Indications for catheter ablation in 2010: Ventricular Tachycardia

Transcription

1 Indications for catheter ablation in 2010: Ventricular Tachycardia Paolo Della Bella, MD Arrhythmia Department and Clinical Electrophysiology Laboratories Ospedale San Raffaele, IRCCS, Milan, Italy

2 Europace June 2009; Heart Rhythm, June 2009

3 Europace June 2009; Heart Rhythm, June 2009; ARVC/D, arrhythmogenic right ventricular crdiomyopathy/dysplasia; ICD, implantable cardioverter defibrillator; MI, myocardial infarction; VT, ventricular tachycardia; VF, ventricular fibrillation. *This recommendation for ablation stands regardless of whether VT is stable or unstable, or multiple VTs are present.

4 Catheter ablation in post-mi Ventricular Tachycardia Authors Pts Pts with post-mi VT EF% ICD carriers Acute success Proced mortality FU mo VT recurrence Death FU Rothman ±8 51% 86% 0 17±12 31% 6/35 Ortiz ±10 44% 68% 0 26±15 38% 3/34 Stevenson ±11 44% 71% 2% 18±15 31% 15/51 O'Callaghan % 82% 1.8% 39±23 NA 20/54 Borger % 79% 2.2% 34±11 23% 12/87 O'Donnell NA 26% 72% % 25/109 Della Bella % 73% 0.8% 41±5 28% 25/123 Segal % 82% 2.5% 36±21 57% 13/39 Sacher ±13 87% 66% NA 3±2 yrs 29% 75/213

5 Catheter ablation in post-mi Ventricular Tachycardia Borger Van Der Burg, JCE, May 2002 Della Bella P., et al. Eur Heart J, March 2002

6 Catheter ablation in post-mi Ventricular Tachycardia High rate of success (75%) Acceptable risk of major complications (2%) Excellent choice when anti-arrhythmic drugs are not effective, tolerated or preferred

7 Catheter ablation of post-mi VT: multicenter trials 231 pts, Frequent VT episodes Mean LVEF: 0.25 No VT inducible after ablation in 49% 1 or more VT inducible after ablation in 43% Previous uneffective AADs for 6 months after discharge At 6 months FU freedom from VT recurrence:123 pts (53%). Reduction of median VT episodes in patients with ICD at 6 months after procedure from 11.5 to 0, but an increase in the number of VT episodes was observed in 20% of patients. Stevenson WG et al, Circulation 2008

8 Catheter ablation of post-mi VT: multicenter trials Stevenson WG et al, Circulation 2008

9 Catheter ablation of post-mi VT: multicenter trials 63 pts ; mean LVEF: 0.3 All inducible VT targeted Unmappable VTs in 41% pts No VT inducible after ablation in 81 % AADs at discretion of investigator Acute success rate of 81% and a low rate (1.5%) of acute and subacute major adverse events. During mean 12 months FU 49% of pts presented VT recurrence (37% of the initially successful ablated patients) Tanner H, JCE, Jan 2010

10 Catheter ablation of VT in ARVD N pts Acute success F.U duration F.U event Van der Burg et al 32 28/32 pts 34+/- 11 VT recurrence: 5 pts Witcher et al 30 22/30 pts 52 +/-37 VT recurrence: 16 pts Syncope: 2 pts Cardiac arrest: 2 pts Marchlinski et al 19 14/19 pts 27 +/- 22 VT recurrence: 2 pts Verma et al 22 18/22 pts 37 (25-44) VT recurrence: 8 pts AAD in all pts Satomi et al 17 15/17 pts 26+/-15 VT recurrence: 2 pts AADs in 9 pts Dalal et al 24 37/48 procedures 32+/-36 (1 day to 12 yrs) VT recurrence after 40/48 procedures betablockers in 7 pts, I and III class AADs in 14 pts Yao et al 32 27/32 pts 28+/-16 VT recurrence: 4 pts Marchlinski et al 30 29/30 pts 34+/-28 VT recurrence: 9 pts AADs in 13 pts Garcia et al 13 10/13 pts 18.3+/ cardiac transplantion, 2 pts: VT recurrence AADs in 3 pts modified from Arbelo E, Josephson ME. JCE, Apr 2010

11 Catheter ablation of VT in ARVD The evaluation of the efficacy of catheter ablation is difficult, due to the different ablation techniques, procedural endpoints, AAD management and follow-up among the different studies. Acute success rates with RF catheter ablation range from 50 90% but recurrences are not rare The patchy nature of ARVD may account for the better ablation acute and followup success observed in substrate-based VT ablation Progressive nature of the disease: development of new arrhythmogenic substrates over time Predominance of the epicardial degeneration in patients with ARVD

12 Multiple morphologies and untolerated VT induction frequently occur in patients with ES Catheter ablation is successful in up to 72% of patients with ES Carbucicchio C, Circulation 2008

13 Carbucicchio C, Circulation 2008

14 Carbucicchio C, Circulation 2008

15 Sarrazin JF, Heart Rhythm. 2009

16 *This recommendation for ablation stands regardless of whether VT is stable or unstable, or multiple VTs are present. Catheter ablation in pts without ICD Almendral J and Josephson M: Circulation 2007

17 Della Bella P et al. Eur Heart J 2004 *This recommendation for ablation stands regardless of whether VT is stable or unstable, or multiple VTs are present.

18 Della Bella P et al. Eur Heart J 2004

19 Tung R., JCE July 2010 *This recommendation for ablation stands regardless of whether VT is stable or unstable, or multiple VTs are present.

20 Sauer WH. Heart Rhythm, Jan 2010 *This recommendation for ablation stands regardless of whether VT is stable or unstable, or multiple VTs are present.

21 Can VT ablation avoid ICD implantation? 105 pts with structural heart disease (mean EF 48±12%) Ablation of MSVT (77% of well-tolerated VT; 23% of untolerated VT; 11% electrical storm) CAD 54% ARVD: 10% IDCM: 10% Other SHD: 26% ICD not implanted (end-stage extra-cardiac disease; advanced age or well tolerated VT and preserved EF) Acute procedural success: 80% Mean FU 21±16 mo 63% pts addressed to B-blocker therapy 29% pts addressed to amiodarone VT recurrence: 14% pts Mortality rate: 11% (2 SD after second recurrence) There was no difference in VT recurrence rate according to: Type of structural heart disease Clinical variables EF VT rate and tolerance Residual VT inducibility Courtesy of Dr. Maury, personal data

22 Europace June 2009; Heart Rhythm, June 2009 Epicardial VT ablation: timing

23 Epicardial ablation: a first choice or after endocardial approach failure? Garcia FC., Circulation 2009

24 Epicardial ablation: a first choice or after endocardial approach failure? Garcia FC., Circulation 2009

25 Catheter ablation of VT in IDCM: epicardial mapping Radiofrequency energy delivery resulted in noninducibility of all VT in 14 of 21 patients (67%) Patients with a demonstrated epicardial substrate for the VT circuit/origin underwent acutely successful VT ablation in 71% of cases At mean 18 7 months FU 15 of the 21 patients (71%) had no VT during follow-up Cano O. JACC, 2009

26 Ospedale S. Raffaele, Milano, Italy. Thorax Institute, Hospital Clínic, University of Barcelona, Spain. Leiden University Medical Center, Leiden, The Netherlands. Hospital Universitario La Paz, Madrid, Spain. Na Homolce Hospital, Roentgenova Prague, Czech Republic. University Hospital Rangueil, Toulouse Cedex, France. Epicardial ablation: experience from a multicenter european study 218 pts mean EF 40±16 % CENTER INDICATION TOTAL POPULATION CAD 68.3 % ARVD 13.6 % HCM 5.2% no SHD 21% Failure of previous endocardial ablation First choice A 79% 21% 34 B 97% 3% pts had no evidence of epicardial reentry circuit C 100% 0% 8 D 47% 53% 57 Acute complete success: 156 pts (71%) E 39% 61% 66 No procedure-related deaths F 77% 23% 13 Total population 64% 36% 218

27 Cum Survival Cum Survival Epicardial ablation: experience from a multicenter european study Long term outcome Survival Functions Survival Functions 1,0 0,8 1,0inducible,00 1,00,00-censored 0,8 1,00-censored Not Inducible in,0 1,0 1 0,6 Not Inducible 0,6 Inducible 0,4 0,4 Inducible 0,2 0,2 0,0 LR< ,0 LR< ,00 20,00 40,00 60,00 80,00 100,00 0,00 20,00 40,00 60,00 80,00 100,00 MONTHS MONTHS VT recurrence ES recurrence

28 Reddy VY, N Engl J Med Dec pts with previuos Myocardial infarction and severe LV dysfunction Enrollement criteria: 1) Indication to ICD implantation related to: 2) ICD implantation for primary prophylaxis and appropriate ICD therapy for a single event Randomized to: no treatment or substrate catheter ablation during sinus rhythm No AAds (except for betablockers) in control group Overall reduction of ICD therapies burden in the ablation group with respect to control group

29 107 pts enrolled Previous myocardial infarction Reduced LV EF (</= 50%) Stable monomorphic VT Overall reduction of ICD therapies burden in the ablation group with respect to control group Difference in outcome after ablation related to degree of LV dysfunction (LVEF>30% versus LVEF 30%) Kuck KH et al Lancet 2010

30 CCFM; from Jan 2010 hospital San Raffaele 415 pts VT ablation: our experience 28; 6,7% 10; 2,4% 8; 1,9% 10; 2,4% 7; 1,7% 2; 0,5% 1; 0,2% 37; 8,9% 86; 20,7% 226; 54,5% Mild LV dysfunction Idiopathic dilated CM Valvular CM Previous Myocarditis Neoplasm Ischemic HD ARVD Hypertrophic CM Congenital HD, Incisional VT Amyloidosis

31 Clinical characteristics N pts % Arrhythmic Storm Incessant VT % Untolerated VT 250 EF<30% % % % % 82-20% % 86-20% 70-18% NYHA 1-2 NYHA 3-4 AF ICD Amiodarone % Amiodarone-related side effects IRC

32 Ablation strategy and acute success N pts % % Endo RFCA Epi RFCA Surgical ablation 150 RFCA success (A class) % RFCA partial success (B Class) % Failure (C Class ) % 13-4% 16-5% Successful ablation of target VT - Control PES not performed

33 Long-term follow-up N pts 300 3% 21% 250 ES recurrence Paroxysmal VT Recurrence No recurrence % 50 5% 30% 0 65% 100% 9% 81% Class A: 284 pts Class B: 46 pts Class C 13 pts non tested 16 pts

34 Procedure-related complications Tab. 1 Vascular injury (not requiring surgery) 3% AV fistula/pseudoaneurysm (surgical repair) 2% Pericardial effusion Total 2% Cardiac tamponade 1% Cardiac tamponade (surgical repair) 0.4% Pulmonary edema 1% PEA 0.5% Subacute haemoperitoneum (injury to diafragmatic vessel during epicardal puncture) 0.2%

35 In-hospital outcome Tab. 2 In-hospital death for refractory acute HF 6 (1.6%) In hospital death for PEA 1 (0.2%) In hospital ES recurrence: new ablation session 14 (4%) VT recurrence 56 (15%)

36 Tab. 3 FOLLOW-UP (16±12 months) Lost at follow-up 38 (9%) VT recurrence 79 (22%) Vt recurrence with ICD shock 38 (10%) Electrical storm 19 (5%) Hospital admission Total 63 (17%) VT recurrence 28 (8%) Heart failure 35 (9%) Death Total 37 (10%) Heart failure 12 (3%) Cardiac arrest 21 (5%) Non-cardiac cause 4 (1%)

37 Conclusions Indications to catheter ablation of Ventricular Tachycardia by the Expert Consensus Document are sound and justified by clear evidence about acute efficacy, safety and long-term outcome Open issues remain concerning: Timing of ES ablation Epicardial ablation: first line approach or following endocardial failure? When catheter ablation can replace ICD implantation