Ventricular Tachycardia Ablation. Saverio Iacopino, MD, FACC, FESC

Transcription

1 Ventricular Tachycardia Ablation Saverio Iacopino, MD, FACC, FESC

2 ü Ventricular arrhythmias, both symptomatic and asymptomatic, are common, but syncope and SCD are infrequent initial manifestations of the cardiac disease

3 Incidence of SAD in Specific Populations and Annual SAD Numbers General adult population Multiple risk subgroups Patients with any previous coronary event Patients with ejection fraction <35% or CHF SCD-HeFT Cardiac arrest, VT/VF survivors High-risk post-mi subgroups AVID, CASH, CIDS MADIT, MUSTT, MADIT II Incidence of Sudden Death (% of group) , ,000 Incidence of Sudden Deaths Per Year (number) 300,000 Adapted from: Myerburg RJ. Sudden Cardiac Death: Exploring the Limits of Our Knowledge. J Cardiovasc Electrophysiol Vol. 12, pp , March 2001.

4 Pathological Progression of CV Disease Coronary artery disease Arrhythmia Underlying etiology in ~60% of CHF 1 Left ventricular injury Pathologic remodeling Low ejection fraction Death ü Hypertension ü Cardiomyopathy ü Valvular Disease Pump failure Underlying etiology in ~40% of CHF 1 ü Neurohormonal stimulation ü Endothelial dysfunction ü Myocardial toxicity ü Vasoconstriction ü Renal sodium retention Symptoms: Dyspnea Fatigue Edema Chronic heart failure 1 Adapted from Cohn JN. N Engl J Med. 1996;335: He J, Ogden LG, Bazzano LA, et al. Risk Factors for Congestive Heart Failure in US Men and women: NHANES I epidemiologic follow-up study. Arch Intern Med 2001, 161:

5 Coronary Heart Disease ü An estimated 13 million people had CHD in the U.S. in ü Sudden death was the first manifestation of coronary heart disease in 50% of men and 63% of women. 1 ü CHD accounts for at least 80% of sudden cardiac deaths in Western cultures. 3 Etiology of Sudden Arrhythmic Death 2,3 5% Other* 15% Cardiomyopathy 1 American Heart Association. Heart Disease and Stroke Statistics 2003 Update. 2 Adapted from Heikki et al. N Engl J Med, Vol. 345, No. 20, Myerberg RJ. Heart Disease, A Textbook of Cardiovascular Medicine. 6 th ed. P % Coronary Heart Disease * ion-channel abnormalities, valvular or congenital heart disease, other causes

6 LVEF and SAD Incidence % SCA Victims % 5.1% 2.8% 1.4% 0-30% 31-40% 41-50% >50% LVEF Vreede-Swagemakers JJ. J Am Coll Cardiol. 1997;30:

7 Idiopathic DCM and Hystopathology Grossly visible scar in 14% of patients NORMAL HEART DCM Histology discloses fibrosis in 57% of patients interstizial fibrosis replacement fibrosis Unverferth DV. AMJ. 1986;57: Roberts WC. AMJ. 1987;60: Nakayama Y. JACC. 1987;10:

8 Reentry VT

9 LV Bipolar Voltage Mapping During SR in Patient with NIDCM and VA Correlation with Histology minimal moderate extensive Pogwizd SM. Circulation. 1998;98:

10 Estimation of the Abnormal LV Endocardium in a patient with Non-ischemic Cardiomyopathy Marchlinski FE. Circulation. 2003;108:

11 Localization and Characterization of the VT circuit Marchlinski FE. Circulation. 2003;108:

12 Non Invasive Detection of Myocardial Fibrosis in DCM Correlation of MR myocardial delayed enhancement with histology findings in DCM Different distribution patterns of Gadolinium within the myocardium ü MRI cannot differentiate inflammation from fibrosis Zimmermann O. EJHF. 2006;8: Prevalence of delayed enhancement was 69% in 42 patients with DCM as compared to 0% in 42 control subjects

13 Relation Between Scar Location on Delayed Enhancement Images and Morphology of VT ü LBB like configuration in lead V1 of the VT ECG suggests an exit site in the right ventricle or interventricular septum and is compatible with the scar location Nazarian S. Circulation. 2005;112:

14 MRI Parameters and Comparison After Stratification by Inducibility at EPS ü noninvasive assessment of scar distribution by MRI may predict EPS results in NIDCM ü scar distribution may identify a subset of patients with mild to moderate LV dysfunction and high risk of arrhythmia not currently identified for ICD implantation Nazarian S. Circulation. 2005;112:

15 Bundle Branch Reentry as the Mechanism of VT ü Accounting for 5-6% of VT cases in CAD ü And up to 40% in non ischemic DCM ü Diagnoses associated with BBR-VT (CAD excluded) ü Non ischemic DCM (50-70% of all BBR-VTs) ü Valvular heart disease ü Muscular dystrophies, hypertrophic CM, Ebstein s anomaly ü No structural heart disease but His-Purkinje conduction delays ü Heart is dilated in the vast majority of cases ü Enlarged QRS, prolonged H to V interval

16 Bundle Branch Reentry VT ü Reentry circuit is confined to the left and right bundle branches ü Usually LBBB, during sinus rhythm ü Presents with: ü Syncope ü Palpitations ü Sudden cardiac death ü Treatment: RF ablation of right bundle

17 Bundle Branch Reentry VT: Mechanism Oreto G. I Disordini del Ritmo Cardiaco - CSE 1997

18 Case History ü Women, 58 years old with single chamber PM ü Syncope and SVT ü Emery-Dreyfuss Syndrome ü Dilated Cardiomyopathy ü EF=40% ü NYHA class II

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21 H H H H H H-H= V 310 V 350 V 330 V 310 V V-V=

22 Ablation Site: Right Bundle RVOT RVOT ABL ABL RV RV RAO LAO

23 Case History ü Men, 59 years old ü palpitations, dispnoea ü Syncope, ventricular ectopies and SVT ü NIDCM (EF=40%), dilated RVOT ü EKG Holter: ventricular monomorfic ectopies (28.650) and NSVT

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25 Pacemapping Clinical Ectopies

26 Inducible VT

27 Pacemapping from ablation site Clinical VT

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29 ü ICD have become the main therapeutic tool for patients with life-threatening VE arrhythmias ü Some patients receive multiple appropriate shocks during a short period due to arrhythmic storm ü The arrhythmic episodes was successfully controlled in the majority of patients with antiarrhythmic drug therapy

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31 Kaplan-Meier event-free Survival Estimates in Patient Population During Follow up P Della bella et al. Circulation 2008

32 Kaplan-Meier event-free Survival Estimates According to Acute CA Results During Follow up P Della bella et al. Circulation 2008

33 ü Despite the evidence-based data and practical recommendations for indications of ICD therapy and ablation, these therapy has not been uniformly implemented worldwide

34 NYHA Ischemia EPS EF VPBs/nsVT HRV SAD TWA SAECG BRS QT d BNP QRS d

35 Markers of Arrhythmic Risk ü Simple factors ü Prognostic indicator ü Determining decision-making?