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1 ΔΠΔΜΒΑΣΙΚΗ ΘΔΡΑΠΔΙΑ ΚΟΙΛΙΑΚΩΝ ΑΡΡΤΘΜΙΩΝ ΣΔΛΙΟ ΠΑΡΑΚΔΤΑÏΓΗ ΓΙΔΤΘΤΝΣΗ ΔΤ Α Καρδιολογική Κλινική ΑΠΘ, Νοζοκομείο ΑΧΕΠΑ, Θεζζαλονίκη

2 NO CONFLICT OF INTEREST

3 INTRODUCTION Sustained VT is an important cause of sudden cardiac death (SCD) and morbidity in pts with heart disease ICDs terminate VTs, SCD but not prevent VT Recurrent VT in ICDs: 40%-60% for secondary prevention : 20% in 3-5 yrs for primary prevention

4 ICD shocks reduce quality of life and are associated with an increased risk of death Antiarrhythmic drug therapy with amiodarone or sotalol reduces VT episodes but with disappointing incidence of side effects and efficacy Catheter ablation is useful : for reducing VT episodes can be life-saving when VT is incessant may be definite cure in pts without structural heart disease

5 VT ABLATION-INDICATIONS Patients with structural heart disease(including prior MI, dilated cardiomyopathy, ARVC/D) Class I. EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias, Heart Rhythm 2009

6 VT ABLATION-INDICATIONS Class IIa

7 Ablation in Pts without structural heart disease Class I

8 ABLATION-INDICATIONS Class III

9 ELECTRICAL STORM 3 separate episodes sustained VT or VF/24 h or aproppriate therapies from ICD (ATP-antitachycardia pacing, shocks) or VT > 30 sec without treatment, in monitor zone of ICD Israel C, Barold S. A.N.E 2007;12:375-82

10 18 ATP, 5 Shock 75 min

11 INCIDENCE secondary prevention : 25% at 3 yrs, 5-55 VT episodes in an electrical storm primary prevention : 4% MADIT II CRT-D : 0.7-7% monomorphic VT:90 %, polymorhic VT or VF: 10%

12 1% initial mortality

13 50-80% hospitalization

14 x 7.4 risk of death

15 survival (total mortality) survival (cardiac mortality) ES ES

16 ELECTRICAL STORM-TREATMENT 1. Treatment of reversible causes (electrolytes, ischaemia, heart failure) 2. Treatment of sympathetic activity (b-blockervenzodiazepines, sedation, sympathectomy) 3. Antiarrhythmic drugs 4. Optimal ICD programming 5. Αblation-RFA

17 VT CLASSIFICATION 5-10 %

18

19 VT LOCALIZATION ECG-V1 RBBB, LBBB

20 Mapping of VTs Activation map (conventional, electroanatomic contact and non contact CARTO, ENSITE system) Pace map, entrainment Voltage-scar or substrate map (sinus rythm) Late potentials map

21

22

23 ACTIVATION MAP AND CONCEALED ENTRAINMENT

24 ACTIVATION MAP-EARLIEST ACTIVATION EGM

25 PACE MAP

26 VOLTAGE MAP-SCAR MAP (sinus rhythm)

27 VOLTAGE MAP AND LINEAR ABLATION LESIONS

28 FRAGMENTED ELECTROGRAMS AND LATE POTENTIALS

29

30 VF Ablation Post MI monomorphic PVCs triggering VF

31 VF Ablation Post MI targeting Purkinje tissue potentials

32 VT TERMINATION DURING RFA

33 RADIOFREQUENCY ENERGY - Solid 4- or 5-mm electrodes are used for ablation of idiopathic VTs - Irrigated RF ablation or larger 8-mm for scarrelatedvts (larger, deeper lesions)

34 man 42yrs, RVOT VT, idiopathic

35 pace mapping score 12/12

36 ENSITE system- electroanatomic non contact map

37 RAO 30 LAO 30

38 RAO 30 LAO 30

39 LAO 30

40 man 63 yrs, ichemic cardiomyopathy, BVP-ICD, recurrent VTs

41 LBBB BVP-ICD

42 PA LAO 30

43 RAO 30 LAO 30

44 woman 44 yrs, arrhythmogenic right ventricular cardiomyopathy, ICD and VT storm

45

46

47

48 LAO 30 RAO 30

49 LAO 30 RAO 30

50 pace mapping score 12/12

51 VT-ELECRICAL STORM, ICD ISCHEMIC CARDIOMYOPATHY 63 yrs man

52 ABLATION DURING SINUS RHYTHM-SUBSTRATE MAPPING Late potentials

53 ABLATION DURING SINUS RHYTHM-SUBSTRATE MAPPING Fragmented electrograms

54 LAO Late Potentials map

55 LAO VIEW

56 EPICARDIAL ORIGIN OF VT epicardial ablation endocardial Berruezo A et al. Circulation 2004;109:

57 VT ABLATION IN PTS WITH ELECTRICAL STORM AND ICD n= 95, F/U: 22 mo event free survival Class A : complete success 72% Class B: partial success 18% Class C: failure 10% Carbucicchio C et al, Circulation 2008 ;117:462-9,

58 SMASH VT Trial -(Substrate Mapping & Ablation in Sinus Rhythm to Halt Ventricular Tachycardia) n= 128, RCT, secondary prevention, F/U: 2 yrs Survival free from ICD therapy Overall survival

59 Survival free of VT n= 110, F/U: 1 year ablation control Conclusion: Prophylactic VT ablation before ICD implantation seemed to prolong time to recurrence of VT in patients with stable VT, previous MI, and reduced LVEF. Prophylactic catheter ablation should therefore be considered before implantation of an ICD in such patients. Kuck KH et al, Lancet 2010;375:31-40

60 SUCCES RATE OF VT ABLATION IN PTS WITH STRUCTURAL HEART DISEASE Kuck KH et al, Lancet 2010;375:31-40

61 VT Ablation Evolution of Patients and Procedures Over 8 Years, n= 493 Survival after VT ablation Sacher F, et al. Circ Arrhythmia Electrophysiol. 2008;1:

62 Predictive Factors of Mortality. Cardiomyopathy and VT Ablation Sacher F, et al. Circ Arrhythmia Electrophysiol. 2008;1:

63 COMPLICATIONS 48 HOURS POST VT RFA: 8% Sacher F, et al. Circ Arrhythmia Electrophysiol. 2008;1:

64 Vaseghi M, et al. J Cardiovasc Electrophysiol, 2006;17:632

65 n= 457, 5 studies, 58% RFA CONCLUSION : Catheter ablation as an adjunct to medical therapy reduces VT recurrences (35%) in patients with structural heart disease and has no impact on mortality Mallidi J et al, Heart Rhythm 2011;8:

66 VT Ablation Versus Enhanced Drug Therapy (VANISH study) Ongoing Pts with prior myocardial infarction who have experienced recurrent appropriate ICD therapy for VT despite at least one antiarrhythmic drug. The primary endpoint will be a composite of appropriate ICD shocks or death.

67 CONCLUSIONS ICD remains the mainstay of therapy to prevent sudden cardiac death in pts with unstable VT/VF and heart disease ICD prolongs life, but does not prevent VT/VF, and causes significant adverse effects in up to 20% of pts Catheter ablation of VT has the potential to cure arrhythmias and is safe

68 CONCLUSIONS Catheter ablation of VT reduces ICD interventions, also if used prophylactically Catheter ablation of VT may improve prognosis in selected pts Time is ready for a randomized trial between VT- RFA vs ICD in pts with stable VT

69 EYXAΡΙΣΩ ΓΙΑ ΣΗΝ ΠΡΟΟΥΗ Α

70

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