- Special VT Cases - Idiopathic Dilated Cardiomyopathy. D. Bänsch

Transcription

1 - Special VT Cases - Idiopathic Dilated Cardiomyopathy D. Bänsch

2 Introduction VT Ablation in CAD Strickberger SA, et al. J Am Coll Cardiol 2000 (35: ) Sra J. et al. Pacing Clin Electrophysiol 2001 (24: ) Soejima K. et al. Circulation 2002 (104: 664-9) De Chillou C. et al. Circulation 2002 (105: ) Soejima K. et al., Circulation 2002 (106: ) Borger van der Burg AE et al. J Cardiovasc Elektrophysiol 2002 (13: ) Arenal A. et al. Am Coll Cardiol 2003 (41: 81-92) Kautzner J. et al. Pacing Clin Electrophysiol 2003 (26: 342-7) Kottkamp H. et al. J Cardiovasc Electrophysiol 2003 (14: ) O Donnel D et al. Pacing Clin Electophysiol 2003 (26: ) Reddy VY et al. J Am Coll Cardiol 2003 (41: ) Della BP et al. Eur Heart J 2004 (25: ) Arenal A. et al. Circulation 2004 (110: ) Segal OR et al. Heart Rhythm 2005 (2: ) Deneke T. et al. Z Kardiol 2005 (94: ) Bogun F. et al. Heart Rhythm 2006 (3: 20-26) Cesario DA et al. Heart Rhythm 2006 (3: 1-10) Dalal D. et al. Am Coll Cardiol 2007 (50: ) Klemm HU et al. Circulation 2007 (115: ) Reddy VY et al. N Engl J Med 2007 (357: ) Stevenson WG et al. Circulation 2008 (118: ) Kuck KH et al. Lancet 2010 Aliot et al., Europace, Epub May 2009.

3 Introduction VT Ablation in CAD N: 1112 Patients with CAD: 100%

4 Introduction VT Ablation in CAD > 1 VT successfully ablated: 72-96% all VTs successfully ablated: 38-72% Freedom of any VT during FU: 50-88% continuing AAD therapy: % Procedure-related mortality: 0,5%

5 Introduction VT Ablation in IDCM Kottkamp H. et al. Circulation 1995 (92: ) Sato M. et al. Jpn Circ J 1997 (61: 55-63) Delacretaz E. et al. J Cardiovascular Electrophysiology 2000 (11:11-17) Soejima K. et al. J Am Coll Cardiol 2004 (43: ) Carbucichio C. et al. Circulation 2008 (117:462-69) Steven D. et al. Circ Arrhythmic Electrophysiol (2: ) Arya A. et al. Pace 2010 (33:1504-9) Kozeluhova M. Europace 2010 (13:109-13) Yokokawa M. Heart Rhythm 2011 (8: )

6 Introduction VT Ablation in IDCM N: 177 (1112) Scarcity of data is somewhat embarrassing

7 Introduction VT Ablation in IDCM vs. CAD Ablation for ES: 42% 1 VT successfully ablated: 58-80% all VTs successfully ablated: (73)% (38-72%) Freedom of any VT during FU: 22-62% (50-88%) ES recurrence: 36% Continuing AAD therapy: % Procedure-related mortality: 0% Long-term mortality: 21-31%

8 VT Ablation in IDCM Mechanism Myocardialer Reentry % Focal % Bundle branch/fascicular Reentry 7 19 %

9 VT Ablation in IDCM Mechanism Myocardialer Reentry % Focal % Bundle branch/fascicular Reentry 7 19 %

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14 # NT-proBNP: pg/ml (Norm bis 222 pg/ml) TNT: 0,112 pg/ml (Norm < 0,03 pg/ml) EF 12% MI II-III Implanted CRT-Device first, because we expected total AV-block After CRT-Implantation we ablated right bundle

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16 # Conclusion 1 HIS-Bundle recording should be present during VT ablation in IDCM BBBRT ablation may be associated with total AV-block especially if VT-QRS is the same as SR-QRS Right bundle may ablated after deviceimplantation

17 VT Ablation in IDCM Mechanism Myocardialer Reentry % Focal % Bundle branch/fascicular Reentry 7 19 %

18 Patient # History male, 69 years IDCM, EF: 44%, NYHA 2 (2008) LZ-EKG: VES, 5 nsvt up to 18 beats and 185/min/ 24hours, highly symptomatic Amio 200mg EF: 32% and NYHA 2-3 (2009) LZ-EKG: 6929 VES, 10 nsvt up to 18 beats and 146/min/ 24hours > Presented for ICD-implantation

19 # Holter ECG

20 # Lead ECGs

21 # nsvt

22 # Electroanatomical and Local Electrogramm

23 # Electroanatomical and X-Ray

24 # Months Follow-Up asymptomatic, no sign of heart failure Metoprolol EF: 44% LZ-EKG: 2428 VES, 1 nsvt with 6 beats and 152/min/ 24hours > ICD-implantation postponed

25 VES and Heart Failure Conclusion 2 Heart Failure/ impaired LV-function may cause VES, nsvt may be caused by VES, nsvt Many nsvts and VES may cause ICD overtherapie Effort to reduce/ abolish VES and mvt and reevaluate LV-function before ICD-implantation Complete abolishion may often not possible, but signficant reduction

26 VT Ablation in IDCM Mechanism Myocardialer Reentry % Focal % Bundle branch/fascicular Reentry 7 19 %

27 # History 55, male IDCM (1993) LV-EF: 41 % Permanentes Vorhofflimmern mvt: /min (2002) Dizziness, no syncope Inducible VTs ICD-Implantation (2002)

28 # VT-Cluster 80 adequate shocks during hemodynamically stable VTs (2007) Amiodarone Monitorzone

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31 I II III avr avl avf V1 V2 V3 V4 V5 V6

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35 # Conclusion RVOT-VT + Reentry ablated (2008) Monomorphic VTs should be taken care of before ICD implantations Indication for ICD-implantation should be revisited after ablation of mvt

36 VT Ablation in IDCM Mechanism Myocardialer Reentry % Focal % Bundle branch/fascicular Reentry 7 19 %

37 VT Ablation in IDCM Patient # IDCM (2005) EF: 20% ICD-Implantation (2005) Recurrent ICD-Shocks (2009)

38 # ICD Report

39 # ECGs: VT 330ms

40 # ECGs

41 # ECGs

42 # Electoanatomical Map endo/epi

43 # Endocardial Pacemap

44 # Electoanatomical Map endo/epi

45 # Xray endo/epi RAO/PA

46 # Electoanatomical Map endo/epi

47 Endo or Epicardial Reentry Conclusion 4 Focal and reentry mechanism may be operative in the same patient Both mechanisms should be adressed Substrate may be either endo or epicardial or both If the endocardial approach reveals no substrate, the procedure should be escalated to the epicardium in the same procedure

48 VT Ablation in IDCM # Dilated Cardiomyopathy/ CAD excluded 2008 EF: 30% Recurrent monomorphic VTs Afib LA Thrombus Left sided Insult Received an ICD 2008 VT-Cluster AA: Amiodaron, Mexitil, Betablocker

49 # ICD Programming

50 # VTs

51 # Recent History Admission to hospital for heart failure (beginning of June) Readmitted to hospital for heart failure (June 8th)

52 # Everyday ECG I II III Diagnosis: Afib, Aflut, Sinustachycardia avr avl AVF

53 # Heart Rate Monitor/ Pacing

54 # Conclusion This very slow VT was repeatedly misdiagnosed The doctor who took care of the home monitoring slept well We took the patient to the EP-Lab and expected Reentry as the the mechanism of the VT Large substrate Prepared for endo- and epicardial map

55 # Endocardial Map

56 # Endocardial/ epikardial Voltage Map

57 # Endocardial/ epikardial Activation Map

58 # Endocardial Activation Map

59 # What to do? No endocardial substrate Small epicardial substrate Carto map represents only part of the VT Exit points can be depicted epi and endocardially Distal CS cannot be reached Depict enodcardial and epicardial exit sites

60 # Ablation Strategy

61 # Local Electrogram

62 # VT termination

63 # Conclusion Reentry may be the main VT mechanism with scar as substrate Substrate may be intramural Even endo and epicardial map may not reveal the substrate easily

64 VT Ablation in IDCM Conclusion The scarcity of information on VT ablation in IDCM is embarrassing Any of the following VT mechanisms may be operative in IDCM: reentry, focal or fascicular - be prepared Substrate may be endocardial, epicardial or intramural - escalation of therapy during the same procedure is feasible (mandatory?) Epicardial approach has improved VT ablation outcome VES, VTs and ES in IDCM seem to have a strong impact on long term mortality

65 Thank you