Technique of Epicardial VT Ablation

Transcription

1 CARTO Club Jan 2014 Technique of Epicardial VT Ablation Amir AbdelWahab, MD Electrophysiology and Pacing Service Department of Cardiovascular Medicine, Cairo University

2 Need for Epicardial VT ablation 10-30% of VT ablation procedures Complication rate 5-10%

3 Epicardial VT Chagas 50-70% Non ischemic cardiomyopathy 25-50% Ischemic cardiomyopathy 10-15% ARVC 5-10% Idiopathic VT 10% mainly around epicardial vessels LV aneurysm, Sarcoid, Non compaction

4 When to consider? Secondary indication Failed endocardial ablation for VT: SRVT Idiopathic VT Primary indication Brugada syndrome ARVC DCM LV thrombus / Mitral and Aortic prosthesis

5 Suggestive ECG features QRS duration > 200 ms Pseudo delta wave > 34 ms Intrinsicoid deflection > 85 ms Shortest RS > 121 ms Precordial MDI > 0.55 Non ischemic cardiomyopathy: lack of q wave in inferior leads q wave in lead I

6 ECG of a PVC originating in the epicardium. Baman T S et al. Circ Arrhythm Electrophysiol 2010;3: Copyright American Heart Association

7 Left, Venogram of the great cardiac vein (GCV). Baman T S et al. Circ Arrhythm Electrophysiol 2010;3: Copyright American Heart Association

8 Epicardial VT in DCM patient

9 Images taken from 2 EPI+ patients in the posterior-anterior (PA) projection: patient 5 (A) and patient 7 (B). Hutchinson M et al. Circ Arrhythm Electrophysiol 2011;4:49-55 Copyright American Heart Association, Inc. All rights reserved.

10 Examples of unmatched cases. Tokuda M et al. J Am Heart Assoc 2013;2:e000215

11 RV endocardial unipolar voltage map indicates small scar in anterior tricuspid annulus (left panel). Tokuda M et al. J Am Heart Assoc 2013;2:e000215

12 Pre-procedure planning Equipment Tuohy needle (18 G 15 cm) Separate radiopaque 0.32 wire Long sheath (23 cm) or better short Agilis sheath At least 9F Double wiring in some cases Anaesthesia and Monitoring GA or Local anaesthesia Invasive arterial monitoring TTE or ICE throughout the procedure

13 Anticoagulation Stopped prior to the procedure INR less than 1.5 No Heparin until epicardial access is safely secured Protamine should be available Access to matched blood transfusion Surgical backup

14 Imaging Obtain MSCT or CE-MRI Scar Coronary arteries Pericardial fat Pericardial adhesions

15 Procedure If combined Endo and Epi, always start epicardial Start with skin snip

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18 Pericardial Access

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22 Where is the wire?

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24 Epicardial mapping

25 Pericardial fat

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27 Ablation in Pericardial space Irrigated-tip catheter 20-35W Flow 30 cc/min Aspirate frequently Avoid introducing air

28 Pericardial Window Pericardial adhesions Prior open heart surgery Myocarditis Prior pericarditis

29 Limitations Septal scar Epicardial fat Coronary arteries Phrenic nerve

30 Coronary arteries

31 Phrenic nerve

32 Post-procedure Care Remove sheath if no blood in pericardium Otherwise leave pigtail for 24 hours Triamcinolone 2mg/kg intrapericardial NSAIDs for few days

33 Complications Hemopericardium/tamponade Hemoperitoneum Injury to epicardial vessel (artery or vein) Phrenic nerve injury Hepatic injury

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35 Intraoperative image of the surgically repaired laceration (arrow) to a large-caliber posterolateral branch of the coronary sinus. Koruth J S et al. Circ Arrhythm Electrophysiol 2011;4: Copyright American Heart Association

36 A, Location of 2 puncture sites (black arrows) within the left hepatic lobe in an image obtained during laparotomy. Koruth J S et al. Circ Arrhythm Electrophysiol 2011;4: Copyright American Heart Association

37 Transverse view of an abdominal CT scan with contrast showing a large heterogeneous lesion in the left hepatic lobe (arrows), measuring cm. Koruth J S et al. Circ Arrhythm Electrophysiol 2011;4: Copyright American Heart Association

38 Summary There is a growing need for epicardial VT ablation Epicardial ablation is associated with better short-term and long-term outcomes in certain disease substrates Procedure is feasible and relatively safe if done by experienced operators and appropriate precautions are taken

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40 Thank you