 200 mg/d until 2009/11/17 No VT under control of cordarone 100 mg/d until 2010/6/1 VT recurrence in 2010/7/11

37 Which is appropriate treatment for this patient? 1. Upgrade to dual-chamber ICD to reduce inappropriate shock 2. Cardiac resynchronization therapy with defibrillator (CRT-D) to improve LV function and reduce ICD shock 3. Catheter ablation 4. Amiodarone 5. Sotalol

38 Treatment of patients with left ventricular dysfunction and sustained recurrent monomorphic ventricular tachycardia 1. Optimization of HF medications according to current HF guidelines is recommended in patients with LV dysfunction and sustained VT. (I, C) 2. Amiodarone treatment should be considered to prevent VT in patients with or without and ICD. (IIA, C)

39 Prevention of ventricular tachycardia recurrences in patients with left ventricular dysfunction and sustained ventricular tachycardia 1. Urgent catheter ablation in specialized or experienced centers is recommended in patients presenting with incessant VT or electrical storm resulting in ICD shocks.(i, B) 2. Amiodarone or catheter ablation is recommended in patients with recurrent ICD shocks due to sustained VT. (I, B) 3. ICD implantation is recommended in patients undergoing catheter ablation whenever they satisfy eligibility criteria for ICD (I, C) 4. Amiodarone or catheter ablation should be considered after a first episode of sustained VT in patients with an ICD (IIA, B)

40 Prevention of ventricular tachycardia recurrences in patients with bundlebranch reentrant tachycardia 1. Catheter ablation as first-line therapy is recommended in patients presenting with bundle branch re-entrant tachycardia. (I, C)

41 Refused to undergo RFCA Follow-up loss after 2010/8/31 Presented with dyspnea in During this period Upgrade to CRT-D(Unify ) in Failed catheter ablation of slow VT Current AAD medications; cordarone 400 mg/d No apical thrombus, LVEF 28%,EDV 195 ml, ESV 141 ml K=3.3 mmol/l 4.0 mmol/l(at the day of procedure)

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43 Late potential

44 mid-diastolic potential

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46 VT termination

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48 VT, pacemap

49 Pace-mapping of clinical VT

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51 Case: CRT is effective 88/M Chest pain & irregular pulse (2002) COPD 2009/4 dyspnea LVEF42% Akinesia of inferoposterior wall 1VD PCI (DES, RCA) LVEF 28%, CHF, LBBB in 2012 LVEF 25%, MR4+, in 2016

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56 Nightmare case 55/M s/p AMI PCI (2002) CAD, 3VD, MI, LV dysfunction 3VD unsuitable for PCI/CABG DM, CKD Abdominal Aortic Aneurym ICD for VF(2016/4/8) Recurrent VT/VF RFCA#2(2016/5/11 & 8/1) Failed PCI acute pulmonary edema(2016/8/17) Recurrent ICD shock refractory to amiodarone

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59 After #1 RFCA

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62 1. Cine MR - Global hypokinesia. - Aneurysm and thinning with akinesia at apex. 2. Delayed enhancement (viabilty) MR: 1) No definite enhancement of mid to basal anterior and anteroseptal wall: high viability. 2) 25-50% transmural delayed enhancement at mid to basal inferoseptal and inferior wall: relatively high viability. 2) > 75% transmural delayed enhancement at apex and mid to basal lateral wall: low viability. 3) 50-75% transmural delayed enhancement at mid inferoseptal and inferior wall: intermediate to low viability.

63 Which is appropriate treatment for this patient? 1. Cardiac resynchronization therapy with defibrillator (CRT-D) 2. Catheter ablation under ECMO support LVAD 6. Heart Transplantation

64 Contents Management of ventricular arrhythmias Acute coronary syndrome Early after myocardial infarction(m) stable coronary artery disease after MI with preserved ejection fraction Therapies for patients with or without left ventricular dysfunction Primary prevention of sudden cardiac death Premature ventricular complex with structural heart disease or left ventricular dysfunction Sustained ventricular tachycardia Cardiomyopathy Dilated cardiomyopathy Hypertrophic cardiomyopathy Arrhythmogenic right ventricular dysplasia Restrictive cardiomyopathy

65 Risk stratification and management of patients with dilated cardiomyopathy 1. Optimal medical therapy (ACE inhibitors, beta-blockers, and MRA) is recommended in patients with DCM to reduce the risk of sudden death and progressive HF. (I, A) 2. Prompt identification and treatment of arrhythmic factors (e.g. proarrhythmic drugs, hypokalemia) and co-morbidities (e.g. thyroid disease) is recommended in patients with DCM and VA. (I, C) 3. A coronary angiography is recommended in stable DCM patients with an intermediate risk of CAD and new onset of VA. (I, B) 4. An ICD is recommended in patients with DCM and hemodynamically not tolerated VT/VF, who are expected to survive for > 1 year with good functional status. (I, A) 5. An ICD is recommended in patients with DCM, symptomatic HF (NYHA class II-III) and an ejection fraction 35% despite 3 months of treatment with optimal pharmacologic therapy who are expected to survive for > 1 year with good functional status (I, B)

66 Risk stratification and management of patients with dilated cardiomyopathy 6. Catheter ablation is recommended in patients with DCM and bundle branch reentry ventricular tachycardia refractory to medical treatment.(i, B) 7. An ICD should be considered in patients with DCM and a confirmed disease-causing LMNA mutation and clinical risk factors (IIA, B) 8. Amiodarone should be considered in patients with and ICD that experience recurrent appropriate shocks in spite of optimal device programming. (IIA, C) 9. Catheter ablation may be considered in patients with DCM and VA not caused by BBR refractory to medical therapy (IIB, C) 10. Invasive EPS and PVS may be considered for risk stratification of SCD (IIB, B) 11. Amiodarone is not recommended for treatment of asymptomatic NSVT in patients with DCM. (III, A) 12. Use of sodium channel blockers and dronedarone to treat VA is not recommended in patients with DCM (III, A)

67 77/M, AF, LBBB, DCM (LVEF 24%), ICD (2010), VT storm

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71 No VT storm ICD replacement (Virtuoso VR) in 27/May/2010 RIATA lead exteriorization in 2013 #2 RFCA for electrical storm in 8/Dec/2015 Unsuccessful RFCA Amiodarone-induced thyroditis VT, NSVT 18/May/2016

72 # 3 RFCA

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78 RAO LAO

79 Case 70/M Tx for CHF (LVEF22%) since Non-compaction, LVEF 28% in 2014 CHF admission in Past medical history; gout+ CHF medications: atacand, concor, lasix, spironolactione LVEF 26%, LV 72/79 mm, 170/231 ml MR 4+, TR1+ TRVmax=3.7 m/s

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85 LVESD=72 LVEDD=79 LVEDV=231 LVESV=170 LVEF=26 LA=46 MR 4 E/E =22 TRVmax=3.7 LVESD=71 LVEDD=79 LVEDV=240 LVESV=192 LVEF=20 LA=42 MR 3 E/E =13 TRVmax= % increase of LVESV

86 Which treatment has been done? (1) Amiodarone (2) catheter ablation (3) other treatment LVESV=115 ml, LVEDV 144 ml, MR trace

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88 Conclusion Treatment of underlying heart disease Coronary revascularization, valve surgery/repair/percutaneous valve intervention ICD treatment if indicated Amiodarone treatment if recurrent VT occurs Catheter ablation if appropriate ICD shock for VT or hemodynamically stable VT/preserved LVEF.

89 추가?

90 Case 72/M Prior anterior MI PAD DM Non-disabling stroke stable VT LVEF 36% Apical aneurysm Two vessel disease Nonviable myocardium

91 Which is appropriate treatment for this patient? 1. dual-chamber ICD 2. Cardiac resynchronization therapy with defibrillator (CRT-D) 3. Catheter ablation 4. Amiodarone 5. Sotalol

92 Progression dual chamber ICD implanted Recurrent ICD shock for slow VT one day after implant TCL ( ms) not terminated by ATP (antitachycardia pacing) termination by 5 J 15 times Amiodarone IV Slow VT tx off, Continue on amio 100 mg, beta-blocker etc Recurrent slow VT (spontaneous termination) ~3.29, TCL=510~520 ms, duration 28 sec~3 min 42 sec

93 2 nd admission due to CHF ( ) A. Clinical VT B PVC during 2 nd admission

94 Pro BNP PFT FVC, FEV1 nearnormal DLCO normal Holter recording PVC ~60% of total beats

95 ms H P H P A D A lead His RVA Abl A lead His A lead His B ICD C RVA ICD Abl E RVA ICD Abl

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97 3 rd admission VT storm,

98 Access to the left ventricle in patients with PAD Femoral transseptal approach Femoral artery approach long sheath Transseptal approach via subclavian or internal jugular vein Radial artery or brachial artery Transcutaneous epicardial approach

99 No evidence of acute myocardial ischemia/infarction Catheter ablation of ventricular tachycardia external irrigation catheter 30 W, 45 C Transseptal approach due to severe atherosclerotic change in abdominal aorta conventional mapping/ablation Pacemapping/entrainment mapping Angiography using a long sheath (24 cm,arrow long sheath)

100 3 rd ablation (4 days later) Mapping and ablation Left radial artery puncture 7-Fr sheath 6-Fr ablation catheter with a 4 mm distal tip 50 W, 60 C Strategy Mapping area with late potential pacemapping Entrainment during induced tachy

101 Stim-to-QRS EGM-to-QRS PPI TCL

102 Stevenson WG et al, JACC 1997

103 Termination of VT

104 VT vs pacemap S-QRS=67ms

105 No catheter in the descending aorta Abl

106 VT vs pacemap S-QRS=165 ms V1 V2 V3 V4 V5 V6 ABL d ABL p RVA

107 Progressive prolongation of late potential ABL d ABL p RVA No capture

108 # CL Conf Axis mapping RF termination RBBB RI activation -84 yes LBBB RS nonsustained Not targeted RBBB RI Entrainment -105 yes RBBB RI Pacemap No but conversion to RBBB RI pacemap RBBB RI pacemap RBBB RS pacemap RBBB N Activation -159 yes RBBB RS Activation -95 yes RBBB N Activation -150 yes RBBB RI Pacemap RBBB N activation -119 yes RBBB RI Entrainment yes RBBB RS activation -127 yes RBBB RS activation -144 yes RBBB RI Activation -104 yes LBBB N Un-mappable Acceleration to V flutter by pacing Not targeted 10/17 VT(59%) terminated by RF energy

109 Procedural data Post procedural course Procedural time (hour) RF duration (sec) 1 st 2 hour nd 6 hour min 3rd 3 hour 2162 No procedure-related complication. After total 3 sessions of catheter ablation, there was no recurrence of VT/VF during 3- year follow-up period with no antiarrhythmic drug treatment.

110 mv 400 ms